64
`
`MEDICAL JOURNAL ]
`
`BLOOD PRESSURE IN MAN.
`
`[JULY 10,
`
`Igog.
`
`impaired, and if the pulse be irregular in force and rhythm
`the coronary arteries are much involved.
`In these cases
`the question of the free calcium ions in the blood must be
`considered, as you must not run any risk of sudden cardiac
`failare. There may be plenty of lime salts in the arteries,
`but the blood may be defective in free calcium ions.
`In
`such cases I find a valuable combination to be small doses
`of the glycerophosphats of calcium and large doses of
`phosphoric acid. The former drug supplies present needs,
`and the latter sets the lime in the vessels free. A long
`course of decalcifying agents has often a wonderful effect
`in clearing the lime out of the vessels.
`In these cases,
`especially if the pulse be infrequent, the iodine prepara-
`tions are valuable, and small doses of thyroid increase
`metabolism and lessen the viscosity of the blood.
`When the 8ystolic and diastolic pressures are failing
`and there i8 oedema of the extremities, a temporary rest to
`restore the statu quo ante is highly beneficial. The diet
`should be dry, light, and nutritious, and nitrogenous if the
`kidneys be fairly healthy, sodium chloride should be
`eliminated, massage is useful, a course of cardiac tonics is
`necessary, alcohol is as a rule injurious. When the cardiac
`balance is restored there should be a course of graduated
`walking exercise, and skipping can also be commended.
`In many cases of myocarditis the right coronary artery
`i8 much more affected than the left. In such cases the
`heart's action may be very irregular, and during any
`strain there is marked dyspnoea and palpitation of the
`heart.
`There may -be no oedema of the extremities, but
`when the- heart beains -to fail you get congestion and
`oedema of the lungs and portal congestion.
`There is
`often marked orthopnoea, and in such cases it is often an
`advantage to wear an abdominal belt so as to assist the
`respiratory pump in supplying the right heart with blood.
`A good cardiac tonic in such cases consists of glycero-
`phosphate of calcium, strychnine, and phosphoric acid.
`For restlessness and insomnia the patient should get
`morphine and atropine. The preparations of iodine are
`often beneficial, and if there be much flatulence the
`tincture is the best.
`All laxatives should be gentle. The
`diet should be dry and largelv nitrogenous, and carbo-
`hydrates are perhaps best suppled in forms of glucose or
`malt.
`Exercise should be on the level.
`In many cases of myocarditis, either right or left, the
`irritability of the heart becomes smpaired, and in order to
`maintain a continuation of
`its contractions a certain
`diastolic pressure in the ventricles must be kept up. An
`abdominal support and an active respiratory pump assists
`the right heart, and for the-left heart you must not reduce
`the arterial pressure too low-there must be some effective
`resistance in the aorta in order that the contraction of the
`left heart- be not wasted, and that the heart itself be
`supplied with blood through its coronaries.
`If the costal
`cartilages are rigid a long course of phosphoric acid is
`useful, and for emphysema the citrate and iodide of
`sodium can be commended. The diet should be light and
`nutritious; for all forms of heart disease corpulence is a
`disadvantage.
`
`STOKES-ADAMs DISEASE.
`The treatment of Stokes-Adams disease has hitherto not
`been very satisfactory or successful. There seems to have
`been a block against any progress in treatment as well as
`against the transmission of the contraction waves. The
`very slow pulse is supposed to be due to degeneration of
`the bundle of His, and so only every second, third, or
`fourthl wave is able to jump the barrier, and reach the
`ventricles.
`There is no drug yet known which will either
`get rid of this block or enable every stimulus to travel
`along this Stannius bridge.
`Fortunately in these cases
`life does not hang by so rotten a thread. The apex of a
`frog's heart when cut off remains at eternal rest, but if
`you tie a cannula in it and supply it with nutritious fluid
`un6ler, pressure, its rhythmical contraction starts again.
`This affords a better indication for 'treatment than any
`idea which you may hold* about the function of the
`auriculo-ventricalar
`diastolic
`bundle.
`Maintain a fair
`pressure in both ventricles, wear a tight abdominal belt,
`or when in bed a heavy shot-bag over the abdomen. 1 am
`inclined to think that in these cases frequent shallow
`breathing is better than long and deep. The degenerative
`changes in these cases are not con6ned to the bundle of
`His, th ouh youl may occasionally hear it stated in post.
`mortem records that every othber part of the heart was
`
`healthy. Personally, I have never seen one of these hearts
`quite healthy, and my reply to such a statement would be
`that the treatment must have been bad to- have allowed
`such a heart to stop.
`The effective force of the right ventricle is often more
`impaired than that of the left, and in such cases it does not
`keep up sufficient diastolic tension in the, left side.
`If the
`patient have a large vital capacity a deep breath may so
`lower the pressure in the pulmonic circuit that there may
`be two or three beats of the right ventricle before there is
`any response of the left.
`If I were suffering from this
`disease I would rather be treated according to the prin-
`ciples of Stokes than by any one of the. modern school, and
`I might even take very kindly to his alcoholic prescription.
`I am inclined to think that a moderate allowance of beer,
`stout, or claret might do good in these cases by increasing
`the diastolic tension in the ventricles. The irritability and
`metabolic activity of the cardiac muscle can be improved
`by thyroid and iodine, and the sodium salts. There is
`usually an excess of lime, probably in a stable state, and
`for this condition I recommend large doses of sodium
`citrate with small doses of sodium iodide.
`This sets free
`the calcium ions, hastens the elimination of the excess of
`Strychnine
`lime, and lessens the viscosity of the blood.
`is useful, and to a less extent atropine, but I think nitro-
`glycerine and the nitrites are injurious.
`Although cases of chronic heart disease afford a fruitful
`field to the. Bad-Aerzt, I have not touched on the question
`of bath treatment, as I felt it would carry me too far
`afield, and the subject could well afford to wait till I was
`dealing with the periphery.
`The fruits are as a rule
`more freely gathered by the bath physicians than by their
`patients, so there is no particular hurry for me to say any-
`thing which might in any way upset their apple-cart,
`especially as I think the judicious use of baths often does
`good and very seldom harm. I hope, gentlemen, that any-
`thing which I have said will not cause you to lose heart,
`but stimulate you to renewed exertions.
`REFERENCES.
`1 Guy's Hospital Reports, vol. Iv.
`2 BRITISH MEnICAL JOURNAL.
`4 A Plea for the More General
`8 Lancet, vol. i, 1897.
`May 1st, 1909.
`Practice of Skipping.
`
`ON
`
`BLOOD PRESSURE IN MAN:
`ITS ESTIMATION AND INDICATIONS FOR
`TREATMENT.
`DELIVERED BEFORE THE WESTMINSTER DIVISION
`OF THE BRITISH MEDICAL ASSOCIATION.
`By SIR LAUDER BRUNTON, BART.,
`M.D., F.R.C.P., F.R.S., ETC.,
`CONSULTING PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL.
`MR. PRESIDENT AND GENTLEMEN,-The measurement of
`blood pressure in man is a subject in which I have taken
`a great interest for more than forty years, partly on its
`own account and partly because I have been fortunate
`enough to reckon amongst my personal friends many of
`the pioneers of this kind of research: Ludwig, Marey,
`von Basch, Burdon-Sanderson, Gamgee, Kronecker, Mosso,
`and Oliver. The circulation of the blood is kept up by
`the pumping action of the heart, but during the intervals
`between each stroke of the ventricle, intervals which
`amount to about thirteen hours out of the twenty-
`is maintained by the arterial
`four,
`the
`circulation
`tension, which depends on the difference between -the
`amount of the blood pumped into the aorta and that leaving
`the arterial-system throuah the capillaries in a given
`Its height will necessarily vary with the increased
`time.
`or diminished action of the heart and with the increased
`or dimninished resistance
`presented by the arterioles
`or capillaries to the outflow of blood into the veins.
`The ordinary method of ascertaining blood prebsure is
`to put three fingers upon the radial pulse.
`The finger
`nearest the hand prevents the recurrent pulse through the
`palmar arch, the middle finger feels the pulse, and the
`finger nearest the heart compresses the artery until the
`middle finger can no longer feel the pulse. The tension
`is estimated by the greater or less amount of pressure
`
`Human Power of N Company
`EX1032
`Page 1 of 4
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`

`JULY IO,
`
`BLOOD PRESSURE IN MAN.
`1 909'.1 ]-'.'~-~
`
`rTHE ]BRITISH
`L MEDICAL JOURNAL
`
`65
`
`required to extiniguish the pulse. Much information can
`be gained in this way, but the chances of error are con-
`siderable, even to an experienced observer, and no
`definite information as to the exact tension can be con-
`veyed from one person to another; in other words, no
`record of the tension can be kept. The difference between
`estimating the tension by merely feeling with the finger
`and by an exact instrument is about the same as that
`between estimating the temperature by feeling the skin
`and using a thermometer.
`The simplest instrument for measuring blood pressure
`was a modified spring balance with a little knob, by
`which the artery could be compressed, and the tension was
`then read off on a scale.
`This, however, proved unsatis-
`factory, and a great improvement upon it was the replace-
`ment of the-solid knob by an, elastic pad filled either with
`air or fluid. Although very useful conclusions regarding
`blood pressure in man could be drawn from observations
`with
`Marey's
`sphygmograph, and such observations
`enabled me in 1867 to use nitrite of amyl with success in
`lowering the tension, yet the first actual measurement of
`blood pressure in practice was made by von Basch. At a
`meeting of the Physiological Society in Berlin he showed
`that when an elastic pad was connected with a mercurial
`manometer and placed upon one femoral artery in a dog it
`stopped the circulation in it when the pressure was equal
`that
`to
`indicated by another mercurial manometer
`connected with the interior of the other femoral.
`The apparatus which he used clinically consisted of a
`mercurial manometer, the bulb of which was surrounded
`by water and rested like a pad upon the artery.
`This
`could be pressed down by means of a screw until the
`circulation in the distal part of the artery was obliterated,
`as was shown by the movements of a small sphygmograph
`placed upon it. The difficulty of using a mercurial mano-
`meter induced him to replace it by an aneroid. To this an
`india-rubber ball filled with air was attached, and it was
`used by pressing the india-rubber ball upon the radial
`artery until the pulse was obliterated. The pressure was
`then read off on the dial of the aneroid.
`This instrument
`is often described as Potain's, but the only difference
`between the two is that while the latest form of von
`Basch's bulb consisted of a metallic ring, the openings of
`which were covered by india-rubber of different thick-
`nesses, the metal ring was replaced in Potain's by thicker
`rabber, so that the whole bulb was made of rubber of
`different thicknesses.-`
`This still forms one of the most
`convenient instruments for measuring blood pressure, but
`in order to get satisfactory results certain precautions
`require to be adopted. The first of these is to have the
`bulb over the lower end of the radius, so that the artery
`can be compressed between the bulb and the bone.
`If the
`bulb is placed higher up, the resistance affordel by the
`underlying tissues is insufficient, and too high a reading is
`obtained. The second precaution is to apply the pressure
`on the bulb perpendicularly to the face of the radius.
`If
`the pressure is applied obliquely, too high a reading is
`again obtained. The third is to prevent recurrent pulsa-
`tion through the palmar arch.
`If the vessels are much
`dilated the blood from the ulnar artery flows so freely
`through the palmar arch that pulsation may be readily
`felt in the distal end of the radial, although the part lying
`over the radius has been completely obliterated by
`In order to prevent this error, the palpating
`pressure.
`finger should be placed over the distal end of the artery
`with its tip towards the bulb.
`The recurrent pulsation
`from the ulnar artery is prevented by the pressure of the
`pulp of the finger, while the direct pulsation from the
`radial artery is perceived by the tip.
`In Oliver's instru-
`ment the artery is also compressed by a bulb containing
`fluid, but the pressure is transmitted by a rod to a spring,
`which indicates the pressure on a dial instead of being
`transmitted by a tube containing air to an aneroid
`In Hill and Barnard's small instrument the
`barometer.
`pressure is also made by an india rubber bag containing
`air, but this bag is larger, and the pressure is indicated by
`a column of flulid working against the compressed air.
`Each of these has its own advantages, but the one, that
`I personally prefer is Potain's modification of von Basch's
`instrument.
`Besides the risk of mistake from imperfect application,
`however, thisinstrument possesss another disadvantage
`* In th
`* ntelatest form supplied by Messrs. Down Bros. the buib is of
`rubber having the same thickness throughout
`
`namely, that by use it may cease to give correct measure-
`ments.
`It is, therefore,
`almost necessary to have at
`home a mercurial manometer with which the aneroid
`may be compared from time to time.
`This, however, is
`very easily done by simply connecting both of thema the
`same time with a bulb which can be squeezed so. as to
`raise the pressure equally in both. The deviatiQn of the
`aneroid from the true pressure can thus be readily ascer-
`taixed and noted down, and the correction made, a
`reqiired.
`using a
`This is no more trouble
`than
`thermometer with a Kew correction.
`A second class of instruments for taking blood pressure
`consists of those in which a finger or arm is compressed
`by a distensible india-rubber bag outside of which lies an
`unyielding ring or band.
`Mosso's sphygmomanometer is
`an example.f
`Gaertner's tonometer is also one of this
`class, and it has the advantage of being easily applied to
`the finger. Rings of various sizes are supplied, and a
`finger is passed into one which fits it fairly. The blood
`is then pressed back from the end of the fnger by
`winding a strip of elastic round it, or by pushing over it a
`small, strong india-rubber ring. By means of a bulb which
`communicates both with the ring and with a manometer,
`air is blown in until the pressure is sufficiently high to
`stop the circulation in the finger. The elastic band, or the
`india-rubber ring by which the blood was driven out, is
`then removed, the pressure is then gradually relaxed
`until the finger flushes, and the height at which the
`mercury stands in the manometer is then noted.
`This
`gives the tension at which the blood within the vessel can
`The objectionss
`overcome external pressure.-
`to this
`instrument are the trouble it takes to empty the finger of
`blood and the difficulty there sometimes is of being quite
`sure of the moment when the bJood returns to it.
`In another subdivision of band apparatus the pressure is
`applied to the forearm or arm by an india-rubber bag
`encircled by a broad unyielding band. The air is blown
`into this until the pulse at the wrist can no longer be
`distinguished, and the pressure is then read off either from
`a mercurial or aneroid manometer, which is
`also con-
`nected with the bulb by which air is pumped into the
`armlet. Two of the most convenient forms of this
`apparatus are Martin's and Lockhart Mummery's.
`In
`Martin's the manometer is formed by a U tube containing
`mercury; in Lockhart Mummery's by a somewhat wide
`cistern from which a graduated tube rises.
`In Martin's
`the mercury descends in one leg of the tube as it rises in
`the other, and the actual height of the mercurial column
`depends on its rise above the zero point in the ascending
`column plu8 its fall below the zero point in the descending
`If both tubes are of equal calibre the height of the
`one.
`column will be exactly given by doubling the rise above
`the zero point; but if the two tubes are of unequal size,
`doubling the rise above zero may give a very inaccurate
`reading indeed, and each manometer ought to have a
`scale made expressly for itself. We can see the effect of
`inequality between the size of the two limbs in Lockhart
`Mummery's, where the cistern which constitutes the
`descending limb is so wide that the fall in it is almost
`negligible, and if we were to double the rise above zero in
`the ascending limb as we did in Martin's we would get
`very nearly twice the true measure. The disadvantage of
`the band apparatus is that, although it may be used above
`the dress, yet it is better to have the arm exposed, and
`It also causes discomfort in the
`this is troublesome.
`hand and arm, and sometimes even pain, which makes
`nervous and sensitive ladies dislike it. The advantago is
`that it is less liable to give a wrong reading through
`imperfect application, and its indications are therefore
`generally much more trustworthy than those obtained by
`simple pressure bulbs.
`Instead of a mercurial manometer
`the pressure may be estimated by a column of coloured
`liquid working against the compressed air, as in Oliver's
`apparatus, or by an aneroid. The latter, I find, is the
`most convenient form.
`The band apparatus is often known by the name of the
`Ri-.a-Rocci, as he first introduced the method, although it
`has been considerably modified by others-Hill and
`Barnard, Martin, Mummery, and many others.
`Its mndi-
`cations are upon the whole, as I have said, more trust-
`-
`_________________
`t It was by means of MOsso's instrument that Tunnicliffe and I
`showed that the blood pressure in man is- raised during exertion, but
`falls after exertion is over (BRITISHX MEDICAL. JOURNAL., October 16th,
`1897).
`
`Page 2 of 4
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`

`66
`
`THE BRITISH
`MEDICAL JOURNAL]
`
`BLOOD PRESSURE IN MAN.
`
`[JULY IO, I909.
`
`-A-
`
`worthy than those of von Basch's, but the latter apparatus
`is so easy to use that if we employ half a minute to count
`the pulse we can ascertain the tension easily in half
`a minute more without any trouble to the patient. We
`can therefore use it in every case and reserve the band
`apparatus for those cases in which special accuracy is
`required. The indications given by the band and by the
`bulb are, as a rule, fairly alike, but it has seemed to me
`that in very stout patients the band apparatus sometimes
`gives a higher reading than the bulb.
`Stiffness of the
`arteries from atheroma is said to be a serious drawback to
`the accuracy of the indication either to bands or by bulbs.
`I think that if either the band or the bulb is placed over
`a bit of stiff artery an error very probably does result, but
`this can be got over to a considerable extent by using the
`bulb on both wrists and the band on both arms in all
`doubtful cases and taking the lowest reading if there is
`It is not likely that all the arteries will
`any difference.
`be so stiffened as to prevent a fairly approximative reading
`being obtained. A short time ago, on feeling the pulse of
`a man aged 76, I was struck with the rigidity of the left
`radial. The tension in it with von Basch's apparatus was
`170, and the right radial was only 150, but in both arms
`with the band apparatus I got a reading of 155.
`According to my own observations the average tension is
`from 100 to 120 in young men, in middle age 125 to 135, and
`above 60 it may rise to about 145 or 150, but even in men
`between 60 and 70 the tension may remain at 125 or 130.
`In women I think the tension is usually 10 to 20 mm. lower.
`The cases in which I find a low tension below 100 in men
`and 80 or 90' in women, are generally (1) weakness after
`some illness, and more especially after influenza; (2) in
`cases of commencing phthisis; and (3) in heavy smokers.
`High tension is apt to come on with advancing years
`and thickened arteries, more especially in gouty people,
`and where the kidneys are contracted the tension may
`rise very high. The common indications of this condition
`usually are (1) rising in the night to pass water, (2) the urine
`being of low specific gravity and often containing a very
`minute trace of albumen, so small that it is apt to escape
`notice unless the urine be acidulated with acetic acid and
`only the top of the test tube boiled so that the lower part
`remains for comparison. On then looking at the top
`against a dark background a faint haze may often be
`observed.
`This usually becomes still more distinct on the
`subsequent addition of picric acid.
`The feelings of a patient which accompany high or low
`tension vary considerably in different individuals. Some
`appear to work easily and well with a tension of 100, while
`others are depressed, languid, and easily fatigued. On the
`other hand, a tension of 160 to 170 may be unaccompanied
`by discomfort of any kind and some patients appear per-
`fectly well, while in others this tension may be accom-
`panied by palpitation, precordial pain, or dyspnoea on
`exertion.
`Tension of 180 or 190 is, I think, of very serious
`import, but I have known one patient continue for several
`years with a tension which was rarely below 180, and
`sometimes rose to 200, or even higher.
`She had occa-
`sionally
`cerebral haemorrhages, but
`small
`died
`in
`the end apparently of
`cardiac failure
`after an acci-
`dental fall.
`In all the cases I have seen, excepting
`one, tension approaching 300 has been quickly followed
`by a fatal
`As a general
`issue.
`rule I look upon
`any tension over 150 as indicating the advisability of
`limiting proteids in the patient's dietary.
`In regard to the
`indications for treatment, I consider that when the tension
`is down to 80 or 90 absolute rest in bed is usually required
`with nutritious diet, beef-tea, and cardiac tonics and stimu-
`lants, such as strophanthus, caffeine, nux vomica or strych-
`nine; gentle massage and graduated exercises in bed may
`also be employed. As the cardiac muscle is feeble, iron in
`some form should be given if it can be tolerated.
`Occa-
`sionally complete rest may be absolutely necessary with a
`tension of 100 to 110 mm., because even with this tension
`one occasionally meets with symptoms of syncope in the
`upright position, and, on the other hand, the tension may
`be as low as 90 in cases of commencing phthisis without
`any indication of anything being wrong with the circula.
`tion. Low tension is therefore not to be regarded as an
`absolute indication for treatment any more than a very
`quick or a very slow pulse, but it must be taken along with
`other factors in determining the patient's condition and
`the necessary treatment. Low tension after influenza
`
`requires, I think, great care, because influenza and diph-
`theria seem to have a power of weakening the cardiac
`Cardiac
`muscle almost more than any other disease.
`weakness after enteric fever is very common, but there is
`less risk of damage to the heart from it, because the con-
`valescence is long and the heart has time to recover.
`In
`influenza the patient often resumes work after the acute
`symptoms are over, and I frequently have patients com-
`plaining of symptoms of cardiac weakness for some years
`after influenza, in one case as much as eight years.
`It is,
`I think, more especially in slight cases of influenza that
`the risk of cardiac overstrain occurs, and great care is
`therefore necessary not to overlook such cases. In them
`tonics, open air, and exercise without strain are what are
`generally indicated.
`But it is in cases of high tension that the sphygmo-
`Like the storm signal
`manometer is especially useful.
`at a seaside port, it gives timely warning of dangers to
`In many men above middle age high tension is
`come.
`associated with extraordinarily great and untiring energy,
`and it is curious to note how often cases are recorded of
`sudden death where the patient has remarked a few hours
`before that he never felt so well in his life.
`In many
`cases of men above 55 or 60 we find a systolic murmur
`over the aorta indicating atheroma, with an accentuated
`second sound indicating high tension.
`In some the
`mitral valve begins to yield, and a systolic murmur
`becomes audible at the apex. When this is the case the
`tension does not rise so high, and I think that a leaking
`mitral in such cases, like a leaking tricuspid, is really a
`safety valve for the high tension, which tends to prevent
`either cardiac failure or cerebral haemorrhage and adds
`considerably to the life of the patient.
`In such cases
`where the tension is over 150 the proteid diet should be
`much limited, and the use of tea, coffee, and alcohol
`restricted, although it may not be necessary to interdict
`The great things to avoid are hurry
`them completely.
`Both of these are specially difficult to avoid,
`and worry.
`high tension are frequently-,
`because patients with
`perhaps I may say generally-very energetic, and if
`anything is to be done they wish it carried through with
`the least possible delay, and are apt to do it themselves
`They often ask
`rather than wait for any one else.
`whether they may take exercise, and it is well to explain
`to them that it is not the length of time during which
`they take exercise that is dangerous, but the amount of
`They may often walk ten
`strain at any one moment.
`miles with advantage, but they must not run twenty
`They may play golf all day if
`yards to catch a train.
`they like; but it is often advisable for them, instead of
`taking a long drive, in which every muscle of their body
`is put on the strain, to take two shorter drives, and
`make up for the loss in driving by fewer strokes at
`Above all things they ought to avoid getting
`putting.
`Emotion, and especially angry emotions, raises
`angry.
`the tension very greatly, and poor John Hunter's death
`was a sad example of the fatal consequences -of anger.
`Ten grains of potassium nitrate, with a like amount of
`bicarbonate and half a gram to two grains of sodium
`nitrite, as a powder, to be taken every morning in hot
`water or an aperient water, such as Apenta, tends to keep
`pressure down, and may be continued daily for a good
`If this is insufficient, a quarter of a grain or
`many years.
`half a grain of nitro-erythrol in the form of a tablet, in
`addition to this morning powder, may serve the purpose,
`and is more convenient for most people than a repetition
`of the morning dose at other times in the day.
`Nitro-
`glycerine tablets should be carried about, and if any pain
`in the chest comes on should be taken immediately, as
`they not only relieve pain but lessen the dangerous condi-
`tion of which the pain is only a symptom.
`When the
`heart begins to fail in face of rising tension, it is frequently
`necessary to give strophanthus or digitalis with strychnine
`In some cases, though these are excep-
`to steady it.
`digitalis does better
`tional, strophanthus or
`without
`strychnine, as the latter drug seems to cause palpitation
`and discomfort.
`In all cases it must be borne constantly in mind that
`the nutrition of the cardiac muscle depends upon the
`quality of the blood going to it, and if the blood be laden
`with waste products its nutrition will be impaired. The
`closest watch must therefore be kept upon the intestinal
`canal, and the liver and bowels carefully attended to.
`
`Page 3 of 4
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`

`.105LY
`IO, 1909.]
`
`CHRONIC GASTRIC AND DUODENAL ULCER.
`
`BRS-A
`
`67
`
`A, dose of blue pill or calomel twice a week, or even on
`alternate nights, followed by a saline in the morning, is
`one of the best methods of keeping the tension down. In
`many cases where the vessels are considerably thickened
`iodide of potassiuip in 5 or 10 grain doses three times a
`day, if the patient stands it, is very useful. Where the
`iodide of potassium and sodium are not well borne a good
`result may be obtained from organic combinations such as
`High-frequency currents appear to
`iodipine and others.
`have a great power of lowering blood pressure; I have
`many cases in which they have been of much service.
`I have heard of similar good effects of static electricity,
`but I have had no personal experience of its use.
`In this paper I have said very little about the diastolic
`pressure, which is now generally reckoned to be that at
`which the oscillations of the artery are greatest. My
`reason for this is that I find it very much less easy to
`estimate the diastolic pressure accurately than the systolic
`with the ordinary instruments for clinical use.
`It is fairly
`easy to do this accurately with Gibson's sphygmomano-
`meter, but this is not well adapted for bedside use. For
`clinical use I think Oliver's is the best for this purpose,
`and I have had one made by Boulitte, which may perhaps
`be ultimately useful. For ordinary purposes I think
`Martin's or Lockhart Mummery's and von Basch's sphygmo-
`manometers and Dudgeon's sphygmograph are the most
`convenient instruments.'
`
`THE DIAGNOSIS AND OPERATIVE TREAT-
`MENT OF CHRONIC GASTRIC AND
`DUODENAL ULCER:
`AN EXPERIENCE OF THREE AND A HALF
`YEARS.
`BY
`DAVID DRUMMOND, and RUTHERFORD MORISON,
`M.D.,
`F.R.C.S.ENG.,
`SENIOR PHYSICIAN,
`SENIOR SURGEON,
`ROYAL VICTORIA INFIRMARY, NEWCASTLE-UPON-TYNE.
`THE co-operation of physician and surgeon is never more
`desirable than in the consideration of cases of gastro-
`duodenal disturbance.
`The pitfalls in diagnosis are so
`many, and the temptation so natural for the physician
`on the one hand to regard the majority of cases as
`medical, and for his surgical colleague on the other to
`view them as cases requiring operation, that when either
`works alone there is considerable risk of his being led to
`one-sided conclusions.
`We feel, therefore, that a combined statement of the
`work we have done and the results we have obtained
`during the whole time we have been associated as col-
`leagues in the infirmary requires no excuse.
`This
`co-operation of ours covers a period of three and a half
`years, from January, 1905, to June, 1908, during which
`123 cases in which a diagnosis of chronic gastric and
`duodenal ulcer was made were treated
`by gastro-
`enterostomy.
`Of these cases, 72 were gastric, 28 were duodenal, and
`23 were not classified. The usual history in all was one
`There had been] pain
`of long-continued "indigestion."
`after taking food, and generally occasional vomiting, which
`relieved the pain.
`Often the first warning to the patient
`of serious trouble impending was the appearance of blood
`in the vomited matter. With or without a variety of
`treatments there had been periods of health so good as to
`give hopes of a care, hopes sooner or later, however, to be
`disappointed by a relapse. The truth is that the healing
`of a chronic gastric or duodenal ulcer is often difficult,
`and occurs much less frequently than has been supposed.
`It is certain, too, that after the healing of one ulcer others
`are likely to form. We have also learnt by observation
`that an active ulcer may,.for some reason unknown to us,
`lose its sensibility and an apparent " cure " be thus brought
`During the painless time, small dietetic restrictions
`about.
`and general care of the health suffice to keep the patient
`comfortable; but after a time, these restrictions have to
`be more rigidly practised, the intervals of ease tend to
`become shorter, and eventually a condition of invalidism
`is established.
`* These instruments can be obtained from Mr. Hawksley, 357, Oxford
`Street.
`
`It is also an increasingly common belief, especially
`amongst surgeons, that cancer of the stomach is frequently
`if not usually sequential to a chronic gastric ulcer, but our
`experience, clinical and pathological, does.not confirm this
`Setting it aside, the arguments in favour of opera-
`view.
`tion in cases of chronic gastric and duodenal ulcer' are
`strong enough. That these ulcers seldom heal, that the
`dangers of perforation or haemorrhage are very real, and
`that the interference with many of the pleasures and much
`of the usefulness of life is undoubted, are facts which
`suffice to justify the risk when the good results of operation
`are borne in mind.
`
`DIAGNOSIS.
`If asked, "In what class of patients is gastric ulcer most
`prevalent?" the majority of physicians and practitioners
`answer without hesitation in favour of the claim of the
`young stout anaemic servant girl. The answer is not
`A fair number of perforating ulcers occur
`correct.
`amongst such young women, but they are of the acute
`(For
`variety which probably own a distinct pathology.
`our views as to this see Lancet, 1906, vol. i, p. 961.)
`Chronic gastric and duodenal ulcers occur at a later
`age. Like similar chronic ulcers elsewhere, they probably
`depend on septic inflammation. They select by choice the
`stomach or duodenal wall of the thin neurotic.
`Our