THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES
 
 &J4&E* 
 

 
 THERAPEUTICS OF THE CIRCULATION 
 
 BRUNTON
 
 THERAPEUTICS OF 
 THE CIRCULATION 
 
 EIGHT LECTURES DELIVERED IN THE SPRING 
 OF 1905 IN THE PHYSIOLOGICAL LABORA- 
 TORY OF THE UNIVERSITY OF LONDON Jk 
 
 BY 
 
 LAUDER BRUNTON 
 
 KT., M.D., D.Sc., LL.D. (EoiN.), LL.D. (ABERD.), F.R.C.P., F.R.S. 
 
 CONSULTING PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL 
 
 PUBLISHED UNDER THE AUSPICES OF 
 THE UNIVERSITY OF LONDON 
 
 TiUitb 240 Illustrations 
 
 PHILADELPHIA 
 P. BLAKISTON'S SON & CO 
 
 IOI2 WALNUT STREET
 
 PRESS OF 
 
 THE NEW ERA PRINTING COMPANY 
 LANCASTER. PA
 
 TO 
 HUGO KRONECKER 
 
 M.D., D.Sc. (CANT.), LL.D. (ABERD. AND GLASG.) 
 ETC., ETC. 
 
 PROFESSOR OF PHYSIOLOGY IN BERNE AND DIRECTOR OF THE 
 MAREY INSTITUTE IN PARIS 
 
 THE AUTHOR DEDICATES THIS BOOK 
 
 IN ACKNOWLEDGMENT OF THE GREAT SERVICES HE HAS RENDERED TO PHYSIOL- 
 OGY, AND ESPECIALLY THE PHYSIOLOGY OF THE CIRCULATION/ IN MEMORY 
 OF MANY PLEASANT HOURS SPENT TOGETHER WHEN WORKING IN 
 LEIPZIG UNDER THE DIRECTION OF THEIR BELOVED MASTER 
 CARL LUDWIG, IN 1869-70, AND IN TOKEN OF A FRIENDSHIP 
 THAT HAS LASTED EVER SINCE.
 
 PREFACE 
 
 THIS book consists of eight lectures which were delivered in 
 January, February, and March, 1905, in the Physiological Lab- 
 oratory of the University of London, in accordance with the 
 general purpose expressed by the University in the establish- 
 ment of the Physiological Laboratory, viz., " to present the 
 results of recent investigations by the investigators themselves, 
 orally and with experimental demonstration in the lecture- 
 room, and outside the lecture-room by monographs approved 
 by the University." 
 
 By the kindness of Professor Waller and of his assistant, 
 Mr. Syme, the lectures were illustrated by experiments, which 
 increased their value to the students. At the same time, the 
 necessity of adapting the lectures to the experiments rather 
 interfered with their orderly sequence, and in consequence of 
 this they are not so sharply divided into the various sections 
 on Physiology, Pathology, Pharmacology, and Treatment, as 
 they were at first intended to be. Semeiology is hardly touched 
 upon, as it is so fully discussed in lectures on Medicine, and 
 the other subjects were more than sufficient to fill a course of 
 eight lectures. 
 
 Opinions may differ as to the proper selection of subjects 
 for the lectures, and my selection may be disapproved of by 
 some, who may consider that I have spent too much time over 
 such subjects as " Self-massage of the Heart and Vessels," 
 " The Conduction of Stimuli in the Heart," etc. My reason 
 for doing so, is that I consider the subjects, on which I have 
 dealt rather fully, to be of practical importance, and they are 
 dealt with shortly, if at all, in ordinary text-books. I had also 
 made an experimental study of some of them myself, and 
 in accordance with the general purposes of the University in
 
 Vlll THERAPEUTICS OF THE CIRCULATION 
 
 establishing such lectures, I presented the results of my own 
 investigations more fully than in a text-book. The lectures 
 were not written out, but were delivered from short notes, so as 
 to suit the experiments. They were taken down in shorthand 
 by Mr. M. A. Donaldson, and I have to thank him for the 
 remarkable accuracy of his transcript. Although he supplied 
 me with a type-written copy within a few days of the delivery 
 of each lecture, yet the pressure of other engagements, and the 
 difficulty of finding sufficient continuous time to obtain and 
 arrange the illustrations and prepare the manuscript for press, 
 has caused an interval of more than three years to elapse 
 between the delivery of the lectures and their appearance in 
 print. During this interval some new instruments for meas- 
 uring the blood pressure in man have been brought out, and 
 several of them have been described in an appendix. 
 
 Owing to my ignorance of the rule that lectures delivered 
 under the auspices of the University and printed with its 
 sanction should be published by Mr. Murray, these lectures 
 were at first advertised to be published by Messrs. Macmillan, 
 who have published my other works, and the change was only 
 made in accordance with the rule. 
 
 I have to thank both Mr. Murray and Messrs. Macmillan 
 for their kindness and courtesy in regard to publication, and 
 my thanks are especially due to Professor Waller for his in- 
 terest and help, to Mr. Syme for assistance in experiments, to 
 Dr. Oliver, M. Boulitte, Messrs. Down, Mr. Hawksley, and 
 especially to M. Charles Verdin for many illustrations. 
 
 Professor Kronecker has kindly supplied some most valuable 
 notes of some of his own work and that of his scholars, which 
 is printed in a special appendix.
 
 CONTENTS 
 
 LECTURE I 
 
 Introduction Harvey's Discovery PHYSIOLOGY OF THE CIRCULATION : 
 The Heart Sleep of the Heart The Arteries Motor and 
 Peristaltic Action of the Arteries Capillaries and Veins Action 
 of Fasciae Accessory Muscles of Circulation Flow of Lymph 
 Arterial Tension or Blood Pressure Regulation of Blood 
 Pressure Heart and Blood Pressure Arteries and Blood Pres- 
 sure Influence of the Muscular Area Influence of the Splanch- 
 nic Area Distension of Liver Depressor Nerves Independent 
 Pulsation of Veins Movements of the Heart Views of Gaskell 
 Comparison between the Heart and a Medusa Experiments 
 of Romanes Transmission of Stimuli in the Heart Nervous 
 and Muscular Conduction in the Heart Experiments of Brunton 
 and Cash Conduction of Impulses both by Muscle and Nerve 
 Valves of the Heart I 
 
 LECTURE II 
 
 Sounds of the Heart Double Nature of the Heart Right Ventricle 
 Aorta Arteries and Capillaries Vaso-motor Nerves Dilating 
 Nerves Elongation of the Muscle ( ?) Rhythmical Contraction 
 of Vessels Stimulation of Vessels from without Stimulation 
 of Vessels from within Effect of Heat and Cold on the Cir- 
 culation Effect of Heat and Cold on the Pulmonary Capillaries 
 Schema of the Circulation Kymographs Blood Pressure in 
 Animals Blood Pressure in Man Measurement of the Blood 
 Pressure in Man Instruments for Measuring the Blood Pres- 
 sure in Man: by Pressure on an Artery; by Pressure on a Finger 
 or Limb ; Sphygmomanometers of Herisson, Waller, Von Basch, 
 Potain, and Oliver Instruments of Marey, Mosso, Gaertner, and 
 others 41 
 
 LECTURE III 
 
 Measurement of the Blood Pressure in Man (continued). Instru- 
 ments of Riva-Rocci, Hill and Barnard, Martin, and others 
 Author's arrangement Standardization of Instruments Meas- 
 urement of the Size of an Artery Olivers Arteriometer Meas-
 
 CONTENTS 
 
 urement of Pressure in the Veins Measurement of Pressure 
 in the Capillaries Measurement of the Volume of Organs 
 Plethysmographs Cardiographs Sphygmographs Forms of 
 Sphygmograph : Marey's, Ludwig and Von Prey's, Dudgeon's, 
 Jacquet's, Laulanie's Size of Vessels Cardiograph and Sphyg- 
 mograph Sphygmograms Retardation of Pulse-Wave Nutri- 
 tion of the Heart Self-massage of the Heart Briicke's View 
 Nutritive Action of Cardiac Tonics Self-massage of the Arteries. 
 PATHOLOGY OF THE CIRCULATION : Effect of Altered Quality of 
 Blood Blocking of Coronary Arteries Effect of Feebleness of 
 the Heart on the Nutrition of Blood- Vessels Nervous Depression 
 Fatty Degeneration Pulse-rate Exophthalmic Goitre 77 
 
 LECTURE IV 
 
 Paroxysmal Tachycardia Bradycardia Intermittent Pulse Palpita- 
 tion Shock Anaesthetics Syncope Embolism and Throm- 
 bosis Claudication Angina Pectoris Raynaud's Disease Chil- 
 blains, Urticaria, Angio-neurotic (Edema Migraine Sensitive- 
 ness of Arteries Sensitiveness of the Heart. VALVULAR DISEASES 
 OF THE HEART : Aortic Obstruction Aortic Regurgitation Fail- 
 ing Compensation Mitral Incompetence (Functional) Cardiac 
 Strain 108 
 
 LECTURE V 
 
 Mitral Regurgitation (Organic) Mitral Obstruction Card'ac Dys- 
 pnoea Venous Engorgement Other Forms of Cardiac Diseases 
 Vicious Circle. METHOD OF TREATMENT IN CARDIAC DISEASE: 
 Uses of Treatment Rest Position Use of Massage Effect of 
 Flatulence on the Heart Use of Drugs in Cardiac Disease 
 Cardiac Nutrients Digitalis and its Congeners Resume of the 
 Action of Digitalis 127 
 
 LECTURE VI 
 
 Action of Digitalis in Mammals Uses of Digitalis Action of Digi- 
 talis on CEdema Toxic Action of Digitalis Action of Digitalis 
 on Arterioles Stages in tbe Action of Digitalis Difference be- 
 tween Digitalis and other Cardiac Tonics Action of Adrenaline 
 on the Heart and Vessels Action of Strychnine on the Heart 
 Action of Caffeine and other Purin Bodies Drawbacks to the 
 Action of Digitalis and other Cardiac Tonics Removal of these 
 Drawbacks by Combination Vaso-dilators : Amyl Nitrite, Iso- 
 butyl Nitrite, Hydroxylamine, Nitroglycerine, Nitro-erythrite, 
 Nitromannite, Sodium, and other Nitrites 149
 
 CONTENTS XI 
 
 LECTURE VII 
 
 Nicotine Tobacco Smoking Attractions of Smoking Results of 
 Excessive Smoking Aconite Local Modification of the Circu- 
 lation Inflammation General Bleeding Local Bleeding. TREAT- 
 MENT OF CARDIAC DISEASES : Treatment of Palpitation Diet and 
 Regimen Graves's Disease Tachycardia from Strain Parox- 
 ysmal Tachycardia 167 
 
 LECTURE VIII 
 
 Bradycardia Irregularity of Pulse Angina Pectoris Treatment of 
 an Attack of Angina Pectoris Diet and Regimen in Angina 
 Cardiac Asthma Sleeplessness Aortic Disease Mitral Regur- 
 gitation Nauheim Treatment Exercises Baths Oertel's Treat- 
 ment Treatment of Venous Stasis Graduated Exercises Elim- 
 ination Milk Diet Chloride-free Food Tapping Surgical 
 Treatment of Cardiac Diseases Senile Rise of Pressure Senile 
 Decay Prolongation of Life i85 
 
 APPENDIX A 211 
 
 APPENDIX B 216 
 
 APPENDIX C 223 
 
 APPENDIX D 225 
 
 INDEX 233 
 
 INDEX TO APPENDIX 267 
 
 CLASSIFIED LIST OF ILLUSTRATIONS ACCORDING TO SUBJECTS 271 
 
 LIST OF ILLUSTRATIONS IN NUMERICAL ORDER 277
 
 THERAPEUTICS OF THE 
 CIRCULATION 
 
 LECTURE I 
 
 Introduction Harvey's Discovery Physiology of the Circulation The 
 Heart Sleep of the Heart The Arteries Motor and Peristaltic Action 
 of the Arteries Capillaries and Veins Action of Fasciae Accessory 
 Muscles of Circulation Flow of Lymph Arterial Tension or Blood Pres- 
 sure Regulation of Blood Pressure Heart and Blood Pressure Arteries 
 and Blood Pressure Influence of the Muscular Area Influence of the 
 Splanchnic Area Distension of Liver Depressor Nerves Independent 
 Pulsation of Veins Movements of the Heart Views of Gaskell Com- 
 parison between the Heart and a Medusa Experiments of Romanes 
 Transmission of Stimuli in the Heart Nervous and Muscular Conduction 
 in the Heart Experiments of Brunton and Cash Conduction of Impulses 
 both by Muscle and Nerve Valves of the Heart. 
 
 THE subject of these lectures is " The Therapeutics of the 
 Circulation " : the means by which we can put right anything 
 that may have gone wrong with the circulation. If I were to 
 hand my watch to any one of you, and tell you that it was not 
 going properly, you would naturally hand it back to me and 
 tell me to take it to a watchmaker ; because you know nothing 
 of the way in which watches are built, of the disorders to 
 which they are liable, or the way in which to put them right. 
 In the same way, before you can put anything right which has 
 gone wrong with the circulation, you must know something 
 about: (i) its normal working, or physiology; (2) of the dis- 
 orders to which it is liable, or pathology ; ( 3 ) of the means by 
 which we can act upon it, or pharmacology; (4) of the indi- 
 cations by which we recognize the particular disorder, or 
 semeiology; and (5) the methods of applying our remedies to 
 the disorders which we have already recognized, or thera- 
 peutics.
 
 2 THERAPEUTICS OF THE CIRCULATION 
 
 It is evident that, before we can deal with therapeutics satis- 
 factorily, we must take up, to a certain extent, the other sub- 
 jects upon which it depends, and, although you have studied 
 them all to a certain extent already, I think it will be advisable 
 to go shortly over them, more especially as I shall have to take 
 them in definite relation to their practical use, instead of 
 merely considering them as scientific subjects unconnected, 
 possibly, with practical medicine. But the treatment of these 
 must necessarily be very brief, because the subject-matter to 
 be considered is very great. 
 
 Harvey's Discovery. There is, perhaps, no discovery, 
 either ancient or modern, which has had such a -far-reaching in- 
 fluence on the health of human beings as the discovery by Har- 
 vey of the circulation. The truth of this discovery was at first 
 denied, then its importance was belittled, then it was attributed 
 to other men; but now its full importance is recognized and 
 the claims of Harvey to the discovery acknowledged. When 
 we look at Harvey's work, it seems almost incredible that for 
 so many thousands of years men should have overlooked the 
 circulation. When we read Harvey's own account of his 
 discovery, it seems one of such amazing simplicity that one is 
 inclined to think that nobody could have helped making it. In 
 his own words, it occurred to him " whether the blood might 
 not go round, as it w r ere, in a circle." That it did go round, 
 Harvey showed by the blood issuing from the proximal end 
 of a cut artery, and from the swelling of the veins when 
 obstruction was put between the periphery and the centre. 
 
 One of the great reasons why the blood had been supposed 
 not to go round, but to flow backwards and forwards, probably 
 was that the ancients looked upon the arteries as conveying air 
 alone instead of blood, or else conveying a mixture of air and 
 blood. They seem to have come to this conclusion from the 
 fact that the arteries were generally found empty in animals 
 that had been killed for sacrifice, and the reason of this empti- 
 ness I shall discuss later on.
 
 SLEEP OF THE HEART 3 
 
 PHYSIOLOGY OF THE CIRCULATION 
 
 The Heart. The great motor power which keeps the cir- 
 culation moving in a circle is the heart, although its action is 
 supplemented by other mechanisms in the vessels and tissues. 
 We are sometimes accustomed to speak of this " unresting " 
 organ, but this is a total mistake. The heart rests in an adult 
 more than thirteen hours out of the twenty-four; the time of 
 rest being the diastole, and the time of work being the systole. 
 Sleep of the Heart. We may say, then, that the heart 
 practically sleeps more than the brain or the body ; but the great 
 distinction between the sleep of the heart and that of the brain, 
 is that the sleep is so short at a time. There are very few 
 healthy men who could not walk a thousand miles in six weeks, 
 walking a little over eight hours a day at an easy pace, and 
 resting for the remainder of the period ; but there are not many 
 men who could emulate the feat of Captain Barclay, of walk- 
 ing a thousand miles in a thousand hours, because the frequent 
 interruptions to their sleep would exhaust them completely; 
 and still fewer are there who could walk a thousand miles in a 
 thousand half-hours, as has been done by various men since 
 Captain Barclay's time. In such trials of endurance a man 
 usually walks two miles at a time, the first mile at the end of 
 one hour or half -hour, and the second at the beginning of the 
 next hour or half -hour. Supposing he walks at the rate of 
 four miles an hour, i. e. a mile in a quarter of an hour, he gets 
 an hour and a half for sleep between every walk when doing a 
 thousand miles in a thousand hours, but only gets one-third as 
 much sleep, viz. half an hour, between his walks when doing 
 this distance in a thousand half-hours. An attempt to do a 
 thousand miles in a thousand quarter-hours is obviously im- 
 possible; if a man walked at the rate of four miles an hour, 
 there would be no time for rest at all, the whole time being 
 required for walking. A little time might, no doubt, be gained 
 by increasing the pace; but this would itself involve greater 
 exertion, and the time thus gained would be quite insufficient 
 for recuperation.
 
 4 THERAPEUTICS OF THE CIRCULATION 
 
 In the same way, when the heart is forced to beat more 
 quickly than normal, it is more and more quickly exhausted the 
 higher the pulse-rate rises, for nearly the whole time for the 
 extra work is taken from the diastolic pauses of sleep of the 
 heart, even though the systole may be slightly shortened. 
 Hence the importance of slowing the pulse-rate by cold, by 
 drugs, or by other measures, when it tends to become too rapid. 
 
 Perhaps it may be as well here that I should note that the 
 heart, at certain periods, is resistant to external stimuli. When 
 Captain Barclay was taking his sleep between his walks, he 
 would be more and more ready to respond to a chance call the 
 nearer the time came for him to begin again ; but while actually 
 engaged in his walk, he would be too much intent upon his 
 work to heed a call from anyone. In the same way, we find 
 that during the period that the heart is contracting it will not 
 respond to a stimulus which, if applied immediately after its 
 action is over, would cause it to contract again. This period, 
 which we have to consider later on, is called the refractory 
 period. 
 
 The Arteries. Now, if the heart is only acting for eleven 
 hours out of the twenty- four, and is entirely cut off from the 
 aorta by the closed aortic valves, what force is carrying on the 
 circulation during the whole of the other thirteen? This force 
 is the elastic recoil of the arteries, which have been stretched 
 by the blood forced into them during the ventricular systole, 
 but which, if healthy, again contract during the diastole. The 
 vessels thus act as storage of energy, just as a watch-spring 
 does when wound up every night, or as the water driven by a 
 force-pump into a high tank from which a house or town can 
 be supplied, or the elastic bag in a spray-producer. 
 
 The arteries have really three functions. They not only act 
 as (i) storers of force, but as (2) regulators, and as (3) 
 motors. Their power of regulating the supply of blood to 
 different parts of the body was known to Harvey, who said : 
 " It is manifest that the blood in its course does not every- 
 where pass with the same celerity, neither with the same force
 
 ACTION OF ARTERIES, CAPILLARIES AND VEINS 5 
 
 in all places, and at all times. ... In fear, and under a sense 
 of infamy and of shame, the face is pale; but the ears burn, as 
 if for the evil they heard or were to hear." As my old teacher, 
 Professor Ludwig, used to put it, " There is not nearly suffi- 
 cient blood in the body to fill all the vessels at once, and the 
 vaso-motor system, which regulates the size of the arteries, 
 is like the turncock in a large town who turns off the water 
 supply to one district at the same time that he turns it on to 
 another; just as in Harvey's " observation, the vessels became 
 contracted in the face at the same time as they became dilated 
 in the ear. 
 
 Motor and Peristaltic Action of Arteries. The motor 
 action of the arteries has received less attention; but it is, I 
 think, very important, and is, I believe, the cause of the empti- 
 ness of the arteries after death, which so long prevented Har- 
 vey's discovery from being made. When working under Pro- 
 fessor Lu.dwig in 1869, he directed my attention to the con- 
 tractile power of the small arteries apart from any nerve centre, 
 and while watching their movements I have sometimes seen a 
 regular peristaltic action take place, by which the blood was 
 driven forward in the arteriole, just as faecal matter would 
 be driven forward in the intestine. 1 
 
 Capillaries and Veins. From the arteries the blood passes 
 into the capillaries, and some of its liquid parts leak through 
 their walls to supply the needs of the tissues, while the remain- 
 der, along with the blood corpuscles, passes into the veins. It 
 is the heart which is the motor power for the blood in the 
 veins also ; but it could barely be sufficient to carry on the cir- 
 culation and bring the blood back to the heart again, were it 
 not for various helping agencies. One of these is the suction 
 exerted by the movements of the respiration, and another is 
 the suction exerted by the heart itself during the ventricular 
 contraction, which drives the blood out of the thorax, through 
 the aorta, and sucks it in through the veins. 
 
 1 Lauder Brunton, Sitz. her. d. k. sack. Gescllsch. d. Wiss., 1869, s. 285, 
 and Ludivig's Arbeiten, 1869, s. 101.
 
 One very important adjunct to the heart in keeping- up the 
 venous circulation, is intermittent pressure upon the veins 
 from without, aided by numerous valves in the veins them- 
 selves; so that while each pressure pushes the blood a little 
 onwards, its return is prevented. External pressure is pro- 
 duced by muscular action. Each contraction of a muscle 
 squeezes the blood and also the lymph out into the veins and 
 lymphatics, both of which have very numerous valves at short 
 distances apart. But every beat of the arteries, as a rule, 
 tends also to help on the venous blood, for the arteries and 
 veins usually have a common sheath of unyielding fibrous 
 tissue, and each time that the artery is distended during a 
 ventricular systole it tends to push a corresponding amount of 
 blood onwards through its accompanying vein. (Fig. i.) 
 
 1'lG. i. Diagram to show the effect of the arterial pulse in aiding the onward flow 
 of venous blood and lymph, by a process of what may be called self-massage. A is 
 an artery during diastole. V is a vein filled with blood. 5 is the fibrous sheath which 
 encloses the artery, the vein, and the lymph space around them. A' is the artery 
 distended with blood by the ventricular systole. As the sheath S' is unyielding, the 
 distension of the artery forces the blood out of the vein and the lymph out of the 
 lymph space, and as the backward flow of both is prevented by the valves of the 
 veins and lymphatics, the circulation is increased in both. 
 
 Action of Fasciae. In addition to these mechanisms, how- 
 ever, we have the pressure upon the veins by the fascine of 
 the limbs, and Braune has shown that when the veins are 
 stretched, their walls tend to come together and press the blood 
 onwards. The veins of the upper limbs are most stretched 
 when the fists are clenched, the hands bent somewhat down, 
 and the arms extended and pushed rather backwards the very 
 attitude, indeed, that is assumed by a man who has been sitting 
 for a length of time at a writing-table and feels himself 
 cramped in consequence. The veins become filled when the leg 
 is bent and turned slightly inwards, whilst the veins become 
 stretched and empty when the foot is turned outwards and the
 
 ACCESSORY MUSCLES OF CIRCULATION 7 
 
 leg extended and pushed somewhat backward. The first of 
 these positions is that assumed by one leg when we advance 
 it for the purpose of walking, and the second when we move 
 the body and other leg forward. 
 
 Accessory Muscles of Circulation. The late Professor 
 Sharpey used to insist a good deal upon the functions of the 
 rotators of the leg, and he pointed out that in books on anat- 
 
 FIG. 2. Diagram of transverse section of voluntary muscle to show the pumping 
 action exerted on the muscle-juice and waste products during action. The blood- 
 vessels cross diagonally. To the left (B) the muscle is contracted and presses the 
 two layers of the fascia together, so as to drive the muscle-juice out into the 
 lymphatics. To the right (A) the muscle is relaxed, and tends to draw the layers of 
 fascia apart and suck the juice out of the muscle into the lymph space, c, Artery. 
 d, Artery, e, Lymphatics. /, Vein, g, Vein. The double arrows in A are intended 
 to indicate the increased blood-flow through the muscle, and the single arrow within 
 the muscle to indicate the passage of fluid from the muscle into the lymph space 
 between it and the surrounding fascia. 
 
 omy the trunk is looked upon as a fixed point, and the rotation 
 is discussed in terms of this; so that we say that the function 
 of the tensor vaginae femoris is to rotate the leg inwards upon 
 the body, and that of the glutens maximus to rotate it out- 
 wards. In reality, he said it is the leg which is the fixed point
 
 8 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 in walking; and the function of these muscles is to rotate the 
 body on the leg, the tensor vaginae femoris rotating, not the 
 leg inwards, but the body outwards, so as to bring the centre 
 
 FIG. 3. Diagram of longitudinal sections of muscles, I. in relaxation and II. in 
 contraction. F is the fibrous fascia or sheath of the muscle. L S a lymph space 
 between the muscle and the outer layer of fascia. L is a lymphatic vessel with 
 numerous valves, by which the lymph containing waste products is removed. A is 
 an artery by which fresh blood is brought to the muscle; and V is A vein by which 
 blood is removed from it. Each time the muscle contracts, as in II., it lessens the 
 size of the lymph space and drives the lymph onward through the lymphatics. 
 Each time it relaxes it tends to create a vacuum within the fascia, and thus lymph 
 is sucked out of the muscle into the lymph space, while fresh arterial blood rushes 
 into the muscle. 
 
 FIG. 4. Injected lymph spaces from the fascia lata of the dog, after Ludwig and 
 Schweigger-Seidel, Lymphgefasse der Fascien und Sehnen. The injected spaces are 
 black in the figure, and the muscular bundles are seen in the cross-section embedded 
 in lymph. 
 
 of gravity over the foot. But in view of Braune's observations 
 these muscles acquire a new value. We speak very frequently 
 of accessory muscles of respiration, but I have not seen any-
 
 FLOW OF LYMPH 9 
 
 where the tensor vaginae femoris and the gluteus maximus 
 spoken of as accessory muscles of circulation, yet both they 
 and the muscles of the calf and thigh may well deserve such 
 an appellation. 
 
 Flow of Lymph. This description of the circulation, how- 
 ever, would be insufficient without a consideration of how the 
 lymph flows, for the circulation of lymph is quite as necessary 
 as that of the blood itself. Here also the muscles form one of 
 the most efficient sources of motor power. At each relaxation 
 of a muscle it tends to cause a vacuum within its surrounding 
 
 FIG. 5. Section of the central tendon of the diaphragm in the rabbit, a, Peri- 
 toneum; b, tendinous fibers in cross-section; c, circular fibers; d, the pleura; e, peri- 
 toneum stretched over a full lymph space; /, peritoneum lying in an empty lymph 
 space; g, blood-vessels. After Ludwig and Schweigger-Seidel. 
 
 FIG. 6. Section of the pleura. The lymph spaces appear black in the figure. After 
 Ludwig and Dybkowsky. 
 
 fascia, into which the lymph flows from the muscular struc- 
 ture. At each contraction the muscle presses this lymph out, 
 and these alternating muscular movements really act as a sub- 
 sidiary heart, and do away with the necessity of having in 
 mammals the lymph hearts which are seen in the frog. (Figs. 
 2, 3, and 4.) 
 
 In the pleura and the diaphragm the movements of respira- 
 tion have a similar pumping action on the pleural and peri- 
 toneal fluids. (Figs. 5 and 6.)
 
 IO THERAPEUTICS OF THE CIRCULATION 
 
 It may seem that I am spending- too much time upon points 
 in the circulation which you all know, but I shall have to return 
 to them again in discussing Treatment, and unless I had put 
 them before you now in the way I have done, you might not 
 
 be so readily able to perceive 
 the reason for the therapeutic 
 measures which I shall after- 
 wards have to mention. 
 
 Arterial Tension or Blood 
 Pressure. During the long 
 sleep of the heart thirteen 
 
 FIG. 7. Diagram of the circulation. hours OUt of CVCry twenty-four 
 a, the heart completely shut off by the ,1 i , , j 
 
 valves during diastole from b, the the circulation is maintained 
 
 arteries; c, the capillaries; d, the veins; by the COlltraCtile force of the 
 
 e, mercurial manometer; /, a float; g, . 1-1 
 
 a recording cylinder. artCriCS, which prCSSCS the blood 
 
 out through the only opening 
 
 which, in health, is available, namely through the capillaries. 
 This contractile force, is, of course, to a great extent, due to 
 elasticity, especially in the larger arteries, although in the 
 arterioles it is probably partly due to contractility. The force 
 with which the blood would be pressed out if a vessel were 
 opened or a cannula put into it, is known as the blood pressure, 
 and this is usually estimated by connecting an artery with a 
 mercurical manometer and seeing the height of mercury re- 
 quired to counterbalance the pressure in the vessels. This was 
 first estimated by a clergyman, the Reverend Stephen Hales, 1 
 w r ho, after cutting an artery in an animal, and after connect- 
 ing a glass tube with the artery, noted the height to which the 
 blood rose in the tube. Poiseuille 2 improved upon this plan 
 by connecting the artery with a mercurial manometer, and an 
 immense advance was made by Ludwig, 3 who registered the 
 movements of a manometer on a revolving cylinder. (Fig. 8.) 
 
 1 Hales, Statistical Essays, London, 1733, vol. ii., p. i. 
 
 2 Poiseuille, Magcndic's Journ. de la physiol, viii., p. 272, 1828; ix., 
 1829, p. 343. 
 
 3 Ludwig, Arch. f. Anat. u. Physiol., 1847, s. 242, Taf. x.-xiv.
 
 ARTERIAL TENSION 1 OR BLOOD PRESSURE 
 
 I I 
 
 Although he did this in 1847, 7 et m 1865, when I first began 
 to work at the action of drugs on the blood pressure, there 
 was, I believe, not a single recording manometer in this coun- 
 
 FIG. 8. Ludwig's kymograph, a b c is a simple mercurial manometer such as 
 was used by Poiseuille. c b and g are the float, and h the recording cylinder, and 
 t the clockwork added by Ludwig. 
 
 try. 1 and it was only at this time that one was first made by 
 Sir John Burdon-Sanderson, 2 and used by him in his research 
 
 1 Lauder Brunton, " On Digitalis," Collected Papers on Circulation and 
 Respiration. First Series, pp. 52 and 104. London : Macmillan & Co. 
 
 2 Burdon-Sanderson, Roy. Soc. Proc., xv., 1857, p. 391; Phil. Trans.. 
 clvii., 1867. p. 391.
 
 12 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 9. Lelaunie's manometer. It consists of (7") a bent tube containing mercury. 
 The open arm bears a float, the movements of which are transmitted by a pulley (P) 
 to the lever (L), which amplifies and records them. By means of a pinion (B) work- 
 ing 011 a rack (C), the apparatus can be moved up and down on a stand (5), which 
 is rendered vertical by three screws (V V V). The open end of the tube can be 
 connected with a caoutchouc bag, as in the figure. It was originally designed to- 
 record the rectal temperature in a dog during tetanization, but it could be used for 
 other purposes. Burdon-Sanderson's kymograph was similar to this, but the two 
 limbs of the U tube were of unequal width, and the lever was longer. 
 
 Carotid artery (full) 
 
 Aorta tense ^.^....^ 
 
 Veins tense and 
 moderately full 
 
 Bladder (full) 
 
 Carotid artery (empty). 
 
 Aorta lax. 
 
 ._ Veins lax and full. 
 
 Bladder (empty). 
 
 FIG. 10. Diagram to show the causation of syncope. In a the carotid artery is 
 full, the aorta full, the veins contracted, and the bladder is full. In b the carotid is. 
 empty, so that the brain is insufficiently supplied with blood, and syncope ensues. 
 The tension in the aorta is low, as indicated by its smaller size, the veins are full, 
 and the bladder is empty.
 
 MEASUREMENT OF BLOOD PRESSURE 
 
 upon the relationship of respiration to circulation. It was just 
 a little before this that Marey 1 invented his sphygmograph, 
 by which much interesting information has been gained re- 
 garding the circulation in man. (Fig. 120.) 
 
 Inhibitory apparatus 
 Motor ganglia 
 
 Heart muscle 
 
 ^l^BMMM^MH 
 
 FIG. ii. Diagram to show the nervous apparatus by which the action of the heart 
 and vessels is coordinated so as to maintain an equal blood pressure. A is the 
 accelerator apparatus. 
 
 accelerator apparatus 
 
 Regulation of Blood Pressure. The blood pressure, one 
 may roughly say, depends upon the difference between the 
 1 Marey, Mem. Soc. Biol., 1859, p. 281; Compt. rend., 1880, 1., p. 634.
 
 14 THERAPEUTICS OF THE CIRCULATION 
 
 amount pumped by the heart into one end of the arterial sys- 
 tem and the amount leaving by the capillaries in any given 
 time. It is obvious that unless some means existed by which 
 these two factors could be brought into proper relationship. 
 
 Cord t va,gti s irrita.fced- 
 
 VdguS 
 alone 
 
 FIG. 12. After Ludwig. Ludwig's Arbeiten, 187, p. 106. Shows the rapidity with 
 which the blood flows through the vessels of the muscles. When the heart is stopped 
 by irritating the vagus the arterial pressure falls continuously, as the blood flows out 
 of the arteries into the veins through the vessels of the intestines, muscle, and 
 brain. The higher the pressure the more quickly will the blood flow through them, 
 and, other things being equal, the quicker will the pressure fall. 
 
 The curves are taken from the arterial pressure in a middle-sized dog whose 
 spinal cord had been divided high up in the neck, a, b and c show the rapidity of 
 fall of blood pressure at various heights during simultaneous stimulation of the vaso- 
 motor nerves in the spinal cord and stoppage of the heart by stimulation of the 
 vague. In d the vagus alone was stimulated. 
 
 If the assumption were correct that all the arterioles in the body were con- 
 tracted by stimulation of the vaso-motor nerves in the cord, the blood pressure should 
 hardly fall at all during stoppage of the heart, when the vaso-motor center is stimu- 
 lated at the same time. But the curves a, b and c, and especially a, show that it 
 falls with such rapidity that it must be assumed that the blood flows through the 
 vessels of the muscles which are not under the same control of the vaso-motor 
 centers as those of the intestine. 
 
 much mischief might be done. If the heart were to continue 
 pumping in blood whilst the arterioles were tightly contracted, 
 the heart would either become strained or a vessel would burst.
 
 HEART AND ARTERIES AND BLOOD PRESSURE I 5 
 
 as it does in apoplexy. On the other hand, if the arterioles 
 were dilated and the heart did not beat more actively in order 
 to supply a larger amount of blood, the arteries would very 
 likely become empty and the pressure in them so low that the 
 circulation through the various organs would be insufficient 
 to maintain their functional activity, and the brain, being es- 
 pecially sensitive, syncope would result. (Fig. 10.) 
 
 Heart and Blood Pressure. Coordination is maintained 
 by means of the nervous system, the chief center of which is 
 in the medulla oblongata, where the most important part of the 
 vaso-motor center is located, and where also the vagus roots 
 are situated. By irritation (a) of the vagus roots or (b] of 
 their trunks, or (c) of their ends in the heart, the movements 
 of the heart become slower and generally weaker, although the 
 slowing and weakness may occur more or less independently 
 of each other. Any excessive tension in the vessels, involving 
 as it does the blood supply of the medulla, acts as an irritant to 
 the vagus center, puts the vagus nerve into action, slows the 
 heart, 1 and thus prevents the tension from rising too high. 
 (Fig. n.) On the other hand, diminished pressure in the 
 arterial system lessens the normal stimulation of the vagus 
 center, and in consequence the vagus nerves act less power- 
 fully on the heart, its beats become quicker, and the pressure 
 rises. 
 
 Arteries and Blood Pressure. On the other hand the 
 vaso-motor center when in action causes the arterioles, es- 
 pecially of the intestines and of the skin, to contract, so that 
 the channels by which the blood can pour from the arteries 
 into the veins are diminished in size, and the pressure, conse- 
 quently, tends to rise. 
 
 Influence of the Muscular Area. There are, however, a 
 number of arteries which are only slightly influenced by the 
 
 1 This has been shown in brain kept alive by artificial circulation and 
 separated from the rest of the body, except that the vagi remained intact, 
 so that the brain could act on the heart. Francois Franck, Trav. du 
 laboratoire de Marey, 1877, vol. iii., p. 276.
 
 i6 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Brain 
 
 vaso-motor center, for, when this center is irritated so as to 
 
 contract all the vessels of the 
 skin and intestines to the ut- 
 most, blood may still pour 
 through those vessels which 
 supply the muscles so rapidly 
 that the effect of the vaso- 
 motor centre hardly appears 
 to be felt at all. (Fig. 12.) 
 Nevertheless, Waller noticed 
 that sometimes by stimulating 
 this center the tension may 
 rise so high as to prevent the 
 heart from beating. These 
 different results depend, of 
 course, upon the different 
 animals experimented upon 
 
 Heart 
 
 Intestine 
 
 Muscle 
 
 FIG. 13. Diagram showing the four , , ,.,-.. 
 
 great areas for the distribution of blood in and the different COndltlOllS 
 
 the body, viz., the muscles, the intestine, unc j er wn i C h the experiments 
 the skin, and the brain. 
 
 are made. 
 
 Influence of the Splanchnic Area. The four largest 
 vascular districts in the body are those of (i) the splanch- 
 nic area, (2) the muscles, (3) the brain, and (4) the skin. 
 (Fig. 13.) It is the splanchnic area which is more especially 
 under the influence of the vaso-motor center. Any disturb- 
 ance of the circulation in this area greatly modifies the blood 
 pressure, and section of the splanchnic nerves will reduce it 
 enormously. The splanchnic area, therefore, serves to a great 
 extent as a regulator of blood pressure, and when the portal 
 vein is tied, the whole of the blood in the body, or at least a 
 large part of it, will collect in the vessels of the intestines and 
 in the liver ; so that, to use Ludwig's words, " an animal may 
 be bled into its own veins." 
 
 In 1868 Ludwig 1 and one of his pupils made some experi- 
 
 'Ludwig and Schmulewitsch, Ludwig's Arbeiten, 3tier Jahrg., 1868, 
 p. 114.
 
 INFLUENCE OF SPLANCHNIC AREA 17 
 
 ments upon the secretion of bile by an excised liver, through 
 which a stream of blood was passed artificially ; and on making 
 experiments myself a year or two later, 1 I was very much 
 struck by the enormous distensibility of the liver. One is 
 misled in regard to this property by the hard, firm appearance 
 
 Qottle containing blood 
 
 Liver. 
 
 Cannula for outflow of 
 *" blood. 
 
 FIG. 14. Diagram to show the effect of artificial circulation of blood through the 
 liver, under different pressures. The continuous lines indicate the size of the liver, 
 and the arrangement of the apparatus during circulation, under a low pressure. The 
 dotted lines indicate the increased size of the liver, and the arrangement of the 
 apparatus, under a high pressure. 
 
 of the liver after death; but during life the liver is more like a 
 sponge, and reacts just like a sponge to the slightest difference 
 in blood pressure, swelling up as the pressure increases, and 
 diminishing as the pressure falls. (Fig. 14.) 
 
 Distension of Liver. In the healthy body we do not notice 
 great changes in the liver, because the pressure in the portal 
 system undergoes but very slight change. However, when 
 there is backward pressure from the heart, in consequence of 
 incompetency of the tricuspid Valves, the liver sometimes be- 
 comes enormously large, reaching down to the umbilicus or 
 even to the iliac fossa. 
 
 Depressor Nerves. As I have already mentioned, when 
 the tension is too great in the heart and aorta, it acts as a 
 stimulus to nerves, starting from the heart and aorta, and 
 
 'Lauder Brunton, Bur don-Sanderson's Handbook for the Physiological 
 Laboratory, 1873, p. 505 et seq., and Lettsomian Lectures, 1885, in Dis- 
 orders of Digestion, p. 25.
 
 1 8 THERAPEUTICS OF THE CIRCULATION 
 
 causing reflex dilatation of the abdominal vessels; so that the 
 tension in the aorta is thus relieved. These nerves may either 
 run as a separate nerve, known as the depressor nerve, 1 or may 
 be partly incorporated with the vagus trunk. 
 
 Independent Pulsation of Veins. All through the veins 
 the circulation is steady and even; but when we come to the 
 vena cava and pulmonary veins, we find that these vessels may 
 have a pulsatile contraction of their own, like that of the venous 
 sinus in the frog. This action of the veins had apparently 
 been lost sight of until Fayrer and I rediscovered it, 2 but we 
 could not then find any mention of it in any of the ordinary 
 text-books on physiology. 3 It was, however, well known to 
 Haller, 4 and also to Senac, 5 a century and a half ago, and we 
 have since found it had been noticed by Colin 6 a year or two 
 before our observation. This contraction is not always pres- 
 ent, and so it can hardly be regarded as a constant part of the 
 cardiac pulsation. 
 
 Movements of the Heart. Views of Gaskell. In con- 
 sidering the motion of the heart, we begin, then, with the auri- 
 cle, which contracts and drives the blood into the empty ven- 
 tricle. The ventricle in turn drives the blood onwards into 
 its corresponding artery. Formerly, the rhythmical action, 
 both of auricles and ventricles, and the coordination of their 
 action, were attributed entirely to nervous influence; but the 
 observations of several writers, and particularly of Gaskell 
 in this country, and of Engelmann in Germany, have led to 
 the adoption of the view that both the rhythm and the co- 
 
 1 Ludwig and Cyon, Ludwig's Arbeiten, vom Jahre 1866, p. 128. 
 
 2 Brunton and Fayrer, Proc. Roy. Soc., 1874, vol. xxii., p. 125, and Proc. 
 Roy. Soc., 1876, vol. xxv., p. 72. 
 
 "According to Rollett (Hermann's Handbuch der Physiologic, vol. iv., 
 p. 152), it was known to Meibomius in 1668 and to Johannes Miiller in 1835. 
 
 4 Haller, Elementa Physiologica, 1757, torn. i.. pp. 410 and 399, and 
 Memoir es sur la Nature Sensible et Irritable des Parties du Corps Animal, 
 1756, torn, iv., p. 4. 
 
 8 Senac, Traite dc la Structure du Cccur, etc., second edition, Paris, 
 1783, torn, ii., pp. 37 and 38. 
 
 "Colin, Compt. rend., 1862, torn. 55, p. 495.
 
 HEART OF THE FROG 1 9 
 
 ordination are characteristics of the muscle, and that the 
 nerves of the heart have little or nothing to do either with its 
 independent pulsation or with the regular sequence in which 
 the action of the auricle follows that of the ventricle. 
 
 Heart of the Frog. The heart of the frog being simpler 
 in structure than the mammalian heart, and more easily 
 
 Lft auricle and pulmonary veins YL. ,., superior vena oav* and vagi nerve.. 
 
 VBIIOUS sinus and Kemak's ganglion. 
 
 Inferior vena cava. 
 
 X .1 L I 1 I 
 
 Bidder's ganglia 
 
 FIG. 15. Diagram of the frog's heart. 
 
 studied, has been used to a great extent for the purpose of 
 discovering the causation of the cardiac movements. It con- 
 sists of the venous sinus, two auricles, one ventricle and the 
 aortic bulb. The vagi nerves pass to the junction of the ven- 
 ous sinus and auricle, and here form a plexus or ganglion 
 
 ive contraction of the cavities in the frog's 
 
 known as Remak's. From this two nerves pass do\vn the 
 auricular septum to the base of the ventricle, where they end 
 in two ganglia usually called Bidder's ganglia (Fig. 15). 
 The origination of rhythmic impulses, their conduction in the
 
 20 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 17. a, diagram of frog's heart ligatured at the junction of the venous sinus 
 with the auricles. The venae cavae and sinus are represented with a crenated out- 
 line resembling the tracing which their beats might give if recorded on a revolving 
 cylinder. The auricle and ventricle being motionless would only trace a straight line 
 if connected with a recording apparatus. Their outline is therefore represented by 
 a straight line, b, diagram of a frog's heart in which sections have been made at 
 the junction of the sinus with the auricles, and at the auriculo-ventricular groove. 
 The sinus and ventricles pulsate, whilst the auricles remain motionless. The beats 
 of the ventricle should have been represented as slower than those of the auricle, as 
 in /, Fig. 1 8. c, the same as b, but with the parts of the heart separated by ligature 
 instead of section. 
 
 FIG. 18. d, diagram of heart with ligature round the venous sinus, e, diagram 
 of heart with ligature round middle of auricles. /, diagram of heart with ligature 
 in the auriculo-ventricular groove. The pulsations of the ventricle are much slower 
 than those of the auricle and venous sinus. This is indicated by the larger dentation 
 of the outline of the ventricle. 
 
 FIG. 19. Author's diagram of the hypothetical nervous apparatus in the heart. 
 M, motor ganglion. I, inhibitory ganglion. Q, quickening ganglion. O, inhibitory 
 fibers; and S, quickening fibers from the medulla. A, A', B and C, intermediate 
 apparatus. E, fibers passing from the motor ganglia E, to the muscular substance F. 
 For simplicity's sake, only one set of motor ganglia has been represented, but other 
 similar ones are to be supposed to be present in other parts of the heart, and so 
 connected with this set that they all work in unison. It must be remembered that 
 this diagram is purely hypothetical; but if this be carefully borne in mind, the sketch 
 will be found of service in remembering and comparing the action of different poisons 
 on the heart. Lauder Brunton, Brit. Med. Jo-urn., Dec. 1871, Collected Papers, 
 p. 311.
 
 EXPERIMENTS OF STANNIUS 21 
 
 heart and their regulation were regarded as due to the nerves. 
 The experiments of Stannius on the effects of ligature or sec- 
 tion of various parts of the heart seemed to show that the 
 nerves of the venous sinus and ventricle were chiefly motor, 
 and those of the auricle inhibitory (Figs. 17 and 18). 
 
 FIG. 20. Author's instrument for showing the action of heat and cold and of 
 poisons on the frog's heart. It consists of a piece of tin plate or glass three or 
 four inches long and two or three wide, at one end of which an ordinary cork cut 
 square is fastened with sealing-wax in such a manner that it projects half an inch or 
 more beyond the edge of the plate. This serves as a support to a little wooden 
 lever about three inches long,, a quarter of an inch broad, and one-eighth of an inch 
 thick. A pin is passed through a hole in the center of this lever, and runs into the 
 cork, so that the lever swings freely about upon it as on a pivot. The easiest way 
 of making a hole of the proper size is simply to heat the pin red hot, and then to 
 burn a hole in the lever with it. To prevent the lever from sliding along the pin, 
 a minute piece of cardboard is put at each side of it, and oiled to prevent friction. 
 A long, fine bonnet-straw, or section of one, is then fastened by sealing-wax to one 
 end of the lever, and to the other end of the straw a round piece of white paper, cut 
 to the size of a shilling or half-crown, according to convenience, is also fixed by a 
 drop of sealing-wax. The pin, which acts as a pivot, should be just sufficiently beyond 
 the edge of the plate to allow the lever to move freely, and the lever itself should 
 lie flat upon the plate. Its. weight, too, increased as it is by the straw and paper 
 flag, would now be too great for the heart to lift, and so it must be counterpoised. 
 This is readily done by clasping a pair of bulldog forceps on the other end. By 
 altering the position of the forceps the weight of the lever can be regulated with 
 great nicety. If the forceps are drawn back as at c, the flag is more than counter- 
 balanced, and does not rest on the heart at all; while the position a brings the center 
 of gravity of the forceps in front of the pivot, and increases the pressure of the 
 lever on the heart. The isolated frog's heart is laid under the lever near the pivot, 
 and as it beats the lever oscillates upwards and downwards. When used for de- 
 monstrating the action of poisons the wooden lever should be covered with sealing- 
 wax, so as to allow every particle of the poison to be washed off it, and thus prevent 
 any portion from being left behind and interfering with a future experiment. By 
 attaching a small point to the end of the straw in place of the paper flag, tracings 
 may be taken upon smoked paper fixed on a revolving cylinder. The fact that heat 
 accelerates and cold retards the pulsations of the heart is one of fundamental im- 
 portance, both in regard to a right understanding of the quick pulse, which is one 
 of the most prominent symptoms of fever, and to a correct knowledge of the proper 
 treatment to apply when the heart's action is failing. 
 
 It may be shown with the apparatus just described by placing a piece of ice under 
 the tin plate. The pulsations will become slower and slower, and if the room be 
 not too warm the heart may stand completely still in diastole. On removing the ice 
 from the plate the pulsations of the heart become quicker. If a spirit-lamp be now 
 held at some distance below it the heart beats quicker and quicker as the heat 
 increases, until at last it stands still in heat-tetanus. On again cooling it by the ice, 
 its pulsations recommence.
 
 22 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Investigation of the Movements of the Frog's Heart. 
 
 The movements of the frog's heart may be investigated either 
 by a simple lever laid upon the ventricle (Fig. 20), or by levers 
 laid on the sinus auricle and ventricle or by connecting the 
 ventricle with a small manometer (Figs. 21, 22, 31 and 170). 
 
 FIG. 21. Dr. H. P. Bowditch's apparatus for experiments on the heart of the 
 frog. A is the frog's heart. B is a cannula tied into the vena cava, and B' one 
 into the aortic bulb. C, C' and C" are three glass stopcocks. By C fresh serum 
 is supplied, by C' old serum is let out, and C" allows the communication between the 
 bent tube B C' B' and the manometer M to be opened or shut at will. D is a glass 
 plate, through which the bent tube B C' B' passes. is a rod ending in a ring into 
 which D is fitted. F is a nut by which the whole apparatus can be moved up and 
 down on the stand G. H is a T-tube. / and /' are two clips to stop the flow of 
 serum from K or K'. K and K' are two fountain-bottles for supplying serum to the 
 heart. K contains pure, and K' poisoned serum. L and L' are bent tubes which 
 convey the serum out of K and K'. M is a small manometer. N is the pen or 
 point which swims on the mercury. The horizontal part is made of glass; the 
 vertical rod of esparto grass, with a small piece of sealing-wax at its lower end. 
 The tracing may be made with ink, or with a dry point on smoked paper. P is a 
 small weight which hangs by a piece of unspun silk from a bent wire, and keeps 
 the pen resting on the paper. Q is the revolving cylinder. R is the clockwork, 
 which is provided with one of Foucault's regulators. 5" is a table, which can be 
 raised or lowered at pleasure, and fixed at any height by the screw T. V is an india- 
 rubber tube, through which the serum is emptied from X. X is a graduated tube, 
 into which the serum is allowed to pass after it has circulated some time. Y is an 
 india-rubber tube, which is generally closed by a clip, but is opened when the 
 apparatus is to be filled, or when we wish to let down the mercury to zero, in order 
 to draw an abscissa. W is a glass vessel, which fits tightly to the under side of D, 
 and protects the heart from external irritation. Into the two holes seen in D 
 tubes may be fitted air-tight, and the heart made to pulsate in an atmosphere of any 
 sort of gas.
 
 MOVEMENTS OF THE FROCKS HEART 
 
 According- to Gaskell, 1 who supports his opinion by numer- 
 ous beautiful experiments, the beat of the heart in cold-blooded 
 vertebrates depends upon the rhythmical power of the inuscu- 
 
 Klask containing 
 
 nutrient fluid - 
 
 Valve opening 
 
 towards heart 
 
 Valve with slit. 
 
 Recording cylinder 
 
 Manometer. 
 
 Heart - 
 Valve opening"! 
 from heart / 
 
 FIG. 22. Diagram of Williams's apparatus for investigating the action of drugs on 
 the heart of the frog. It consists of a Y-shaped cannula whose stem is divided 
 by a longitudinal septum into two halves, each of which is continuous with the fork 
 on its own side. The stem is inserted through the aorta into the ventricle of the 
 heart, which is kept moist by being dipped in a vessel containing serum or a dilute 
 saline solution. One fork of the Y is connected with a flask containing blood-serum 
 or other nutritive fluid, and the other with a manometer. By means of valves these 
 fluids are made to flow only in one direction. These valves consist of a piece of 
 glass tubing with a slit on one side; over this slit is loosely tied a piece of thin 
 membrane (gold-beater's skin) which covers about three-quarters of the circumfer- 
 ence of the tube. This membrane allows fluid to pass readily out of the tube from 
 within outwards, but not from without inwards, any external pressure causing the 
 membrane to become tightly applied to the slit and to close it. 
 
 A very useful form of apparatus for investigating the action of drugs on the 
 frog's heart and on the effect of the vagus upon it is made by combining the valves 
 in Williams's apparatus with the apparatus of Ludwig and Coats. 
 
 FIG. 23. Perfusion cannula with anterior part removed so as to show the septum. 
 a, tube for the introduction of fluid into the heart, b, tube for allowing escape of 
 fluid, c, tube for connecting with manometer, d, end for introduction into the 
 heart. 
 
 lar tissue in the large veins and sinus being greater than the 
 rhythmical power of the other parts of the heart. He thinks 
 that in all cases the greater or less rhythmicity of any part of 
 
 1 Gaskell, Journ. of Physiology, 1883, vol. iv., p. 80.
 
 24 THERAPEUTICS OF THE CIRCULATION 
 
 the heart depends upon the nature of the muscular fiber of 
 which that part is composed, and not upon the presence or 
 absence of ganglion cells. 
 
 k 
 
 FIG. 24. View of the auricular septum in the frog (seen from the left side), 
 he nerves are stained with osmic acid, n is the posterior, and n' the anterior 
 
 cardiac nerve; t is a horizontal portion of the latter nerve; b is the posterior, and 
 b' the anterior auriculo-ventricular ganglion; m is a projecting muscular fold. [This 
 figure is taken by the kind permission of my friend, M. Ranvier, from his Lefons 
 d'Anatomie generate, Annee 1877-78, "Appareils nerveux terminaux," t. 6, p. 79.] 
 
 FIG. 25. Part of the posterior cardiac nerve, highly magnified, showing the ganglia. 
 [Ranvier, Lefons d'Anatomie generals, Annee 1877-78, p. 106.] 
 
 Now there can be no doubt that living protoplasm can be 
 induced to contract rhythmically by a constant stimulus when- 
 ever such contraction is capable of observation. Undifferen-
 
 EMBRYONIC HEART 
 
 tiated protoplasm has the power both of 
 contracting under their influence. As 
 differentiation occurs in muscle and 
 nerve, the contractile power becomes 
 increased, and excitability diminished 
 in muscle; whilst in nerves excitability 
 becomes greatly increased and contrac- 
 tile power so greatly lessened as to be 
 practically abolished. 
 
 In the embryo the heart pulsates 
 rhythmically before any nerves make 
 their appearance, and according to Gas- 
 kell, as the simple tube of the em- 
 bryonic heart becomes developed the 
 specialized muscular walls acquire a 
 power of more rapid contraction. But 
 this nearer approach to striated muscle 
 is made at the expense of the original 
 rhythmical power, so that finally the 
 muscular tissue of the heart becomes 
 differentiated into portions of different 
 kinds of varying rhythmical power, 
 according to the amount of deviation 
 from the original embryonic muscle. 
 The parts that remain least altered are 
 (i) the large veins, (2) the venous 
 sinus, (3) the junction of the sinus 
 and auricle, (4) the circularly 
 arranged fibers of the auriculo- ven- 
 tricular groove, and lastly, (5) the bul- 
 bus arteriosus. 
 
 The sequence of contraction of the 
 different parts of the heart is also, 
 according to Gaskell, no more depend- 
 ent upon the presence of ganglion cells 
 than the heart-beat itself, but is due to 
 
 conducting stimuli and 
 
 A.K. 
 
 FIG. 26. Spiral ganglion 
 cell from the pneumogastric 
 of the frog. This figure is 
 not taken from the cells in 
 the cardiac nerves, as in 
 them the connection between 
 the spiral and straight fibers 
 has not been clearly made 
 out, but it is probable that 
 these cells have a structure 
 similar to the one figured 
 (Ranvier, op. cit., pp. 114- 
 120). a is the cell-body, n 
 the nucleus, r the nucleolus, 
 d nucleus of the capsule, / 
 the straight fiber, g Henle's 
 sheath, sp spiral fiber, g' its 
 gaine, n' nucleus of Henle's 
 sheath. [Ranvier, Lefons 
 d'Anatomie generate, Annee 
 1877-78, p. 114-]
 
 26 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 a peristaltic wave of contraction starting from that part of the 
 heart where the tissue is most automatically rhythmical, travel- 
 ling most quickly over those parts which approach most nearly 
 in properties to striated muscle, and more slowly over those 
 parts which retain a more embryonic character, viz., the auric- 
 ulo-ventricular ring and the bulbus arteriosus. According to 
 Gaskell, the cardiac muscle under certain circumstances will 
 act like a nerve, conveying a stimulus to other parts of the 
 heart without contracting itself. His experiments, I think, 
 clearly show that the rhythmical action and normal sequence 
 of contraction in the cavities can be maintained by the more 
 or less differentiated cardiac muscle without ganglia or nerves. 
 But although this may occur under certain circumstances, 
 more especially when abnormal stimuli are applied, the ques- 
 tions arise 
 
 (i) Is the contraction of the heart, under normal condi- 
 tions, due entirely to its muscular tissue? (2) Are the gan- 
 glia it contains entirely superfluous, 
 except in the way of restraining its 
 beats, or maintaining the nutrition 
 of the cardiac muscle? 
 
 Now, there can be no doubt that 
 the heart of the embryo pulsates 
 rhythmically before any nerves 
 Amoeba quickly chang- make their appearance. The vesi- 
 cle in an amoeba contracts (Fig. 
 27), although there are no nerves, 
 and numerous observations go to show that living protoplasm 
 can be induced to contract by a constant stimulus wherever 
 such contraction is capable of observation. But the question 
 is not whether the heart can contract rhythmically without 
 nervous action, but does it do this under ordinary circum- 
 stances ? 
 
 Comparison between the Heart and a Medusa. Experi- 
 ments of Romanes. The nervous and muscular structures of 
 
 FIG. 27. 
 
 ing its form, n is the nucleus, and 
 f is an ingested diatom.
 
 COMPARISON BETWEEN HEART AND MEDUSA 
 
 Polypite 
 
 Tentacles. IJell.. 
 Lithocyst and 
 ganglion. 
 
 Lithocyst and 
 
 ganglion 
 
 Bell. Tentacles.... 
 
 Polypite. 
 
 Fie. 28. Medusa (Sarsia), natural 
 size. 
 
 FIG. 29. Medusa (Sarsia), natural 
 size (inverted). 
 
 , 
 
 FIG. 30. Ventricle of 
 frog's heart with Bid- 
 der's ganglia. 
 
 the heart are very intimately related, and it is perhaps easier 
 to observe the relationship between protoplasm and nerves in 
 the medusae, or jelly-fish, where they can be more easily sepa- 
 rated. A number of observations 
 were made upon medusse by Romanes. 1 
 A medusa consists of a bell-shaped 
 piece of contractile protoplasm, from 
 the center of which a polyp descends, 
 and round the margin of the bell is a 
 nervous gangliated chain and a fringe of mobile tentacles. 
 (Fig. 28.) For the purpose of description, we may put the 
 polyp, for the present, out of account, and if we invert the bell 
 (Fig. 29) we find that it bears a very close resemblance to the 
 ventricle of the frog, which, like it, consists of a contractile 
 portion with ganglia at its margin. (Fig. 30.) When the 
 complete medusa is placed in sea-water, the bell contracts rhyth- 
 mically,' just like a heart. When the nerves are removed by 
 cutting off the marginal strip which contains them, the bell 
 ceases to contract; but it will recommence if a constant stimu- 
 lus, either chemical or electrical, be applied to it by the addition 
 of acid to the water in which it floats, by alcohol or glycerine 
 dropped on its surface, or by the passage of a constant or 
 interrupted electrical current through it. 2 In this respect it 
 completely resembles the apex of the frog's heart, which ceases 
 
 1 Romanes, Phil. Trans., 1877, for 1876, vol. clxvi., p. 269; for 1878, vol. 
 clxvii., p. 659; for 1881, vol. clxxi., p. 161. Proc. Roy. Soc., 1876, p. 143, etc. 
 
 2 Romanes, op. cit., and Jelly-fish, Star-fish and Sea-urchins, p. 175 
 et seq.; vol. iv. of International Scientific Series (Kegan Paul, Trench & 
 Co., London, 1885).
 
 28 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 to beat when the ganglia at its base are removed, but which 
 will again beat rhythmically if a constant stimulus be applied 
 
 FIG. 31. Diagram to show 
 the difference in the mode of 
 experimenting with the heart 
 and with the apex alone. In 
 a the apex alone is attached 
 to the cannula. In b the heart, 
 consisting of ventricle and 
 auricles, or of the venous sinus 
 also, is attached to the cannula. 
 
 FIG. 32. Shows the increasing contrac- 
 tions of the tissue of the medusa when 
 stimulated by repeated weak induction 
 shocks of the same intensity. The first 
 two shocks had no apparent effect, and the 
 first feeble contraction seen in the figure 
 was caused by the third shock. (From a 
 paper by Romanes in Phil. Trans.) 
 
 to it by pressure of fluid in its inside, by the application of 
 stimuli such as dilute acids or alkalies, ammonia, strong saline 
 
 FIG. 33. Increasing contractions of the ventricle of the frog's heart with successive 
 stimuli. (After Bowditch, Ludwig's Arbeiten.) Cf. Fig. 57. 
 
 solution, alcohol, etc., or by the passage of a constant current 
 through it. Moreover, when a stimulus is first applied it may 
 
 Strip of contractile tissue with 
 fringe of tentacles 
 
 FIG. 34. Diagram of a medusa (Tiaropsis), about one-third natural size, with a strip 
 of contractile tissue cut from the bell, but left attached at one end.
 
 PROPAGATION OF STIMULI IN MEDUSA 29 
 
 not appear to act, but when applied several times the contrac- 
 tions it induces are stronger and stronger up to a certain maxi- 
 mum (Fig. 32), so as to produce the appearance of a staircase 
 a phenomenon which was also observed by Bowditch 1 in the 
 case of the heart. (Fig. 33.) When a strip of medusa con- 
 taining the ganglia is detached only at one end from the animal 
 and is left attached at the other, irritation of the strip will 
 cause a wave to pass along, which is of two kinds. The first 
 is that of contraction in the protoplasm, and the other is a ner- 
 vous stimulus, which makes itself evident by the movements of 
 the tentacles. (Fig. 34.) These waves generally pass to- 
 gether, the nervous wave being usually a little in front of the 
 contraction wave; but it may also occur, as is shown by the 
 movements of the tentacles, without any contraction-wave in 
 the protoplasm of the strip. This nervous wave is more easily 
 excited than the contraction-wave, so that it may be started by 
 stimuli which are too slight to affect the contractile substance, 
 the ganglia apparently being more sensitive than the proto- 
 plasm. Apparently, also, for this reason, when the nervous 
 wave reaches the bell it will cause it to contract if there be 
 ganglia still present in the bell ; but if these have been removed, 
 the nervous wave has not the power of stimulating the proto- 
 plasm in the bell, which, consequently, remains motionless. 
 
 The passage of stimuli along the strip may be hindered or 
 prevented by compressing it, by partially dividing it so as to 
 narrow it, or by straining it so as to injure it, or by poisons, 
 and as one would expect- from different kinds of injury, some- 
 times the contraction wave is blocked first and sometimes the 
 nervous wave. 
 
 The effects of poisons on medusae were localized by Romanes 
 (Phil. Trans, for 1876 and 1877) in two ways. One way was 
 to divide the medusa almost into two halves, connected only by 
 a narrow strip of tissue. These halves were plunged into 
 two beakers filled with sea-water, pure in one and poisoned in 
 1 Bowditch, Ludti'ig's Arbeitcn, 1871, p. 155.
 
 THERAPEUTICS OF THE CIRCULATION 
 
 the other. The connecting strip rested upon the edges of the 
 beaker. (Fig. 35.) When curare was employed in this way, 
 it was found to paralyze the motor nerves, while it left the 
 sensory nerves capable of action. Thus, on nipping the half 
 of a medusa which was plunged in the curare solution, it re- 
 mained absolutely motionless, while the other half at once re- 
 sponded by a peculiar contraction to the stimulus. 
 
 Nicotine appeared to paralyze the ganglionic structures and 
 not the nerves. 
 
 The rhythmical movements of medusae depend upon the 
 ganglia: when these are all cut off the 
 movements cease, but if only one be left 
 the movements continue. In the medusa 
 divided into two halves, as already de- 
 scribed, it is evident that if the ganglia 
 are removed from one half, or one half 
 rendered functionally inactive by poison, 
 that half will still continue to contract, so 
 long as it remains connected with the 
 other half, but will cease to move when 
 it is completely divided from the half 
 which still contains ganglia. The effect of nicotine is such 
 as one would expect if the poison paralyzes the ganglia, 
 for it is found that when one half of a medusa is steeped in 
 water containing nicotine, both halves still continue to pulsate 
 rhythmically; so soon as the connecting band of tissue is di- 
 vided, the poisoned half at once ceases to move, while the other 
 half continues to pulsate. 
 
 The second way in which Romanes localized the action of 
 poisons on medusae was by applying them to a strip of contrac- 
 tile tissue. (Fig. 36.) He found that various poisons ap- 
 plied to the strip, or injected into it, caused a blockage of con- 
 tractile waves, preceded by a progressive slowing of the rate 
 of transmission along the poisoned part. Chloroform, ether, 
 alcohol, morphine, strychnine and curare all have this effect. 
 
 FIG. 35. Diagram- 
 matic representation of 
 the method of localizing 
 the action of poisons on 
 medusae. One vessel con- 
 tains normal sea-water; 
 another contains poi- 
 soned sea-water, which is 
 shaded in order to dis- 
 tinguish it.
 
 EFFECT OF POISONS ON MEDUSA 31 
 
 When the block is only partial, it may happen that three 
 waves come up to it before one can pass across, as if each wave 
 had prepared the passage for the remainder, and at last the 
 third or fourth overcomes the obstacle. 
 
 Gaskell has noticed a similar effect from compression of the 
 
 FIG. 36. Medusa (Aurelia aurita) from which the ganglia have been removed, 
 and the bell cut into a long strip with cross cuts to block the passage of contractile 
 and tentacular waves. The polypite is at the other end. a and b are at the two 
 ends of the strip. When stimulation was applied to either a or b, a tentacular wave 
 started from that point and travelled all the way to the other end. After Romanes, 
 Phil. Trans, for the year 1877, vol. clxvii., part ii., p. 719, and Plate 31. 
 
 auriculo-ventricular groove in the frog's heart, and the same 
 thing is also observed in certain cases of cardiac disease and 
 from the action of cardiac poisons. (Fig. 37.) 
 
 Transmission of Stimuli in the Heart. If (i) all the 
 rhythmical power of the auricles and ventricles and (2) all
 
 32 THERAPEUTICS OF THE CIRCULATION 
 
 their coordinated action are dependent only on the cardiac 
 muscle, one would say that it was quite unnecessary to have 
 such an extraordinary abundance of nerves as exists in the 
 heart. One would be inclined to say that they are superabund- 
 ant and useless, but one cannot help remembering that years 
 
 _U_ Hi IV ptr 
 
 yi i i etc. 
 y 
 
 a- o 
 
 FIG. 37. Diagram to illustrate Gaskell's experiment. At a the jaws of the clamp 
 hold the heart without compressing it, and each beat of the auricle is succeeded by 
 
 one of the ventricle, as shown by the figure i. At b the heart is compressed, and 
 
 its rhythm disturbed, so that one beat of the ventricle only occurs for several of 
 the auricles. This is indicated by the Roman numbers, the upper line of which shows 
 the number of auricular, and the lower- of ventricular beats. 
 
 ago the liver was looked upon as a totally unimportant organ, 
 whose only function it was to secrete a little bile. Fuller 
 knowledge has shown that instead of being useless, it is one 
 of the most important organs in the body; and in all proba- 
 bility increased knowledge will again show the importance of 
 the cardiac nerves. 1 
 
 In order that we may understand the object of these nerves 
 more easily, I may perhaps be allowed to employ a simple com- 
 parison. A railway train, when once started, usually proceeds 
 from station to station without interference; but alongside the 
 rail, or overhead, run the telegraph wires, and at any station 
 the progress of the train may be stopped by a message sent by 
 the telegraph. You will notice also that in many railways an 
 electric bell rings before the train actually appears, so that all 
 preparations may be made for its arrival. In the heart the 
 transmission of stimuli by the cardiac muscle would correspond 
 to the passage of the train; the transmission by the nerves 
 would correspond to the telegraph, by which the movement of 
 
 1 The importance of the cardiac ganglia in originating the beats of the 
 heart has been prominently brought forward since these lectures were 
 given, by Dogiel and Archangelsky, Pfliiger's Archiv, July, 1906, vol. cxiii., 
 pp. 1-96.
 
 CONDUCTION OF STIMULI IN THE HEART 33 
 
 the ventricle might either be stopped, even after an impulse had 
 been sent on from the auricle, or, on the other hand, the ven- 
 tricle might be prepared to respond more quickly to the stimu- 
 lus passing from the auricle. The advantage of such a prepa- 
 ration is evident from Romanes' experiments, in which stimuli 
 did not always produce the proper effect unless they had been 
 preceded by another stimulus which prepared the protoplasm 
 to react. 
 
 Nervous and Muscular Conduction in the Heart. Act- 
 ing upon the idea which I have tried to illustrate to you by the 
 train and the telegraph, Dr. Cash and I endeavored to find out 
 whether we were able, by stimulation of the venous sinus or of 
 the auricle in the excised frog's heart, to produce such changes 
 in the ventricular contraction as one might expect if there were 
 really two lines of communication, nervous and muscular, 
 instead of muscular alone. The bearing of this upon cardiac 
 irregularity is naturally of the greatest importance. 
 
 I have already mentioned that there is a refractory period 
 during which the ventricle does not appear to react to stimula- 
 tion. This was pointed out by Marey, and the time relations 
 of this period, as well as the electrical changes which accom- 
 pany it, were investigated by Sir John Burdon-Sanderson and 
 Mr. Page. 1 
 
 Experiments of Brunton and Cash. The results that 
 Cash and I obtained agree with those of previous observers, 
 and I show you here some tracings to illustrate this point. In 
 regard to these tracings, as well as to all the others contained 
 in the paper from which it is taken, I may say that the investi- 
 gation extended over nearly three years, that the number of 
 tracings was enormous, and that our conclusions were founded 
 upon very numerous observations, and not merely upon the 
 small pieces which are printed in the paper, which were cut 
 down to the lowest possible minimum, on account of the ex- 
 pense of printing. These illustrations are merely to show the 
 
 1 Burdon-Sanderson and Page, Roy. Soc. Proc., 1878, p. 410; 1880, p. 373. 
 
 4
 
 34 THERAPEUTICS OF THE CIRCULATION 
 
 points which we made out, but are not to be regarded as being 
 the basis upon which our conclusions were founded. 1 I wish 
 to lay particular stress upon this point, lest the small number 
 of tracings printed in the paper should lead other workers on 
 this subject to reject our conclusions as being founded on 
 insufficient data, when in fact the number of experiments was 
 very large. 
 
 Irritation of the ventricle at the commencement of systole 
 nearly up to its maximum, i. e., during the refractory period, 
 has no 1 effect at all. (Fig. 38, a, &.) Stimulation from the 
 maximum of systole to its end causes a reduplication of the 
 systole (Fig. 39), and in the diastole it does the same almost 
 immediately. (Fig. 40.) 
 
 When the auricle is stimulated, the stimulation may cause 
 a second auricular beat immediately after the first. (Fig. 41.) 
 This second beat, in place of being succeeded by a ventricular 
 pulse, prevents the next ventricular beat from following in 
 order, just as two trains may be started in almost immediate 
 succession from one station, and a telegraphic message may be 
 sent on at the same time that the second train is not to be 
 allowed to pass the next station. 
 
 When the venous sinus was stimulated it produced redupli- 
 cation of the auricular beat, but absence of the ventricular beat 
 which should have succeeded it, in much the same way. (Fig. 
 
 42.) 
 
 Conduction of Impulses both by Muscle and Nerves. 
 
 These experiments, which were not only very numerous, but 
 very varied, seemed to us to show that, just as in a medusa, 
 there are in the heart two distinct channels, the nervous as well 
 as the muscular, by which stimuli are conducted from one part 
 
 1 Brunton and Cash, " On electrical stimulation of the Frog's Heart, and 
 its modification by cold, heat, and the action of drugs," Roy. Soc. Proc., 
 1881, vol. xxxii., No. 214, and 1883, vol. 35, No. 227, p. 455. The instru- 
 ment with which the observations were made was devised by Dr. Cash, 
 and described by him, Journ. of Physiology, iv., 1883, p. 128.
 
 BRUNTON AND CASH S EXPERIMENTS 
 
 35 
 
 FIG. 38. Tracing showing the effect of electrical stimulation upon the ventricle of 
 the frog's heart. The upper line shows the ventricular contraction, the lower one the 
 auricular contraction, and the middle line the time of application of the electrical 
 stimulus. The depression shows the time of breaking, and the ascent the time of 
 again making the current. In most of these tracings only the break is effective as a 
 stimulus. The arrow shows the direction in which the tracing is to be read. The 
 dotted line shows more exactly the exact time in regard to the systole at which the 
 stimulus was applied. In both o and b the stimulus falls within the refractory period, 
 and produces no effect. In this and the following tracings the movements of the 
 ventricle and auricle were registered by levers resting on them. 
 
 FIG. 39. Effect of electrical stimulation of the 
 frog's ventricle after the refractory period has 
 passed. It shows different forms of reduplication; 
 also, that the auricular systole following the stimu- 
 lation is nearly coincident with, or even a little 
 later than, the ventricular systole, instead of pre- 
 ceding it in the usual way. 
 
 FIG. 40. Shows redupli- 
 cation of the beat of the 
 ventricle from stimulation 
 applied to it during the 
 diastole. 
 
 of the heart to another, and that the nervous conduction may 
 interfere with the muscular conduction. 1 
 
 explanation is in accord with the conducting function of the 
 bundles of His, or the fibers of Purkinje, which may be regarded as neuro- 
 muscular. Since these lectures were given, the conducting function of the 
 muscular bundle described by Stanley Kent in 1892 (Proc. Physiol. Soc., 
 Nov., 1892), and by William His, junior, in 1893, which connects the 
 auricles and ventricles, has attracted much attention, and the neuro- 
 muscular fibers described by Purkinje have also come again more into 
 notice. The bundle of His is thus described by him: "The bundle springs 
 from the posterior wall of the right auricle, near the auricular septum, in
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 41. Shows effect of stimulation of the auricle on the beats of the auricle itself 
 and of the ventricle. The weaker stimulus in a produces no reduplication of the 
 auricular beat, although other experiments showed that it usually produced a very 
 prolonged pause. In the lower tracing b, stimulation had various effects, according 
 to the time of the auricular systole at which it was applied. At b i it caused redupli- 
 cation of the auricular beat, with omission of the ventricular beat; at 2 it only pro- 
 duces prolongation of diastole in both auricle and ventricle, and the third had no 
 apparent effect. 
 
 FIG. 42. Shows the effect of stimulation of the venous sinus. It is much more 
 sensitive to stimulation than either the auricle or ventricle, so stimuli will produce an 
 effect upon it, although too weak to act on either auricle or ventricle. It causes re- 
 duplication of the auricular and omission of the ventricular beat, like stimulation of 
 the auricle at a, Fig. 40. In the experiment of which this is a tracing a minimal 
 stimulus was employed, and only the opening of the current was effective. The open- 
 ing is indicated by the sinking of the continuous line, and its closing by the rise. 
 The closing shock produced no effect. The relation between the time of stimulation 
 and the auricular contraction (lower tracing) and the ventricular contraction (upper 
 tracing) is shown by the dotted lines. 
 
 FIG. 43. Periodic rhythm of the heart, the pulsations occurring in groups separated 
 by intervals of complete quiescence.
 
 KRONECKER AND SCHMEY KENT AND HIS 37 
 
 Another experiment which is very striking is that of 
 Kronecker and Schmey, 1 who found that by puncturing a point 
 in the septum of the ventricles, at about the junction of its 
 upper third with its lower two-thirds, the rhythmical action of 
 the heart is stopped immediately, and little, quivering tremors 
 are to be seen all over the ventricle, but, while the fibers are 
 
 FIG. 44. Tracing of the pulsations of a ventricle separated from the auricles by sec- 
 tion at the auriculo-ventricular groove. After Ranvier, Lcfons, 1877-78. 
 
 contracting, the heart, as a whole, is quiescent. It is not 
 always easy to hit this point. My friend, Professor Kron- 
 ecker, tells me that he has sometimes struck it at the third 
 
 the auriculo-ventricular sulcus, is attached to the superior edge of the 
 muscle forming the ventricular septum, and exchanges fibers with it. It 
 passes forwards on the ventricular septum, till near the aorta it divides 
 into a right and left branch, the latter of which ends in the base of the 
 aortic cusp of the mitral valve. (William His, junior, Arbeitcn aus der 
 medicinischen Klinik Zu Leipzig herausgegeben, von Dr. H. Curshmann, 
 Leipzig, F. C. Vogel, 1893, p. 23.) No nerve trunks are to be found in 
 this bundle (Ritzer, quoted by Erlanger), but it contains nerve fibers 
 (Tawara and Aschdff, Zeitsch. f. Physiol., 1905, xix., p. 298), and the 
 muscle fibers are very fine and of an embryonal character. The ventricular 
 part of the bundle passes as a finely ramifying system to the ventricular 
 wall and papillary muscles, and consists of Purkinje's fibers. These fibers 
 consist of cells which are only striated on their periphery, and may be re- 
 garded as only partially differentiated, and possessing the properties of 
 nerve as well as muscle (Ranvier, Legons d' Anatomic Generate, Systeme 
 Musculaire, Paris, 1850, p. 300). They appear to conduct the stimuli from 
 the auricle to the ventricle in mammalian hearts more slowly than nerves. 
 When the conducting power of the bundle of His is destroyed by clamp- 
 ing it, similar disturbances of the relation between the rhythm of the 
 auricles and ventricles is produced, as Gaskell observed in the frog's heart 
 (Stanley Kent, Journ. of Physiol., 1893, vol. xiv., p. 250; and Erlanger, 
 Journ. of Experimental Medicine, vol. viii., p. 8). Their degeneration 
 produces heart block and intermittence of the pulse. 
 
 1 Kronecker and Schmey, Sits. bcr. d. Akad. d. IViss. zu Berlin, 1884, 
 s. 87.
 
 38 THERAPEUTICS OF THE CIRCULATION 
 
 attempt, but on other occasions he has tried more than thirty, 
 and I think that when he showed it to me it was quite fifty 
 times, but the difference between the time when he did not 
 strike it and the time when he did so was most extraordinary. 
 The effect of the thin needle penetrating the heart appeared to 
 be nil until he struck the proper point, and then the rhythmical 
 power was instantly and completely abolished. The effect on 
 the heart was similar to that of puncture of the nceud vital in 
 the fourth ventricle upon respiration. 
 
 FIG. 45. Diagram of the author's instrument for ascertaining the competence ot 
 the mitral or tricuspid valves, and illustrating the action of the musculi papillares. 
 D is a section of the heart, with the valves () and the chordae tendineae (F). The 
 nozzle (A) of an enema apparatus is taken off and its longer end thrust from the 
 inside through the ventricular wall (B), and is there kept in place by the flange on the 
 inside and a thick rubber ring (C) on the outside. On pumping water gently in, the 
 valves () will be seen to float upon the surface of the water, then to become firmly 
 opposed or screwed together, and only when the ventricle is forcibly distended or dis- 
 torted by unequal pressure on its sides do the valves leak. (Lauder Brunton, St. 
 Bartholomew's Hospital Reports, 1878, vol. xv., p. 283.) 
 
 It is almost impossible to explain such a result as this on 
 the idea that rhythmical contractility is dependent only upon 
 the muscular structure ; but one can quite readily understand it 
 on the other idea, viz., that there are two controlling conditions
 
 VALVES OF THE HEART 
 
 39 
 
 in the heart (i) the nervous and (2) the muscular, and that 
 these may, under certain circumstances, interfere with each 
 
 FIG. 46. Heart in full sys- FIG. 47. The same heart as 
 
 tole, showing the mitral and in Fig. 46, from another point 
 
 tricuspid orifices so diminished of view, 
 
 by the muscular contraction 
 that the valves close them 
 easily. 
 
 other, and thus abolish contraction more or less completely, 
 and produce intermittence or irregularity of the pulse. 
 
 FIG. 48. Heart fully distended, showing insufficiency of the valves to close the mitral 
 and tricuspid orifices. 
 
 Valves of the Heart. All these experiments have a bear- 
 ing upon the rhythm of the heart, as we shall afterwards see,
 
 4O THERAPEUTICS OF THE CIRCULATION 
 
 but the more common diseases of the heart are really those 
 associated with imperfection of the valves. If the valves were 
 not present, the blood, instead of being forced steadily onward, 
 would tend to regurgitate, but the presence of the valves pre- 
 vents this. In the aorta and pulmonary artery we have three 
 segments which are simply brought together like those of an 
 ordinary pump, by the pressure within the artery when the 
 ventricle ceases to contract. In the valves which separate the 
 auricle from the ventricle, we require something more than 
 this, because the valves are large, and when the walls of the 
 ventricle approximate during systole the thin valves would be 
 driven back into the auricle, were it not that they are attached 
 by fine cords and by muscular columns which, contracting with 
 the rest of the ventricle, draw the valves downwards and pre- 
 vent them from being forced back into the auricles. (Fig. 
 45.) The action of these valves is aided by the contraction of 
 the muscular fibers around the auriculo-ventricular orifices, 
 which are greatly lessened in diameter, so much so that one 
 might say that even imperfect valves might close them (Figs. 
 46 and 47) ; whereas when the cardiac contraction is feeble the 
 orifices may be too large to be completely covered, and thus a 
 certain amount of regurgitation may take place even though 
 the valves themselves are perfectly healthy (Fig. 48).
 
 LECTURE II 
 
 Sounds of the Heart Double Nature of the Heart Right Ventricle 
 Aorta Arteries and Capillaries Vaso-motor Nerves Dilating Nerves 
 Elongation of Muscle(?) Rhythmical Contraction of Vessels Stimula- 
 tion of Vessels from without Stimulation of Vessels from within Effect 
 of Heat and Cold on the Circulation Effect of Heat and Cold on the 
 Pulmonary Capillaries Schema of the Circulation Kymographs Blood 
 Pressure in Animals Blood Pressure in Man Measurement of the Blood 
 Pressure in Man Instruments for Measuring the Blood Pressure in Man : 
 By Pressure on an Artery ; By Pressure on a Finger or Limb ; Sphygmo- 
 manometers of Herisson, Waller, Von Basch, Potain and Oliver; Instru- 
 ments of Marey, Mosso and Gaertner. 
 
 Sounds of the Heart. The closure of the valves in the 
 heart occasions sounds which can be heard by putting the ear 
 to the chest wall, and they can be still better localized by the 
 use of a stethoscope. When we do this, we hear sounds which 
 are well imitated by the syllables " lub-dup," close to one an- 
 other. These syllables follow one another quickly, and then 
 comes an interval, which represents the diastole of the heart. 
 The credit of showing that the second sound, " dup," is caused 
 by the closure of the aortic valves, belongs to C. J. B. Williams, 
 and the committee in which he, Hale, and Glendinning took 
 part. 1 They showed that when the aortic valves were de- 
 stroyed, the sound disappeared. The causation of the first 
 sound, however, has given rise to a great deal of discussion. 
 Some authors have considered it to be a valvular sound, and 
 due to the flapping together of the auriculo-ventricular valves ; 
 whilst others, like Magendie, have thought it to be caused by 
 the striking of the apex against the chest wall, and yet others 
 have looked upon it as being a muscular sound, due to the 
 ventricular contraction. There seems to be little doubt now, 
 from the experiments of Ludwig, Dogiel, 2 and others, that the 
 
 1 Sixth Report of the British Association, 1836, p. 265. 
 
 2 Ludwig' 's Arbeiten, 1878, p. 78.
 
 42 THERAPEUTICS OF THE CIRCULATION 
 
 first sound is chiefly muscular, and brought about by the con- 
 traction of the ventricle; but the experiments of Ottomar 
 Bayer 1 in Ludvvig's laboratory demonstrated that, apart from 
 the muscular sound, a distinct valvular click could be obtained 
 by the closure of the auriculo-ventricular valves in a dead 
 heart, whilst Williams and his confreres found, in addition, 
 that the first sound was intensified by allowing the exposed 
 heart to beat against a piece of board. We may thus consider 
 that there are three factors which all take part in the produc- 
 tion of the first sound, viz., (i) the ventricular contraction, 
 (2) the closure of the auriculo-ventricular valves, and (3) the 
 impulse of the apex against the chest wall. 
 
 As we would expect, the first sound is heard most loudly 
 over the apex, which is the point of the chest wall nearest to 
 the ventricle. The second sound is heard more sharply over 
 the aortic valves, which lie beneath the left side of the sternum, 
 at about the level of the third intercostal space, but is heard still 
 better at the point where the aorta most nearly approaches the 
 sternum at its right edge, and at the level of the second inter- 
 costal space or third costal cartilage. 
 
 Alterations in the Second Sound. When we hear a door 
 slammed loudly, we know that it is closed quickly in conse- 
 quence of the application of unusual force; and just as we 
 would expect, when tension is high in the aorta the second 
 sound is louder than usual, or as it is termed, is accentuated, 
 and this accentuation of the second sound over the aorta is one 
 of great clinical importance, indicating as it does, high arterial 
 tension or aortic atheroma or aneurism. 
 
 Alteration in the First Sound. The causation of the first 
 sound being more complex, alterations in it occur from a 
 greater number of causes. As it is to a great extent a muscu- 
 lar sound, we should naturally expect that weakness of the 
 cardiac muscle, such as occurs in fevers, would lessen the sound, 
 and this is exactly what occurs. In cases of typhoid fever, 
 when the first sound becomes inaudible we know that the heart 
 
 1 O. Bayer, Arch. f. Hcilk., xi., p. 157.
 
 SOUNDS OF THE HEART MURMURS 43 
 
 is so weak as to render the prognosis grave. But it would 
 appear that it is not mere muscular strength which causes the 
 sound to become loud : it is rather rapidity of contraction ; and 
 even a comparatively feeble heart may have a loud, clear first 
 sound if the tension in the aorta is low, or, in other words, if 
 the resistance it has to overcome is small, so that it can contract 
 rapidly. When the arterial tension is high, and the resistance 
 to be overcome is consequently great, the muscular walls of 
 the ventricle contract comparatively slowly, and even when 
 hypertrophied far beyond their normal size, they may give rise 
 to a sound weaker and duller than normal. Of course, the 
 rapid contraction not only gives rise to a greater muscular 
 sound, but it closes the auriculo-ventricular valves more 
 sharply, and thus increases also the valvular part of the first 
 sound. And yet, again, a heart contracting quickly gives a 
 sharp, or as it is sometimes called, a slapping impulse to the 
 chest wall, while the more powerfully hypertrophied heart, act- 
 ing on a greater resistance, gives a thudding or pushing im- 
 pulse not likely to cause so much resonance, and thus the sound 
 will again be diminished. The last factor in the production of 
 the first sound in the heart may also be lessened by a thick 
 layer of lung between the ventricle and the chest wall, as in 
 emphysema, and the lung will also tend to deaden the sound by 
 acting as a non-conductor between the ventricle and the ear. 
 
 Cardiac Murmurs. When the aortic valves are destroyed, 
 the sharp " dup " which their closure causes in health disap- 
 pears, and is replaced by a bruit or murmur. You will most 
 easily understand this by trying to say " dup " with your lips 
 apart, and you will then find that without thinking of it you 
 reproduce the sounds actually heard in aortic incompetency. 
 When it is slight, the closure of the valves is still heard, but is 
 followed by a whiff, as when you say " duff," and in aortic 
 regurgitation the sounds are like " lub-duff." The same hap- 
 pens with the mitral valve, and when this valve alone is incom- 
 petent, the sounds of the heart are like " luff-dup " " luff- 
 dup." When both valves are slightly incompetent, the sounds
 
 44 THERAPEUTICS OF THE CIRCULATION 
 
 are like " luff-duff " " luff-duff "; and when both valves are 
 very incompetent, a bellows murmur occurs, like " oho-oho." 
 
 Double Nature of the Heart. For the sake of simplicity, 
 I have spoken hitherto of the heart as if it consisted only of 
 the left side, but we have in man, as in other mammals, really 
 two hearts joined together in one, the right and the left; the 
 right sending the blood through the lungs for the purpose of 
 aerating it, and the left sending the blood through the body in 
 order to nourish the tissues. Both hearts receive the blood 
 from the large veins into the auricles, which, contracting, send 
 it on to the ventricles, and thence it is propelled by the right 
 ventricle into the pulmonary artery, and by the left ventricle 
 into the aorta. As I mentioned before, both the vena cava 
 and the pulmonary veins have the power of rhythmically inde- 
 pendent pulsation apart from the auricle, and the cardiac beat 
 may frequently though probably not always, originate in them. 1 
 
 Right Ventricle. The resistance which the right ventricle 
 has to overcome in driving the blood through the pulmonary 
 artery is only about one-third that presented by the aorta, and, 
 consequently, the right ventricle is only about one-third the 
 strength of the left. The tricuspid valves, which separate the 
 right ventricle from the right auricle, are much more easily 
 rendered incompetent by distension of the ventricle than are 
 the mitral valves, and' this tendency to incompetency has been 
 regarded, and I think with truth, as a safety valve, preventing 
 the stoppage of the right ventricle by over-distension, and 
 allowing the blood to pass back into the venous reservoirs, of 
 which I have already spoken. 
 
 Aorta. On looking at the aorta, one would say that it is 
 entirely composed of fibrous tissue, and consequently is not 
 likely to possess any contractile power, and yet it would appear 
 to have such a power, for in the case of a criminal executed at 
 Wurzburg, it was found to contract on the application of elec- 
 tricity shortly after death. 2 
 
 1 Vide, p. 20. 
 
 * Vcrhandl. d. Med. Phys. Gescllsch., Wurzburg, 1854, p. i ; and Schmidt's 
 Jahrb., vol. Ixxxv., p. 12.
 
 VASO-MOTOR NERVES DILATING NERVES 45 
 
 Arteries and Capillaries. As we pass down the arterial 
 system the muscular fibers become more developed, and in the 
 arterioles we find a continuous muscular layer, while in the 
 capillaries we have nothing but contractile cells. Just as in the 
 case of the heart, where we have two kinds of nerves having 
 an opposing action, so we have in the vessels nerves which 
 cause contraction and others which cause dilatation. When 
 working with Schweigger-Seidel in Ludwig's laboratory in 
 1869, I made a number of observations on the nerves of the 
 arterioles and veins, but these were not published, as I did not 
 discover anything new. I tried in vain to find any evidence 
 of nerve fibers entering the muscular cells of the arterioles, but 
 could never observe it. All that I could find was a regular net- 
 work of minute nervous fibrils running over the surface of the 
 muscular layer. At the points where these fibrils cross there 
 are small thickenings or knots, but nothing at all like ganglion 
 cells. 
 
 Vaso-motor Nerves. Dilating Nerves. Elongation of 
 Muscle (?). The vaso-motor system, as I have already said, 
 has its chief center in the medulla oblongata, but it has sub- 
 sidiary centers in the spinal cord itself, and in the ganglionic 
 chain of the sympathetic. When the centers or nervous trunks 
 of the vaso-motor nerves are irritated, the vessels contract ; but 
 there are other nerves which when irritated cause dilatation 
 instead of contraction, and this dilatation is greater than that 
 which occurs on the division of the vaso-motor fibers supplying 
 the vessel. 1 This fact is generally explained by supposing that 
 irritation of the dilating nerves has an inhibitory action upon 
 local vaso-motor mechanisms close to the vessels, though, for 
 my own part, I should be inclined to accept the much simpler 
 explanation that a transverse as well as a longitudinal contrac- 
 tion may occur in the muscular cells of the arterioles, and such 
 a transverse contraction would elongate each cell and dilate the 
 vessel, just as the longitudinal contraction would shorten and 
 
 1 Vide Tigerstedt, Lehrb. d. Physiol. d. Kreislaufs, p. 512 (Leipzig: Veit 
 & Co., 1893).
 
 4 6 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 thicken the cell and thus contract the vessel. In many in- 
 stances, dilatation or dilation is connected with peripheral gan- 
 glia ; for example, in the sub-maxillary gland and in the nervi 
 erigentes, but that it is always due to such nervous causation 
 is, I think, doubtful. For a good while, the contractility of 
 capillaries was doubted, but the observations of Strieker and 
 others have now, I think, put this fact be- 
 yond dispute. 1 When working under Lud- 
 wig's direction I also noticed that local irri- 
 tation would sometimes cause, not contrac- 
 tion, but dilatation of an arteriole. 2 Similar 
 observations were made by Gunning and 
 Cohnheim in the frog; so that, just as the 
 effect of nerves upon the heart itself, to the 
 exclusion of muscular irritability, is now 
 recognized to be wrong, so in all probability 
 the properties of the muscular elements of 
 the arterioles, like those of the heart, will by 
 FIG. 49. Diagram to and by receive more atten tion than they have 
 
 hitherto done. 
 
 Rhythmical Contraction of Vessels.- 
 
 illustrate the hypothet- 
 ical transverse contrac- 
 tion of muscle. (a) 
 Muscle in relaxed con- 
 
 dition, (&) in contrac- Rhythmical contraction of the veins was 
 
 tion, (c) in elongation. 
 
 observed to exist by Wharton Jones, 3 
 Schiff, 4 and Vulpian. 5 The arteries also contract rhythmically 
 under the influence of the vaso-motor center, and give rise to 
 periodic pulsations which are coincident with respiration. In 
 addition to these, however, the arteries themselves pulsate 6 
 periodically. 7 It is difficult to see this pulsation in healthy 
 people, but it can be well observed, as a rule, in patients suffer- 
 
 1 Strieker, Sits. Ber. d. k. k. Akad. d. Wiss. Math.-nat. Cl, 1865, 41, Abt. 
 2-3, 51; 1866, 52; 1876, Abt. 3, 316. 
 
 2 Lauder Brunton, Ludwig's Arbeiten, 4ter Jahrg., and Collected Papers 
 on Circulation (First Series, pp. 160, 178). 
 
 8 Wharton Jones, Phil. Trans., 1842, p. 131. 
 
 * Schiff, Arch. d. ges. Physiol., xxvi., p. 456. 
 
 6 Vulpian, Mem. Soc. Biol., iii., 1856, p. 223, and 1858, p. 3. 
 
 6 Schiff. 
 
 7 Lauder Brunton, Ludwig's Arbeiten, 4ter Jahrg., 1869.
 
 STIMULATION OF BLOOD-VESSELS EXTERNAL 47 
 
 ing from aortic regurgitation. In such cases the face is usu- 
 ally pale, but if the finger-nail be rapidly drawn across the 
 forehead, a red streak appears which alternately widens and 
 narrows, and this movement on careful observation will be seen 
 to show three rhythms. The first coincides with the pulse, and 
 occurs between sixty and seventy times per minute ; the second 
 with respiration, about eighteen or twenty times per minute; 
 and the third, or capillary rhythm, is only about three times 
 per minute. 1 
 
 Stimulation of Blood-vessels from without. It is difficult 
 
 FIG. 50. Vessels in the web of a frog's foot in the normal condition (after Lister). 
 
 to explain the various local alterations of the circulation, if we 
 look entirely to the nervous system for an explanation of them ; 
 whereas the explanation is easy if we acknowledge the power 
 of vessels to contract or dilate from alterations in their con- 
 tractile element apart from the nervous, although, just as in 
 the heart, we must fully recognize the enormous influence of 
 the nervous system upon the vessels. Thus, when we apply a 
 mustard poultice to the skin the rapid dilatation of the vessels 
 and consequent redness which immediately follows the applica- 
 
 1 Lander Brunton, Journ. of Physiol., 1884, vol. v., p. 14.
 
 4 8 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 51- The same vessels after irritation. 
 
 FIG. 52. Apparatus for registering muscular contraction. It consists of an up- 
 right stand on which two horizontal bars may be moved by a rack and pinion. The 
 upper bar ends in a clamp, the lower carries a delicate lever, the part near the hinge 
 being of metal, and the part beyond of light wood tipped with quill or tinfoil. a, a 
 Wires for exciting muscle; b, muscle; c, writing lever. In the figure no arrange- 
 ment is shown for exciting the nerve, and for the sake of simplicity the weight is 
 shown directly under the muscle. In actual experiment, however, the weight should 
 be applied close to the axle, or on it, so as to lessen oscillation due to the inertia of 
 the lever.
 
 STIMULATION OF BLOOD-VESSELS INTERNAL 
 
 49 
 
 tion are probably due to nervous influence, but the permanent 
 redness, which may remain for several days, is more likely to 
 be due to a local alteration in the .vessels themselves. (Fig. 
 
 Si-) 
 
 Stimulation of Vessels from within. A still more impor- 
 tant question, however, than the effect of irritation of the ves- 
 
 Screw 
 
 Screw 
 
 Framework 
 
 Clockwork 
 
 ur 
 
 FIG. 53. Revolving cylinder for recording movements. The screws at the top are 
 for fixing the cylinder in position. The brass pin is for making or breaking a cur- 
 rent at a given time in the revolution. It does this by striking against a small key. 
 The curve is described by the lever, Fig. 73. The abscissa, or zero line, is drawn 
 by a fixed point, and serves to show the height of the contraction. 
 
 sels from the outside, is that of stimulation from the inside by 
 various products of tissue waste or by strain. In chronic inter- 
 stitial nephritis the blood pressure tends to rise gradually, so as 
 to threaten life either from cardiac failure or from arterial rup- 
 ture. This high tension appears to commence by increased 
 resistance to the passage of blood through the arterioles and 
 5
 
 SO THERAPEUTICS OF THE CIRCULATION 
 
 capillaries. By some it is attributed to chronic contraction of 
 the arterioles with hypertrophy of their muscular walls, by 
 
 FIG. 54. Tracing of the normal contraction of the gastrocnemius of a frog. 
 
 FIG. 55. Effect of heat and cold on muscle. In a the muscle has been artificially 
 warmed, and in b it has been cooled. Heat makes the contraction more rapid, cold 
 makes it slower. 
 
 FIG. 56. Effect of fatigue on muscle. 
 
 FIG. 57. Tracing of the contractions of a muscle with stimuli of increasing strength. 
 The numbers indicate the distance in centimeters of the secondary from the primary 
 coil in the induction apparatus. As and Des indicate the ascending and descending 
 direction of the current. Cf. Figs. 31 and 32. 
 
 others to a fibroid thickening. It is probable that both of 
 these conditions occur, but for my own part I am inclined to 
 believe that the arterial contraction plays a very great part in
 
 EFFECT OF HEAT AND COLD ON THE CIRCULATION 5 I 
 
 it, as we are able to reduce the tension by means of appropriate 
 medicines, such as nitrites, which one would hardly do if it 
 were entirely or even mainly due to a fibroid condition. 
 
 Effect of Heat and Cold on the Circulation. Two agents 
 which have a very marked effect, both upon the vessels and 
 the heart, as well as on muscular tissue generally, are heat and 
 cold. When we put the hand into hot water we find at once 
 that the arteries dilate and the hand becomes red, showing that 
 the capillary circulation is free; but we notice also that the 
 veins not only become full, but become lighter in color, evi- 
 dencing that the blood within them is more arterial. Heat 
 applied to the heart quickens the pulsations 1 and at the same 
 time increases their strength, the quickening being chiefly due 
 to the effect of the heat upon the sinus or auricles, and the 
 increased strength to its effect upon the ventricle. (Fig. 59.) 
 Cold has an opposite effect. (Fig. 64.) When applied to the 
 extremities, it makes the arteries contract, the fingers shrink 
 and become pale, though after a while the veins appear to 
 dilate, and the skin assumes a bluish color from venous conges- 
 tion. Cold applied to the heart makes its movements both 
 slower and feebler. 
 
 It is evident from what I have said that the local action of 
 either heat and cold upon the vessels and heart is of such a 
 character as in itself to coordinate the effect it produces upon 
 both, independently of a nervous system, if applied to both at 
 the same time; because when heat causes the vessels to dilate, 
 so that a larger supply of blood is demanded, it also causes the 
 heart to pulsate more quickly and more forcibly, so as to give 
 the necessary supply. When the arteries are contracted by 
 cold and a small amount of blood only can pass through them, 
 the cold acts on the heart also, slowing and weakening its con- 
 traction and thus lessening the supply. But while cold and 
 heat may act nearly equally upon the extremities and the heart 
 of a frog, it is not so in warm-blooded animals, where the 
 
 1 Lauder Brunton, St. Bartholomew's Hospital Reports, 1871, vol. vii., 
 and Collected Papers (First Series, p. 204).
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIGS. 58 TO 67. EFFECT OF COLD AND HEAT ON 
 THE HEART. 
 
 FIG. 58. Tracing of the beats of a frog's heart, just after excision, made by the 
 author with a simple lever (Fig. 20). The beats are abnormally slow, probably from 
 irritation of the vagus or venous sinus during excision. 
 
 FIG. 59. Tracing from the same heart, in which the beats have been quickened by 
 heat applied by placing a spirit lamp a good way under the plate on which the heart 
 rests. 
 
 FIG. 60. Continuation of Fig. 59. The heart is becoming warmer, and the beats 
 become quicker, irregular, and intermittent. 
 
 FIG. 61. Continuation of Fig. 60. The heat has become greater, and the heart 
 stops in heat tetanus. On the removal of the spirit lamp the beats recommence, but 
 are faint and irregular. 
 
 FIG. 62. Subsequent extreme slowing by placing a piece of ice under the plate on 
 which the heart rested. The tremors are probably entirely due to the movement of 
 the hand holding the ice, and not to the heart.
 
 EFFECT OF HEAT AND COLD ON THE HEART 
 
 53 
 
 FIG. 63. 
 
 Shows the spontaneous recovery after removal of the ice. 
 in groups of three. 
 
 The beats occur 
 
 FIG. 64. Cold was reapplied, and the beats again became slow. 
 
 FIG. 65. . Continuation of Fig. 64. Increasing slowness of the beats as the heart 
 
 becomes colder. 
 
 FIG. 66. The first part of the tracing shows normal beats, the heart having recov- 
 ered from the effects of the cold. The second part shows the effect of renewed heating. 
 The slowness is probably due to the rapid change of temperature having irritated the 
 vagus ends or inhibitory apparatus in the heart. 
 
 FIG. 67. 
 
 Continuation of Fig. 66. Shows increased slowness, then great rapidity, 
 and final stoppage in heat rigor.
 
 54 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 temperature of the interior of the body remains nearly the 
 same, notwithstanding the extremes of heat and cold to which 
 the extremities may be subjected, and in them it is necessary 
 to have a nervous system to regulate the pressure of blood. 
 
 FIG. 68. Author's apparatus for ascertaining the effect of heat and cold on the 
 vessels of the frog's lungs. A, a piece of cork to which the frog is fastened, is laid on 
 B, the stage of a microscope, and attached by an india-rubber strap, C. D is a small 
 ring of cork covered with a thin circle of glass. B is the inflated frog's lung. F is 
 a tube by which a current of air can be directed on the frog's lung. It is held in 
 position by a piece of wire, G, which can be bent to any position. I is a flask con- 
 taining ice and water. H, a flask containing hot water. K is a three-way stopcock, 
 by which a current of air may be sent from the spray-producer, L and M, through 
 tither 7 or H at will, and thus cold or hot air may be applied alternately to the lung.
 
 SCHEMA OF CIRCULATION HJEMODYNAMOMETER 
 
 55 
 
 FIG. 69. Author's schema of the circulation. It consists of a spray producer, 
 bladder, and mercurial manometer. The elastic ball of the spray producer represents 
 the heart, the elastic bag covered with netting to prevent too great distension repre- 
 sents the aorta and arterial system, and the bladder represents the venous system. 
 
 FIG. 70. Marey's haemodynamometer. By having the reservoir of mercury very 
 large, the descent of mercury in it is practically negligible, and the pressure may be 
 read off directly from the ascending limb. Two tubes are attached. In one the 
 mercury oscillates rapidly, with variations in pressure. In the other there is a con- 
 striction, the mercury hardly oscillates at all, and the mean pressure is thus easily 
 ascertained.
 
 50 THERAPEUTICS OF THE CIRCULATION 
 
 Effect of Heat and Cold on Pulmonary Capillaries. By 
 
 means of the apparatus shown in Fig. 68, I found that if a 
 stream of warm moist air be first directed in the lung of a frog., 
 and immediately afterwards a stream of cold moist air. the 
 
 FIG. 71. Ludwig's kymograph, copied from Ludwig's Lehrbuch der Physiologic, 
 2te Auflage, 2ter Band, p. 122. It consists of a bent glass tube, abc, containing 
 mercury, and connected by d with the artery of an animal. ef is a slender upright 
 rod, swimming on the surface of the mercury, and bearing at its free end, /, a brush, 
 g, which registers the movements of the mercury on the revolving cylinder, hh. 
 
 capillaries sometimes contract as much as one-third of their 
 diameter under the influence of the cold. British Medical 
 Journal, February 13, 1875.
 
 SCHEMA OF THE CIRCULATION MANOMETER 
 
 57 
 
 Schema of the Circulation. I have here a simple schema, 
 consisting of an india-rubber ball representing a heart, an elas- 
 tic bulb representing the arteries, a soft-walled bag represent- 
 ing the veins, and this I have connected with a mercurial 
 manometer, in order that you may see the comparative effects 
 of the heart and vessels upon the pressure in the arterial sys- 
 tem. (Fig. 69.) The soft-walled bag, or veins, can contain 
 
 FIG. 72. Registering metallic manometer of Marey. m is the capsule of an 
 aneroid barometer filled with liquid. T is a tube connecting m with an artery. b is 
 a mercurial manometer, which can either be put in communication with m, and the 
 exact pressure in it and the artery connected with it ascertained, or may be cut off 
 by the stopcock. * is a registering apparatus, and p a blackened plate on which the 
 lever writes. When the stopcock is open the lever will record the oscillations caused 
 by the momentum of the mercury, but if it be shut as soon as the actual pressure 
 has been ascertained, only the actual variations in the blood pressure will be recorded. 
 
 all the fluid in the whole vascular system, or even more, so that 
 we may commence with the pressure at zero. As the india- 
 rubber ball, which I may shortly call the heart, is emptied, it 
 drives the fluid into the elastic bulb, or arterial system. If the 
 passage is left open into the venous bag, the mercurial column 
 oscillates with each pulse, rising as the fluid is driven in, and 
 sinking again in the interval. But if I slightly turn the stop-
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 73. Tracing of the oscil- 
 lations in a mercurial manometer. 
 The first upward stroke is due to 
 sudden rise of pressure. The 
 subsequent fall below zero and 
 the other oscillations are due to 
 the inertia of the mercury, and 
 not to any external force. Com- 
 pare with Fig. 53. 
 
 FIG. 74. Tracing made with one of Marey's tam- 
 bours. The upward strokes correspond to rise of pres- 
 sure in the tambour. The inertia of the lever is very 
 small, and consequently there are no secondary falls 
 below the zero line, nor secondary oscillations, as in a 
 mercurial manometer. Compare with Fig. 73. 
 
 Writing point. -\. 
 
 Piston to lessen | 
 oscillation of 
 point 
 
 Tube filled with 
 glycerine 
 
 Syringe for altering 
 pressure in the 
 manometer. 
 
 Flat metal tube form- 
 ing the manometer. 
 
 Leaden tube to con- 
 nect the manometer 
 and the artery. 
 
 FIG. 75. Pick's kymograph. It consists of a flat metal tube, bent into a nearly 
 circular form, filled with alcohol, and connected with the artery by means of a leaden 
 tube, filled with a solution of sodium carbonate. When the pressure increases within 
 it, the tube straightens, and when the pressure diminishes it bends. These changes 
 are magnified, and recorded on a cylinder by a light lever. The vibrations of the 
 lever are lessened by a piston, which works in a tube filled with glycerine.
 
 KYMOGRAPHS 
 
 59 
 
 cock so as to prevent all the fluid driven in at each pulsation 
 from going into the veins, the pressure will gradually rise in 
 the bulb until it is sufficient to drive out during the diastole all 
 the fluid sent in during the systole. 
 
 Kymographs. The pressure is measured in animals by 
 putting a cannula into an artery and connecting it with a mer- 
 curial manometer. In order to prevent coagulation, the tube 
 leading from the artery to the manometer is filled either with 
 
 A 
 
 FIG. 76. Diagram to illustrate author's method of combining Ludwig's and Pick's 
 kymographs for registering the blood pressure and pulse. A is the cannula for inser- 
 tion into an artery. B is a Y-tube by which the artery can be put in communication 
 either with a mercurial manometer D, or a Fick's kymograph F, or with both of 
 them at the same time. C and C' are two clips by which the communication of either 
 or of both manometers with the artery can be shut off at will, or a three-way stopcock 
 may be employed instead. is a slowly revolving cylinder on which the mercurial 
 manometer registers the blood pressure. G is a rapidly revolving cylinder on which 
 the Fick's kymograph registers the pulse beats from time to time, and on which the 
 respiration can also be registered. (Phil. Trans., 1891, vol. clxxxii.) 
 
 some saline solution, or solution of peptone, which hinders 
 coagulation. The oscillations of the mercurial column are 
 recorded on a revolving cylinder, and the whole instrument, 
 consisting of mercurial manometer and recording cylinder, is 
 called a kymograph. 
 
 You will notice that when the mercury is once set into oscil-
 
 6o 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 lation it continues to oscillate for a length of time after the 
 force which first started it has ceased, and in this way prevents 
 us from getting any exact information regarding the time dur- 
 ing which the force has acted. (Fig. 73.) 
 
 In order to avoid these intrinsic oscillations other recording 
 instruments have been employed, such as the spring manometer 
 of Fick, in which the tension causes a curved tube to straighten 
 or bend (Figs. 75 and 76), or the manometers of Hurtle or 
 Roy, where the oscillations are very small, but are much mag- 
 nified by the recording lever. 
 
 Blood Pressure in Animals. The average blood pressure 
 in animals varies according to their size, but not to the extent 
 that we should imagine. In a horse it has been found to be 
 roughly between 200 and 300 millimeters, in a dog 140 to 170, 
 in a sheep 150 to 170. 
 
 Blood Pressure in Man. In man it has been found to be 
 from 100 to I6O, 1 in cases where it was estimated in a limb 
 before amputation. 
 
 FIG. 77. a, Simple instrument for measuring the blood pressure in an artery. 
 b, In this an improvement has been made on the simple form by adding a side spring 
 catch, which obviates the necessity of reading the index before removing it from 
 the arm. 
 
 Measurement of the Blood Pressure in Man. It is nat- 
 urally of very great importance that we should be able to esti- 
 mate the pressure in man, and numerous instruments have been 
 devised for this purpose. 
 
 By simply feeling the pulse with a finger, one can roughly 
 
 1 Faivre and Albert, quoted by Tigerstedt, Lehrb. d. Physiol. d. Kreis- 
 laufs, p. 329 (Leipzig: Veit & Co., 1893).
 
 MEASUREMENT OF BLOOD PRESSURE IN MAN 
 
 6l 
 
 make out whether the pressure within it is high or low, and 
 this is still better done by placing three fingers upon the pulse 
 
 FIG. 78. Shows the mode of applying the simple sphygmomanometer, by pressing 
 it directly on the palpating finger instead of pressing it on the artery, and feeling 
 the artery nearer the hand. (After Verdin.) 
 
 and compressing it with the one nearest the heart and noticing 
 with the middle one when it ceases to beat. By the amount 
 
 FIG. 79. Shows an instrument in which the movements of the spring are magnified 
 and read off on a dial. There is a movable index which is pushed on by the indicator, 
 and left at the maximum point. (After Verdin.) 
 
 of pressure exercised, one can form some judgment regarding 
 the tension, but it is evident that one cannot convey any quan- 
 titative knowledge regarding the pulse felt this way to another.
 
 62 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 The third finger nearest the hand compresses the artery so as 
 to obstruct the recurrent pulse from blood flowing through the 
 ulnar artery and palmar arch. 
 
 Instruments for Measuring the Blood Pressure in Man. 
 
 FIG. 80. Instrum 
 
 of blood in the capillaries. 
 
 These may be roughly divided into two classes : ( i ) those 
 which compress a single artery; (2) those which compress a 
 digit or limb. One instrument of the first class is simply a 
 little knob attached to a graduated scale 
 in a spring balance, like what is often 
 used for weighing letters. (Figs. 77 and 
 78.) The movement of the scale here is 
 so small that it is practically of little use. 
 In another more elaborate one the move- 
 ment is multiplied by a wheel, so that the 
 pointer shows the pressure on a large dial 
 (Fig. 79), but this instrument also is un- 
 satisfactory, as it is difficult to apply it 
 directly over the vessel, and the data ob- 
 tained from it are not very trustworthy. 
 Better and more exact results are obtained 
 by the substitution of a fluid of a solid 
 pad. So far as I know, the first man to 
 use a fluid pad over the artery was Heris- 
 son. His instrument consisted of a small 
 funnel covered at its larger end by a thin 
 membrane, and having a long graduated 
 glass stem at its other end. (Fig. 81.) 
 The whole apparatus was filled with mer- 
 cury. The simple apparatus of this sort 
 which I now show you was made by Professor Waller. "\Yhen 
 it is placed upon the radial artery you see the mercury oscillat- 
 ing with each beat, and by and by when the pressure applied 
 
 FIG. 8 1. Sphygmoma- 
 nometer of Herisson. 
 (After Marey.)
 
 VON BASCH S SPHYGMOMANOMETER 
 
 to the vessel becomes sufficiently great the pulsations below the 
 instrument cease. 
 
 The disadvantage of Herisson's instrument and others made 
 upon the same pattern is, that it is very difficult to keep the 
 mercury from oozing out between the end of the funnel and 
 
 --Graduated tube 
 
 lj|--Water 
 
 Opening in 
 glass bulb 
 
 Mercury 
 Glass bulb 
 
 Brass collar 
 
 Membranfj 
 
 -Graduated tube 
 -Rubber stopper 
 
 ^-^ -Water 
 
 -Bulb 
 -- Mercury 
 
 - Rubber stopper 
 
 > with central hole 
 
 Grounded lower 
 
 end 
 
 --Membrane 
 
 b 
 
 FIG. 82. Early form of Von Basch's sphygmomanometer (a). The lower part, 
 showing the india-rubber or oil-silk cap, is not quite correct, as this part of the instru- 
 ment in the author's possession has been lost, b shows the author's cheap modification 
 made by Messrs. Cetti & Co. 
 
 the membrane which covers it. To obviate this difficulty, my 
 old friend Von Basch enclosed the mercury in a glass bulb 
 into which the glass tube passed. This was then enclosed in 
 an outer cylinder the lower end of which was covered by 
 membrane, and which was filled with water, which trans- 
 mitted the pressure to the mercury through a small hole in 
 the bulb. This manometer was screwed into a stand in 
 which the wrist was clamped, and the manometer gently 
 depressed on the radial until the pulsation ceased, as was
 
 6 4 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 indicated by a small pad resting on the artery and communi- 
 cating with a Marey's tambour. This was the first instru- 
 ment of real practical use, and although Herisson's instru- 
 ment was long anterior, yet Von Basch must, I think, be re- 
 
 FIG. 83. Von Basch's sphygmomanometer and stand. Drawn from one in the 
 author's possession. A is the india-rubber cap of the sphygmomanometer resting on 
 the radial artery. B is a metal ring which holds the sphygmomanometer, and can be 
 raised or lowered at will by the screw C. D is the stand in which the arm rests. 
 is a sliding piece which holds the arm in position, and also supports the sphygmo- 
 graph I. F is a screw to fix in position. G is a fixed projection at the other end 
 of D, and the wrist is clamped between E and G. G consists of two parts, one of 
 which is quite fixed; the other, indicated by K, can be pressed more or less firmly 
 against the arm by a fine screw not shown in the drawing. H is a fine screw by which 
 the tambour of the sphygmograph can be raised or lowered so that it rests with more 
 or less pressure on the top of the rod which passes up from a small pad which rests 
 in the artery. K indicates the position of this pad as well as of the movable piece 
 of G. L is a joint in which a lever plays, the outer end of which is fixed to the 
 pad K, and keeps it moving in a perpendicular line. M is a joint allowing of con- 
 siderable horizontal play backwards, forwards, laterally, and circularly, so that the 
 sphygmograph may be accurately adjusted over the artery. N is a screw by which 
 the whole sphygmograph may be moved up and down on the stand O. P is one of 
 Marey's tambours, communicating by a piece of elastic tubing with the tambour of the 
 sphygmograph, and writing the pulse on the blackened cylinder V. R is a screw work- 
 ing on a spring, by which the resistance of the lever resting on the tambour may be 
 adjusted. S is a screw by which the tambour may be moved up and down on the 
 stand T. F is a revolving cylinder covered with blackened paper, on which the 
 tracing is taken. It is moved by clockwork, which is not shown in the drawing.
 
 VON BASCH S SPHYGMOMANOMETER 65 
 
 garded as the practical founder* of the measurement of blood 
 pressure in man. (Figs. 82 and 83.) 
 
 A good many years ago I got Mr. Cetti, of Brook Street, 
 Holborn, to make up instruments of this sort for me for use in 
 the wards at St. Bartholomew's Hospital. Instead of the 
 metal collars at the ends of the cylinder, I used two rubber 
 stoppers with a hole in the center of each. Through the upper 
 one passed the stem of the manometer. The lower end of the 
 other stopper was rounded at the edges, so that the membrane 
 fitted better over it, and it could be applied more easily to the 
 artery. These instruments Mr. Cetti manufactured for a few 
 
 FIG. 84. Von Basch's sphygmomanometer, from a specimen in the possession of the 
 author. A is a three-way stopcock, by which the aneroid B can be put in communica- 
 tion either with the bulb C or with the outer air. This is not the first form of Von 
 Basch's sphygmomanometer. The bulb which he first used was included in a metal 
 case somewhat resembling Marey's cardiograph. My instrument needed repair, so I 
 sent it to Vienna, and it was returned by the maker, with the bulb figured above. 
 
 shillings. I found a small stopcock in the upper stopper use- 
 ful for the removal of air-bubbles, and complete filling of the 
 cylinder with water. (Fig. 826). 
 
 The instrument had the great disadvantage of not being 
 portable. Unless it was kept upright and was not shaken, the 
 mercury and water became mixed, and the instrument was use- 
 6
 
 66 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 85. Potain's modification of Von Basch's sphygmomanometer. This is made by 
 M. Boulitte, successor to M. Charles Verdin, 7 Rue Linne, Paris. 
 
 less for the time. It was therefore of little value for clinical 
 work. Von Basch accordingly invented another model, in 
 which pressure was applied over the artery by a metal cap 
 covered at one end by a thin membrane, and communicating 
 
 FIG. 86. Mode of applying Potain's sphygmomanometer. This figure is not quite 
 correct, for it is better to place the palpitating finger parallel to the artery instead of 
 at right angles to it. Only one finger should be used to feel the pulse, as, if two 
 are used, the elastic bulb is pushed too high above the end of the radius, and too 
 high a reading is obtained.
 
 OLIVER S SPHYGMOMANOMETER 67 
 
 at the other by a thick-walled rubber tube with an aneroid 
 barometer graduated in millimeters of mercury. In a later 
 model the metal ring communicated with the aneroid by an 
 opening in its side ; one end was covered with thin india-rubber 
 for application over the artery, and the other with thick india- 
 
 FIG. 87. Most recent form of Von Basch's sphygmomanometer. 
 
 rubber on which the finger was pressed until the pressure in- 
 side the apparatus was sufficient to stop the pulse. (Fig. 84.) 
 A further improvement was introduced by Potain, who 
 replaced the metal ring by moderately thick rubber, so that 
 the bulb for application over the radial consists of thin rubber 
 
 FIG. 88. Oliver's Sphygmomanometer. Instead of the pad which rests on the 
 artery being solid, it consists of an elastic capsule containing fluid. This is made by 
 Mr. Hawksley, 357 Oxford Street, London. 
 
 at the side which lies against the wrist, thick rubber (usually 
 of a red color) at the opposite side on which the compressing 
 finger rests, and moderately thick rubber between. With this 
 exception, Potain's instrument is the same as Von Basch's 
 (Fig. 85).
 
 68 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 The latest form of Von Basch's apparatus is still simpler, 
 and consists of an elongated rubber bag of the same thickness 
 in every part. 1 (Fig. 86.) 
 
 Fallacies in Applying Von Basch's or Potain's Instru- 
 ments. Unless the elastic bulb is placed above the end of the 
 radius, and not over the soft tissues, so that the artery can be 
 compressed between it and the bone, too high a reading is 
 
 FIG. 
 
 Pick's apparatus for measuring and recording changes in the volume of 
 organs. (After Marey.) 
 
 obtained. If the palmar arch is dilated the recurrent pulse 
 through it from the ulnar artery may cause pulsation to be 
 felt after the radial has been completely compressed by the 
 bulb. To avoid this the palpating finger should be placed on 
 the radial artery with the tip pointing upwards. Any recur- 
 rent pulse is then stopped by the pulp of the finger, and the 
 central radial pulse is felt by the finger tip. 
 
 Another apparatus which also depends on the application of 
 a fluid bulb over the pulse, is a very neat little one invented by 
 Mr. Leonard Hill. Like Herisson's, it consists of a funnel 
 closed at one end by a thin membrane. The funnel is very 
 flat, and Mr. Hill has avoided the difficulty of using mercury, 
 and has rendered the instrument portable by employing a 
 
 1 This is made in Vienna, but can be obtained from Messrs. Down Bros., 
 21 St. Thomas's Street, S. W., London.
 
 FALLACIES OF BULB INSTRUMENTS 
 
 6 9 
 
 colored liquid having no weight in itself, but working against 
 the resistance of a column of air prevented from escaping by 
 a stop-cock at the upper end of the tube, and compressed by 
 any pressure on the membrane. It is very light and portable, 
 but unless a good deal of care is taken, air-bubbles are apt 
 to become mixed with the liquid, and cause some loss of time 
 before they can be got rid of. Oliver's hsemodynamometer 
 has, like those just described, a fluid pad consisting of thin 
 
 FIG. 90. Mosso's plethysmograph. A is a glass vessel filled with oil or water in 
 which the arm is inserted and the liquid prevented from escaping by an india-rubber 
 cap. t is a thermometer, b an opening for filling or emptying the apparatus. When 
 the arm swells, a little of the fluid passes from the glass vessel through the tube a 
 into the test-tube B, which is thus rendered heavier, and by a thread running over a 
 pulley raises the writing point and registers the increased size of the arm. When the 
 vessels of the arm contract, its size diminishes, fluid returns into A and the writing 
 point falls. c is a vessel containing water, in which the tube B is partially immersed 
 so that its weight is counterbalanced. is a burette which can be made to com- 
 municate or clamped off at will, and the quantity of fluid in B regulated to a nicety. 
 
 rubber filled with water and glycerine, for application over the 
 artery. The pressure from this pad is not conveyed from its 
 interior to a recording apparatus, but by a rod, one end of
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 91. This is a combination of the plethysmograph with 
 Marey's metallic manometer. By raising or depressing the vessel 
 R the pressure inside the' plethysmograph may be increased or 
 diminished at will, and the pressure measured by noting the 
 point of maximum oscillation or entire arrest of pulsation. 
 (After Verdin.)
 
 BAND INSTRUMENTS FOR ESTIMATING BLOOD PRESSURE 
 
 which rests upon it whilst the other presses in a spring. The 
 motion of the spring is shown, greatly magnified, by an index, 
 which moves over a scale 1 1 inches long, but conveniently ar- 
 ranged in the form of a helix on a dial 2 inches in diameter. 
 Band Instruments for Estimating Blood Pressure. In- 
 struments belonging to the second class, viz. encircling a digit 
 or a limb, were first used by Piegu, Chelius, Pick, Buisson, 
 Marey, Mosso, and Frangois to measure the volume of blood 
 which enters a limb at each pulse, and show the kind of pulsa- 
 tion in them under various conditions of the circulation rather 
 than to measure the pressure of blood in the arteries. Piegu 
 enclosed an entire limb in a vessel filled with tepid water, and 
 furnished with a narrow tube in which the water could be 
 
 8* 
 
 FIG. 92. Marey's apparatus for measuring the blood pressure in a finger. 
 
 seen to rise and fall with each pulsation. Chelius and Pick 
 independently connected this tube with Ludwig's kymograph, 
 and were thus able to obtain tracings of the variations. The 
 apparatus was perfected by A. Mosso, who gave it the name 
 of plethysmograph.
 
 72 THERAPEUTICS OF THE CIRCULATION 
 
 When the pressure in such an instrument is artificially raised 
 the oscillations increase up to a certain maximum, then dimin- 
 ish, and finally cease. The maximum is considered to repre- 
 sent the diastolic pressure in the arteries, and the cessation to 
 be equal to the systolic pressure. It is not easy to prevent 
 
 FIG. 93. Mosso's sphygmomanometer. It consists of metal tubes () filled 
 with water, which is prevented from coming out by india-rubber finger-stalls into 
 which the fingers are inserted. The apparatus is then quite filled with water from the 
 bottle B, air being allowed to escape at C. The pressure is then raised by com- 
 pressing the water in the reservoir (A) by the screw at its top until the mercury in 
 the manometer (G) registers the maximum oscillation, which may be taken as the 
 diastolic pressure. The pressure is then raised until the mercury ceases to oscillate, 
 and this may be taken as the systolic pressure. 
 
 leakage when the pressure is raised in an instrument where the 
 limb is immersed directly in the fluid, for it is apt to exude 
 between the skin and the rubber collar surrounding the limb,
 
 PLETHYSMOGRAPHS 
 
 73 
 
 unless the ligature is so tight as both to be very uncomfortable 
 to the subject, and to interfere with the circulation. 
 
 Marey 1 and Mosso both overcame this difficulty, by enclos- 
 ing liquid by a thin membrane through which the pulsations 
 of the finger or limb were transmitted. In Marey's instrument 
 
 FIG. 94. Plethysmograph of Hallion and Comte. 
 
 only one finger was enclosed, while in Mosso's four fingers are 
 introduced into the sphygmomanometer. In both of these 
 instruments the pressure is raised artificially by driving in air 
 or water, until the oscillations of the manometer reach a 
 maximum, and then pushing the pressure till they cease alto- 
 gether, and the circulation in the fingers is stopped. By re- 
 laxing the pressure the oscillations again reach a maximum as 
 the circulation again returns. In this way, a double observa- 
 tion is made. 
 
 In Gaertner's tonometer the pressure is measured by empty- 
 ing a finger of blood, and noting under what pressure the 
 circulation returns. (Fig. 95.) 
 
 It consists of a metal ring 1.5 cm. broad, to the inside of 
 which an india-rubber membrane is fixed, so as to leave an air 
 space between it and the ring. This space communicates by an 
 
 1 Marey, Trav. Lab., torn, ii., p. 31.3.
 
 74 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 95. Gaertner's tonometer. 
 
 opening in the side of the ring, and a T-tube with a mercurial 
 manometer and a pressure ball consisting of a closed india- 
 rubber bag compressed in a wooden vise. An open bag with 
 good valves and adjustable outlet may be employed instead. 
 This is placed loosely on the middle phalanx of one finger, and
 
 MODE OF USING GAERTNER S TONOMETER 
 
 75 
 
 the blood pressed out of the last phalanx either by rolling a 
 thick narrow india-rubber ring upwards, or by wrapping a piece 
 
 FIG. 96. Gaertner's tonometer, portable fo 
 
 FIG. 97. Mode of using Gaertner's tonometer. 
 
 of fine india-rubber tubing tightly round the finger from its 
 tip upwards. The pressure is then raised in the apparatus to
 
 7 6 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 a point which is certain to be above the pressure in the arteries, 
 e. g., 200 mm. of mercury. The india-rubber ring is then 
 rolled off or the tube unwound, leaving the last phalanx white 
 and bloodless. The pressure is then lessened and the finger- 
 tip watched, so as carefully to note when it begins to flush 
 with the returning circulation. The height of the mercurial 
 
 FIG. 98. Combined Potain's and Gaertner's apparatus. AP is Potain's bulb. 
 DG is Gaertner's tonometer. P is an india-rubber bulb containing air, by which 
 the pressure can be raised in the tonometer. M is an aneroid manometer. R', R" 
 and R'" are stopcocks by which communication can be established at will between the 
 various parts of the apparatus. 
 
 column at this moment indicates the systolic pressure in the 
 digital arteries. 
 
 For ordinary bedside work, Professor Gaertner replaces the 
 mercurial by an aneroid manometer, and thus renders his 
 instrument convenient and portable. (Fig. 96.)
 
 LECTURE III 
 
 Measurement of the Blood Pressure in Man (continued) : Instruments 
 of Riva-Rocci, Hill and Barnard, Martin, and others; Author's arrange- 
 ment Systolic and Diastolic Pressures Standardization of Instruments 
 Measurement of the Size of an Artery Oliver's Arteriometer Measure- 
 ment of Pressure in the Veins Measurement of Pressure in the Cap- 
 illaries Measurement of the Volume of Organs Plethysrhographs Car- 
 diographs Sphygmographs Forms of Sphygmograph : Marey's, Ludwig 
 and Von Frey's, Dudgeon's, Jacquet's, Laulanie's Size of Vessels 
 Cardiograph and Sphygmograph Sphygmograms Retardation of Pulse- 
 wave Nutrition of the Heart Self-massage of the Heart Brucke's 
 View Nutritive Action of Cardiac Tonics Self-massage of the Arteries. 
 PATHOLOGY OF THE CIRCULATION Effect of Altered Quality of Blood 
 Blocking of Coronary Arteries Effect of Feebleness of the Heart on the 
 Nutrition of Blood-vessels Nervous Depression Fatty Degeneration 
 Pulse-rate Exophthalmic Goitre. 
 
 PERHAPS the most practically useful of all the instruments 
 for estimating the blood pressure in man is that invented by 
 Riva-Rocci, with its numerous alterations and improvements. 
 It consists of an elongated distensible but resistant bag con- 
 nected with a mercurial manometer (Fig. 99). The bag is 
 fastened round the arm and inflated by a small india-rubber 
 hand-pump until the pressure is sufficiently great to stop the 
 pulse. This point is noted, and the pressure is then increased 
 a little further; air is then gradually let out, and the pressure 
 is again noted when the pulse begins to reappear. In this 
 way one has actually two observations made close together of 
 the pressure which stops the flow of blood in the artery. The 
 objections to the instrument in its original form are that the 
 narrow band appears to give a higher reading than what is 
 attained by a broader one, and that mercurial manometers are 
 always inconvenient for carrying about. Hill and Barnard 
 have made an instrument in which these objections are avoided, 
 by making the band broader, by making its outside of leather 
 so that it does not yield, and its inside of thin rubber, and by 
 
 77
 
 7<5 THERAPEUTICS OF THE CIRCULATION 
 
 employing an aneroid instead of a mercurial manometer. 1 
 Another modification is Martin's, in which the band is made of 
 soft pliable metal covered with cloth, and it is sufficiently broad 
 to overlap the elastic bag by about half an inch on either side, 
 and thus prevent the bag being blown out to one side. 2 He 
 has also added a convenient screw valve, by which the air may 
 be allowed to pass out of the apparatus very slowly and the 
 
 FIG. 99. Riva-Rocci's sphygmomanometer. 
 
 pressure to diminish very gradually. Martin retains the mer- 
 curial manometer, so that this is inconvenient for carrying 
 about. I have had one made which I think is more convenient 
 than any of the others, but I can hardly claim it as my own, 
 because it is simply a patchwork of pieces from one instrument 
 and pieces from another. (Fig. 100.) The principle of the 
 
 1 Hill and Barnard. * C. J. Martin.
 
 AUTHORS APPARATUS 
 
 79 
 
 band is Riva-Rocci's ; the broad band I have copied from 
 Martin, but have substituted a piece of unyielding tissue which 
 is light to carry, in place of the heavier metal; the principle 
 of the aneroid is Von Basch's, the particular modification of 
 it is Potain's. By combining all these parts together, however, 
 
 FIG. 100. The author's modified Riva-Rocci band. AB is a band of thin gutta 
 percha inside which is a narrower india-rubber bag C. D are three straps to fasten 
 the band round the arm. is a tube leading into the bag C, and allowing air to 
 pass from it either to a mercurial or aneroid manometer. In using it along with the 
 other instruments, all that is necessary is to detach the tonometer DG, Fig. 81, and 
 replace it by the band. A spray-producer ball, like that in Fig. 81, should also be 
 used instead of the simple bulb P, or a small one with Martin's valve may be em- 
 ployed. For practice one rarely needs all three, and Potain's bulb with the band 
 and aneroid are all that are necessary. 
 
 I have obtained a very convenient instrument by which we can 
 in a few minutes measure the tension of the blood in the 
 radial artery by pressure upon it with Potain's bulb, and con- 
 trol this observation by means of Gaertner's tonometer, or by 
 measuring the pressure in the arm necessary to stop the radial 
 pulse with the modified Riva-Rocci band. I have been making 
 a number of comparative experiments in regard to the ten- 
 sion in man, as ascertained by different instruments, and have 
 been rather disappointed by the want of concordance between 
 the results. Using these three instruments together, however, 
 I am certain of obtaining results which agree very well with 
 one another. 
 
 Many modifications of Riva-Rocci's instrument have been 
 made and used in America. They are described by Janeway 1 
 
 1 T. C. Janeway, "The Clinical Study of Blood Pressure" (New York 
 and London: Appleton & Co.), 1004.
 
 8O THERAPEUTICS OF THE CIRCULATION 
 
 in his work on " The Clinical Study of Blood Pressure," but 
 I do not think it necessary to describe them fully here. I may 
 
 FIG. 101. Author's arrangement for using a broad Riva-Rocci band with Von Basch's 
 or Potain's sphygmomanometer instead of a mercurial manometer. 
 
 merely mention that the principal are Stanton's, Janeway's 
 and Erlang-er's. They are all modifications of Riva-Rocci's.
 
 AMERICAN SPHYGMOMANOMETERS 
 
 8l 
 
 Janeway's has the mercurial manometer jointed for conveni- 
 ence of carriage, and Erlanger's has a large sphygmoscope at- 
 tached, which enabled the alterations in pressure to be recorded 
 
 FIG. 102. Marey's Improved Metallic Manometer. This was originally intended 
 to be connected to an artery, but I find it can be connected to an armlet, or used 
 to measure the blood pressure in the same way as Riva-Rocci's, while at the same 
 time tracings can be got of the pulse. (Cf. Fig. 91, p. 70.) It consists of a flat, 
 metallic vessel B in which the capsule of an aneroid barometer filled with liquid is 
 fixed, CA. To this leads an afferent tube T, which is put in communication with 
 the artery, the pressure in which is to be measured. An efferent tube Y, leads to 
 a mercurial manometer, which indicates the absolute pressure and controls the readings 
 of the metallic manometer. The metallic vessel B has at its upper part a glass tube 
 TV, and is filled with water which rises a little way up in the glass tube. The 
 upper part of this tube is closed by a caoutchouc stopper, through which a tube T 
 passes; this tube is connected by a piece of elastic tubing with one of Marey's tam- 
 bours, which records the oscillations of the aneroid capsule. By means of the stop- 
 cock R, the metallic may be separated from the mercurial manometer; P is a pair 
 of pincers closing an exit tube, by which the instrument can be either emptied or 
 filled, or the tension lowered. 
 
 on a revolving cylinder in somewhat the same way as Marey's 
 instrument. (Figs. 91 and 102.) 
 
 7
 
 82 THERAPEUTICS OF THE CIRCULATION 
 
 Systolic and Diastolic Pressures. The point of maximum 
 oscillation indicates the diastolic pressure, the point of ob- 
 literation indicates the highest systolic pressure, and I find the 
 relation which these bear to one another is usually as 4 to 5, 
 or 80 to 100, though sometimes as 4 to 6. 
 
 The systolic pressure shows the maximum height to which 
 the blood pressure is raised by the wave of blood driven into 
 the aorta by the contraction of the left ventricle. It thus 
 indicates in a general way the strength of the ventricle. The 
 diastolic pressure shows the minimum to which the blood 
 pressure sinks during the interval when no blood is coming 
 into the aorta from the heart and the arterial system is empty- 
 ing itself through the capillaries into the veins. It therefore 
 indicates generally the degree of contraction or relaxation of 
 the capillaries. A glance at Figs. 182 (pp. 155-157) to 186, 
 which are reproductions of tracings taken with a mercurial 
 kymograph from the carotid arteries of dogs, will show at once 
 how greatly the relation between the systolic and diastolic 
 pressures and the relation of both of them to the general 
 blood pressure may differ under different circumstances. Thus, 
 in Fig. 183, the systolic maximum is 94 and the diastolic 
 minimum is 54, or, roughly, as 5 to 2. In Fig. 184 the sys- 
 tolic maximum is 100 and the diastolic minimum 62, or, 
 roughly, as 5 to 3. In Fig. 185 the systolic is 106 and the 
 diastolic 78, or, roughly, as 5 to 4. The great oscillation in 
 Fig. 182 may be partly due to inertia of the mercurial column 
 (cf. Fig. 73), but only to a slight extent. In Fig. 185 the 
 normal systolic is to the diastolic pressure as 5 to 4, but after 
 stoppage of the heart by irritation of the vagus it is nearly as 
 3 to i. 
 
 Standardization of Instruments. As an aneroid manom- 
 eter is apt to become altered by use, it is well to compare it 
 frequently with a mercurial one, and this can be done in less 
 than five minutes, by connecting both by means of a T-piece 
 with a spray-pump, raising the tension by 5 mm. at a time, 
 and noting the correspondence or difference in the readings of 
 the two instruments. (Fig. 103.)
 
 SIZE OF VESSELS PRESSURE IN VEINS 83 
 
 Size of Vessels. A most ingenious instrument for measur- 
 ing the size of the arteries has been devised by Dr. Oliver, and 
 is called by him the arteriometer. 
 
 Measurement of Pressure in the Veins. This may be 
 done by choosing any convenient portion of a subcutaneous 
 vein and pressing an instrument such as Figs. 78, 85, 87, or 
 
 FIG. 103. Author's apparatus for ascertaining the correctness or amount of error 
 in an aneroid sphygmomanometer. By means of a three-way stopcock both the aneroid 
 and a mercurial manometer are put into communication with a pressure bulb of a 
 spray apparatus. The pressure is then raised 50 mm. at a time, and the readings of 
 the mercurial and aneroid compared at each pressure. 
 
 88 upon its distal end with sufficient force to stop the flow of 
 blood. The proximal part is then emptied of blood by pressing 
 the tip of a finger along it. The pressure of the pad or bulb 
 is then relaxed, and the pressure noted at which the vein 
 again fills.
 
 84 THERAPEUTICS OF THE CIRCULATION 
 
 A simple way of roughly estimating the venous pressure is 
 to notice at what height above the level of the heart the veins 
 of the hand become empty. Normally, they should do so 
 about the level of the third rib, or a little above. The greater 
 the venous pressure the higher must the hand be raised. 
 
 Measurement of Pressure in the Capillaries. The method 
 of doing this we owe to Ludwig (N. v. Kries, " Ludwig's 
 Arbeiten," 1875, p. 69). It consists on laying in the skin a 
 piece of glass of a definite size, which can be pressed down 
 with more or less force, and noting the lowest pressure at 
 which the skin becomes white. The pressure can be applied 
 by a weight or by a spring. (Fig. 80.) The pressure may 
 be measured anywhere, but the back of a finger or the lobe of 
 the ear is most suitable. The pressure varies with the height 
 at which the hand is held. When level with the top of the 
 head, it is about 24 mm. of mercury (328 of water) : 8 inches 
 
 I CU 
 
 FIG. 104. Marey's tambour for recording movements. It is a metal ring which 
 slides on an upright rod, and can be fixed at any height by the screw B. C is the 
 tube through which the air from the receiving instrument (sphygmograph, cardiograph, 
 etc.) communicates with that inside the tambour and causes the cover E to rise or 
 fall. Into a long straw is fastened bearing a point which records its movements 
 on a cylinder. 
 
 below this, 28 mm. (397 of water). In the ear it is about 
 20 mm. of mercury (272 mm. of water). 
 
 Cardiograph and Sphygmograph. All the instruments I 
 have hitherto described have been chiefly for measuring the 
 amount of blood pressure, or the size of the artery, but they do 
 not give us any indication of the mode of contraction of the 
 heart or the nature of the pulse-wave. These have chiefly 
 been worked out by instruments devised by the late Professor 
 Marey, and the principle upon which most of them depend is
 
 INTRACARDIAC PRESSURE 
 
 that of the transmission of motion by air from one elastic 
 vessel to another. The recording vessel consists of a shallow 
 
 FIG. 105. Cardiac sounds by which the tracings, Fig. 108, were obtained. V is 
 a bulb which is introduced into the right ventricle, and communicates by a tube, TV, 
 with a tambour (Fig. 104). O is another bulb, which is placed in the auricle, and 
 communicates by a tube, TO, with another tambour. These tambours register the 
 intra-ventricular and intra-auricular pressures. af is a sound for the left ventricle, 
 communicating with a tambour by the tube g.
 
 86 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 metal dish covered at the top by a piece of thin india-rubber. 
 Over this rests a light lever, and the movements of the rubber 
 are thus greatly amplified, are rendered visible to the eye, and 
 can also be recorded on a revolving cylinder. The elastic ves- 
 sel by which the movements are received varies in shape ac- 
 cording to the purpose it is required to serve. For the heart 
 it is a long metal bulb with openings in its sides over which 
 the thin india-rubber is tied (Fig. 105). For the apex beat 
 it may be simply a tambour with a spring to press it against 
 the chest wall (Figs. 106 and 107), and for the pulse a tam- 
 
 FIG. 1 06. Marey's cardiograph. 
 
 MBb_- 
 
 FIG. 107. Burden-Sanderson's cardiograph for the 
 apex beat. 
 
 bour with a spring attached, which rests upon the pulse and 
 transmits its movements to the receiving tambour (Fig. 122). 
 The air within this is, of course, alternately condensed and 
 rarefied, and each movement is faithfully transmitted to the 
 recording tambour (Fig. 104). By introducing one of the 
 elongated bulbs just mentioned through the aortic valves into 
 the ventricle, Marey obtained tracings of the changes in pres- 
 sure throughout the ventricular cycle, as shown in Fig. 108. 
 There is first a slight rise, due to the auricular contraction, 
 then a sudden rise, which becomes somewhat slower as it 
 increases. At the top of this is a plateau showing several
 
 VENTRICULAR AND AORTIC PRESSURE 
 
 oscillations, then a sudden descent, marked at its end by a little 
 wave, and then an almost level line, after which the same se- 
 quence again occurs. The alteration in rapidity of ascent 
 which takes place about the middle of the systole probably indi- 
 cates the time at which the auriculo-ventricular valves become 
 screwed together, and the aortic valves are forced open by 
 the increasing pressure behind. The oscillations which occur 
 on the plateau, according to Marey, do not indicate mere vi- 
 brations of the auriculo-ventricular valves, but real oscilla- 
 tions in them and in the blood on both sides of them. The 
 sharp fall indicates the diastolic relaxation of the ventricle, 
 
 r 
 
 i. 
 
 FIG. 108. Tracings of the ventricular systole (i) and of the aortic pulse (2). In 
 the first tracing a manometric sound was placed in the left ventricle; after two beats 
 it was withdrawn at a from the auricle into the aorta. The second tracing is ob- 
 tained from a manometric sound placed permanently in the aorta. The part be and 
 &'</ is common both to the ventricular and aortic tracing. At this point the aortic 
 valves are open and the ventricle and aorta are in free communication; V in the 
 second tracing marks the point where the blood begins to flow into the aorta; v marks 
 the point where the mitral valves and v' where the sigmoid valves close. 
 
 and the little wave at the end marks the time of closure of the 
 sigmoid valves. 
 
 When the bulb is withdrawn from the ventricle into the 
 aorta, a tracing is obtained which is almost exactly like that 
 of the ventricle with the lower part of it cut off and a gradual 
 descent substituted for the sudden fall (Fig. 108, i (a, b, 
 and c), and 2).
 
 88 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 109. 
 
 Diagram to show the analogy of the senile pulse to the ventricular beat. 
 (After Marey.) 
 
 FIG. no. Sphygmogram showing the effect of increased tension on the pulse. 
 The first half was taken while both femoral arteries were compressed. The latter 
 half after the tension had been reduced by ceasing the compression. (After Marey.) 
 
 FIG. in. Tracing of a normal pulse. 
 
 FIG. 112. Shows three tracings of a healthy pulse with varying degrees of tension. 
 In i the tension is high owing to the contraction of the arterioles from cold; 2 and 
 3 show diminished tension from warm clothing causing relaxation of the arterioles. 
 (After Marey.)
 
 EFFECT OF ARTERIES ON PULSE WAVES 
 
 8 9 
 
 If the aorta were rigid, this form of curve would be trans- 
 mitted on to the periphery, and we do, indeed, find that the 
 
 FIG. 113. Effect of fever on the pulse; i is a tracing taken during fever; 2 is one 
 from the same patient when the fever was absent. (After Marey.) 
 
 radial pulse tracing shows the characters of the aortic pulse, 
 namely, the flattened plateau, and slow, rather even, descent 
 
 FIG. 114. Tracings of the pulse at different stages of intermittent fever: i, Pulse 
 in apyrexia; 2, stage of chill; 3 and 4, hot and sweating stages; 5, apyrexia; 6, an- 
 other chill. 
 
 whenever the elasticity of the arteries is impaired by athero- 
 matous change, as in old people (Fig. 109), or by great dis-
 
 9 o 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 tension from high arterial pressure (Fig. no), as in cases 
 of Bright's disease. 
 
 Sphygmograms. In ordinary healthy people the elasticity 
 of the aorta and arterial walls is sufficient to modify the trac- 
 ing very greatly, and in healthy people the sphygmogram has 
 the following characters : A fairly sudden and extensive rise 
 followed by a moderately quick fall for a certain distance, 
 
 FIG. 115. Tracing from a case of aortic regurgitation, showing hook at top of tracing. 
 
 then a second rise and then a second slower fall. (Fig. in.) 
 Whenever the vessels are empty, so that the blood is driven 
 in quickly during systole, the rise is sudden. When the ves- 
 sels are full and tense, so that the blood pressure within them 
 is high and blood is driven in slowly, the rise is slow. (Fig. 
 112, i ; 114, i, 2, and 6.) The same form of tracing may, to 
 a certain extent, also come from the feeble heart. The arteries 
 
 FIG. 1 1 6. Tracing showing dichrotism. 
 
 may be empty from aortic regurgitation, when the blood flows 
 backwards from the heart ; or from capillary dilatation, when 
 it flows rapidly onwards into the veins. (Fig. 112, 3; 113, 
 i.) In the former case the fall is, as a rule, very sudden 
 at the commencement, and the movements are very extensive. 
 In the latter, the fall is more gradual. In both cases, however, 
 the lever of the tambour may be raised so suddenly that its
 
 RETARDATION OF PULSE 
 
 FIG. 117. Radial pulse before a haemorrhage. (From Marey, after Lorain.) 
 
 FIG. 1 1 8. Radial pulse from the same patient, after a hemorrhage. (After Lorain.) 
 
 FIG. 119. Retardation of the pulse in different arteries. PV, curve o pres- 
 sure in the ventricle of the horse. A, aortic pulse. Ca, carotid pulse. F, femoral 
 pulse. Each square corresponds horizontally to one-tenth of a second. (After Marey.)
 
 92 THERAPEUTICS OF THE CIRCULATION 
 
 own inertia carries it beyond the point to which it ought to 
 go, and a little crochet or hook is formed at the summit of the 
 tracing. (Fig. 115.) A great deal of trouble has been taken 
 to ascertain the exact cause of the second, or dicrotic wave, 
 as it is termed, on the descending limb of the sphygmograph 
 tracing. (Fig. 116.) I shall not attempt to go into this ques- 
 tion here, but I shall merely say that exaggeration of the 
 dicrotic wave means increased power of the heart in reference 
 to the resistance it has to overcome, just as when I take this 
 elastic ball and strike it against the floor, it rebounds higher 
 the more force that I use. When the aortic valves are in- 
 competent, however, as a rule we do not get this rebound, and 
 the commonest cause of dicrotism is relaxation of the capil- 
 laries or arterioles. The most marked tracing of it that I 
 ever obtained was from a youth who had had very profuse 
 haemoptysis, so that he had become almost drained of blood. 
 (Cf. Fig. 118.) 
 
 Retardation of Pulse-wave. The pulse-wave takes a 
 certain time to travel from the heart to the periphery (Fig. 
 1 1 6), and if the heart is acting quickly this retardation may 
 make the radial pulse coincide with the cardiac diastole rather 
 
 FIG. 1 20. Marey's sphygmograph. 
 
 than the systole, and the carotid pulse should be used and not 
 the radial to fix the time of cardiac murmurs. 
 
 Forms of Sphygmograph. There are a number of forms 
 of sphygmograph: Marey's original one (Fig. 120) ; Marey's 
 as modified by Ludwig and Von Frey; Marey's sphygmo- 
 graph for transmission (Fig. 122), which is very convenient
 
 MAREY'S SPHYGMOGRAPHS 
 
 93 
 
 when one wishes to get simultaneous tracings of the heart, 
 radial pulse, and sometimes also of the large veins ; Dudgeon's 
 
 FIG. 121. Mode of applying Marey's sphygmograph. 
 
 FIG. 122. Marey's transmitting sphygmograph. 
 
 (Fig. 123), which, though perhaps less accurate, has come 
 much into use on account of its great convenience, readiness of 
 application, and portability : Jacquet's, which is like Dudgeon's,
 
 94 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 but is provided with a time-marker; and Laulanie's, which- can 
 be used on a finger. (Fig-. 124.) 
 
 The sphygmograph has given us much useful information 
 regarding the circulation, but has not become so extensively 
 
 FIG. 123. Dudgeon's sphygmograph. 
 
 used clinically as one expected forty years ago. (Vide Figs. 
 204 to 214.) No doubt, this is to a great extent due to the 
 very different tracings that are obtained according to the mode 
 of application, although when one is accustomed to use it 
 regularly the fallacies which would thus be introduced are 
 greatly lessened, and I. think it quite possible that the sphygmo- 
 graph may again be used more frequently, if employed in com- 
 bination with some instrument for estimating exactly the 
 arterial tension. 
 
 Nutrition of the Heart. The power of the heart to con- 
 tract quickly and powerfully depends, like that of the skeletal 
 muscles, on its nutrition, and this is regulated to a great extent 
 both by the quality and quantity of blood it receives. The 
 heart is like the priests of old, who took the best parts of the 
 offerings before the remainder was distributed to the people. 
 For the coronary arteries leave the aorta just above the sig- 
 moid valves, and consequently they get the first portion of 
 blood as it comes fully arterialized from the lungs, and, as 
 Sir R. Douglas Powell has pointed out, the heart is thus almost 
 more dependent than other organs upon proper pulmonary 
 aeration.
 
 CORONARY ARTERIES 
 
 95 
 
 The right coronary artery supplies chiefly the right side of 
 the heart. The left coronary artery supplies both the left 
 auricle and ventricle and also part of the right ventricle. The 
 terminal branches of the two coronary arteries communicate, 
 
 FIG. 124. Laulanie's digital sphygmograph. E, disc on which the pulp of the 
 finger rests. L, aluminium lever which rests by its projection H on the root of the 
 nail. M is a movable counterpoise which can be moved along the rod J so as to exert 
 on the finger the proper amount of pressure' required to obtain the maximum oscil- 
 lations of the lever. P, pulley with a writing point to magnify the movements of the 
 lever L. G is a rod terminating in a button for taking the radial pulse. In doing 
 this the disc E and the rod F which carries it are moved out of the way, and a heavier 
 counterpoise is employed. K is a bent rod which permits of an india-rubber band 
 being employed instead of the counterpoise. N Is a milled head which allows the rod 
 R to be moved up and down on the stem O, and tracings taken at different heights 
 on a revolving cylinder.
 
 g THERAPEUTICS OF THE CIRCULATION 
 
 but not freely enough to maintain circulation, if one of the 
 arteries be closed, although no doubt differences in this respect 
 exist in different animals, and probably in different men. 
 When an artery is closed very slowly, the communication with 
 the other one may gradually become sufficiently increased to 
 maintain the circulation after the first has become completely 
 occluded ; and the vessels of Thebesius, at least in the dog, 
 may maintain the circulation even after both coronary vessels 
 have been obstructed. In consequence of this, if one artery 
 be ligatured the heart usually ceases to beat, and the same 
 occurs if an embolism should obstruct the artery. If one 
 artery be narrowed by atheroma, that part of the heart which 
 it ought to nourish is apt to undergo fatty degeneration, and 
 one can readily see that, even if the artery remains of its 
 proper size, it may become relatively too small for a heart 
 which has undergone hypertrophy. 
 
 FIG. 125. Diagram to illustrate Bruck's view of the suction action of the ven- 
 tricular systole in drawing blood from the veins into the auricle. In both figures p 
 is the pericardium, v the ventricle, a the auricle, ao the aorta, and vc the vena cava. 
 For the sake of simplicity only one auricle and ventricle are represented. 
 
 Self-massage of the Heart. In speaking of the venous 
 circulation in the limbs, I mentioned that the muscular move- 
 ments tend to aid the return of venous blood, and the same 
 thing occurs in the heart; for, during the contraction of the 
 ventricle, blood is pressed out mechanically from its vessels, 
 and during diastole the arteries are filled again at high pres- 
 sure with blood from the aorta. The same thing probably 
 happens also with regard to the lymphatics, which run along- 
 side of the coronary arteries.
 
 SELF-MASSAGE OF THE HEART 97 
 
 As Briicke pointed out in one of his lectures, which I heard 
 in Vienna in 1867, the pericardium may be likened to a bell 
 jar, the walls of which are more or less rigid, the pericardium 
 being attached to the tissues all round it. (Fig. 125.) When 
 
 FIG. 126. Diagram of a transverse section of the thorax during inspiration and 
 cardiac systole. It shows the tendency to the formation of a vacuum in the pleural 
 and pericardial cavities. 
 
 the ventricle contracts, it tends to produce a vacuum in the 
 pericardium, and thus not only to suck blood into the auricles, 
 but to exert suction upon the ventricle itself, and thus to draw 
 
 FIG. 127. Diagram of a transverse section of the chest during expiration and 
 cardiac diastole, showing the pressure of the walls of the pleural and pericardial 
 cavities against each other. 
 
 plasma from the blood vessels into the cardiac muscle, and 
 also lymph into the pericardial space. When the heart dilates
 
 98 THERAPEUTICS OF THE CIRCULATION 
 
 again in diastole it tends to press the lymph out of the peri- 
 cardium, and thus keeps the pericardium always moist with- 
 out any accumulation of fluid occurring. The alternate con- 
 traction and dilatation of the heart thus keep up what we may 
 term a sort of self -massage, by which both the circulation of 
 blood and of lymph in and around it are properly maintained. 
 (Figs. 126 and 127.) It is evident, therefore, from what I 
 have just said, that the maintenance of the heart's nutrition 
 depends greatly upon its own activity, and this is a point of 
 extreme practical importance. 
 
 Nutritive Action of Cardiac Tonics. We can thus see 
 that, in cases where the nutrition of the heart is failing, drugs 
 
 FIG. 128. After Ziegler. Section of an atheromatous cerebral artery. a, Intima 
 considerably thickened; b, bounding elastic lamella of intima; c, media; d, adventitia; 
 e, necrosed denucleated tissue with masses of fatty detritus; / and /, detritus with 
 cholesterin tablets; g, infiltrated leucocytes in the intima; h, infiltrated leucocytes 
 in the adventitia. 
 
 which stimulate it to increased action do not act merely tem- 
 porarily as cardiac stimulants, but that they are really at the 
 same time cardiac nutrients. It is because of this fact that 
 the good effects which we see from the use of strychnine, 
 digitalis, strophanthus, caffeine, etc., in cardiac disease do not
 
 SELF-MASSAGE OF THE ARTERIES 99 
 
 cease when the drugs are withdrawn, but may continue and 
 increase, these drugs having given a temporary increase to 
 the power of the cardiac muscle which has enabled it to 
 nourish itself more efficiently. 
 
 Self-massage of the Arteries. Now, a very important set 
 of vessels in the body are the vasa-vasorum, the blood-vessels 
 which supply other blood-vessels. When these undergo 
 change, so that the blood-vessels themselves are badly nour- 
 ished, the condition of the circulation generally becomes very 
 precarious, for there is a great deal of truth in the old saying 
 that " a man is as old as his arteries." When his arteries 
 become atheromatous (Fig. 128) or calcareous, the termina- 
 
 i-iG. 129. Artery and vein in common sheath to show the effect of the arterial 
 
 pulse in aiding venous circulation. A, artery in diastole. V, distended vein. 5", 
 
 common sheath. A', artery distended by the cardiac systole. V, the vein compressed 
 and partially emptied of blood. 
 
 tion of the man's life is not likely to be very far off. But 
 the arteries also have a power of self -massage. The hard 
 fibrous tissue which forms their sheath usually envelops not 
 only the artery and vein, but also the lymphatics. Between 
 the intima and media of the artery, and probably in the media 
 itself, there are lymphatic spaces, and in the adventitia there 
 are distinct lymphatic vessels. The alternate distension and 
 relaxation of the arterial wall at each pulsation not only drives 
 blood and lymph onwards towards the heart at each beat of 
 the heart, but, during the diastole, as the blood runs out of 
 the artery, there is a tendency for the arterial coats to sepa- 
 rate from one another, and thus draw in fresh supplies of 
 blood into the vasa-vasorum, and of plasma from them into 
 the arterial walls. (Figs. 129 and 162.)
 
 IOO THERAPEUTICS OF THE CIRCULATION 
 
 PATHOLOGY OF THE CIRCULATION 
 
 Effect of Altered Quality of Blood. However good the 
 circulation may be through the heart or vessels, they will 
 suffer if the quality of the blood is bad. Thus, fatty degen- 
 eration of the heart is found in acute and chronic ansemia, in 
 old age, in failing nutrition from disease, and from various 
 poisons, e. g., in chronic alcoholism, or after the administra- 
 tion of chloroform, arsenic, or phosphorus. But a very fre- 
 quent cause are the toxins which occur in various diseases, 
 especially those of the infective fevers. Sometimes these 
 toxins instead of producing fatty degeneration, cause a general 
 softening of the muscular tissue or parenchymatous degenera- 
 tion, in which the muscular cells become degenerated but not 
 fatty. 
 
 Blocking of Coronary Arteries. Partial blocking of a 
 branch of the coronary artery may produce a local necrosis 
 of the cardiac wall, causing either sudden death or the forma- 
 tion of a fibrous patch. When the coronary arteries undergo 
 
 FIG. 130. After Gaskell. Tracing showing stoppage of the heart by stimulation 
 of the vagus. Aur. indicates the auricular, and Vent, the ventricular tracing. The 
 part included between the upright lines indicates the time during which the vagus 
 was stimulated. C.8 indicates that the secondary coil used for stimulation was eight 
 centimeters distant from the primary. The part of the tracing to the left hand shows 
 the regular contraction of moderate height before stimulation. During stimulation, and 
 for some time after, the movements of both auricle and ventricle are entirely arrested. 
 After they again commence, they are small at first, but soon acquire a much greater 
 amplitude than before the application of the stimulus. 
 
 gradual closure, the muscular tissue they supply either under- 
 goes fibrous change or fatty degeneration. In either case 
 the heart is much weakened; and in chronic valvular disease, 
 .and in old people, brown atrophy is common.
 
 BLOCKING OF CORONARY ARTERIES 
 
 IOI 
 
 In the arteries, as in the heart, interference with the blood 
 supply causes degeneration. In one form the nodular form 
 there is inflammation in and around the arterial coats with 
 local infiltration about the vasa-vasorum, leading to spots of 
 degeneration, and formation of an atheromatous button, or 
 a patch of nodular arterio-sclerosis. In old people the arterial 
 walls become stiff, and are often as rigid as pipe-stems from 
 calcareous deposit, while the tissue underneath the intima may 
 break up and form rough atheromatous ulcers. One of the 
 most important changes of all is the diffuse arterio-sclerosis, 
 or as Gull and Sutton call it, arterio-capillary fibrosis, in 
 which the wall becomes thickened from a deposit of hyaline 
 tissue between the muscular and the endothelial coats. This 
 deposit, which is so liable to occur in kidney disease, is of 
 great importance, because a lessening of the lumen of the 
 
 FIG. 131. After Gaskell. Tracing showing diminished amplitude and slowing of the 
 pulsations without complete stoppage, during irritation of the vagus. 
 
 arterioles increases the peripheral resistance, leads to hyper- 
 trophy of the heart, and thus to an enormous increase in blood 
 pressure, with consequent danger of rupture and apoplexy. 
 
 It is evident that thickening of this sort is not likely to 
 yield readily to vascular dilators, and that consequently one 
 may not be able to reduce the tension in a case of gouty kidney 
 by vascular relaxants, such as the nitrites, to the same extent 
 that one would expect if the increased tension had been de- 
 pendent upon spasm of the muscular coats of the arterioles 
 alone. It is clear, therefore, that more permanent good is to 
 be hoped for from such drugs as cause absorption, and es-
 
 IO2 THERAPEUTICS OF THE CIRCULATION 
 
 pecially from iodides, than from vascular dilators alone. At 
 the same time this high tension either depends to a certain 
 extent on muscular spasm or does not affect the whole of the 
 vessels equally, because nitrites will reduce the blood pressure 
 to a certain degree in such cases. 
 
 Effect of Feebleness of the Heart on the Nutrition of 
 Bloodvessels. From what I have said regarding self-mas- 
 
 FIG. 132. Pulse tracing, showing the effect of massage and graduated movements. 
 Each tracing is taken partly with a slow and partly with a quick movement of the 
 sphygmograph. The upper shows high tension and a feeble heart; the lower shows 
 less tension and a stronger heart. These tracings I owe to the kindness of Dr. 
 Gustav Hamel, to whose treatment I had recommended the patient. 
 
 sage of the arteries, veins, and lymphatics within their com- 
 mon fibrous sheath, it is evident that smallness of the pulse- 
 wave and imperfect expansion of the artery tends of itself, 
 whether it be due to feebleness of the heart, high tension, or 
 rigidity of the artery, to lessen the massage and to interfere 
 both with the nutrition of the vessels and with the onward 
 passage of venous blood and lymph. On the other hand, if 
 the alternate dilatation and contraction of the artery at- each 
 pulse be extensive, as in the lower tracing, Fig. 132, the self- 
 massage will be well effected. Baths, exercises, general mas- 
 sage, and drugs, which increase the amplitude of the pulse, 
 are therefore useful aids to the nutrition of the arteries. Digi- 
 talis and its congeners increase the amplitude of the pulse 
 by strengthening and slowing the heart; vascular dilators, 
 like the nitrites, do so by diminishing the tension. 
 
 Nervous Depression. One of the causes of feeble pulse 
 is feebleness of the heart's action, and this may be due to 
 many causes. One common and important cause is nervous
 
 EFFECT OF VAGUS ON HEART 
 
 103 
 
 FIG. 133. 
 
 After Gaskell. Tracing showing diminished amplitude of contraction with- 
 out slowing or stoppage during irritation of vagus. 
 
 FIG. 134. After Gaskell. Showing increased cardiac action from stimulation 
 of the vagus. In this figure the lower tracing is that of the auricle and the upper 
 that of the ventricle. 
 
 FIG. 135. Showing the effect of cold upon the arteries. A shows the normal 
 sphygmogram from the radial artery. B is the same after the application of a cold 
 compress above the elbow. (After Winfernitz.)
 
 IO4 THERAPEUTICS OF THE CIRCULATION 
 
 depression, which acts through the vagus nerve. This nerve, 
 which has received its name of vagus from its wandering 
 course, and which the Germans have translated as " die her- 
 umschweifende Nerv," gives branches to the heart, lungs, 
 stomach, intestines, liver, and kidneys. 1 As I have already 
 mentioned in another paper, nearly all the emotions can be 
 expressed in terms of this nerve. We say that the man's 
 heart sinks within him for fear or apprehension, it beats high 
 with joy or hope, he sighs for grief ; the stomach is affected, 
 and vomiting may ensue from disgust ; the bowels move with 
 compassion; and the effect upon the kidneys from simple ex- 
 citement is well known to all those who have had to do with 
 examinations. Nervous depression from emotional causes is, 
 I believe, a much more potent factor in disease of the circu- 
 lation than is generally recognized. The effect of grief, 
 worry, and anxiety upon the circulation, especially in elderly 
 people, is sometimes very marked. Not long ago, I saw a 
 man whose heart was very much diseased indeed, as shown 
 by physical examination, but he displayed wonderfully few 
 symptoms until he was told the actual condition of his circu- 
 lation, when he seemed, to use a common expression, " to 
 take it to heart," and from that moment he went down steadily 
 and rapidly, and died within a few days. The coincidence 
 was very marked, as the change in him occurred within a 
 couple of hours, so that one could hardly ascribe it to anything 
 else than nervous depression. Conversely, hope and joy are 
 most potent factors in stimulating the cardiac action, and thus 
 increasing the circulation throughout the body, and putting 
 into action all those subsidiary aids to the nutrition of the 
 vessels, and the return of venous blood and lymph, of which I 
 have already spoken. 
 
 One can plainly see that long-continued depression of the 
 heart's action by grief may bring about a condition of mal- 
 nutrition with no very definite organic change to explain it; 
 
 1 The pneumogastric appears to exert its action on the last three organs 
 through the coeliac, hepatic, and splenic plexuses.
 
 FATTY DEGENERATION IO5 
 
 and such a condition is indeed frequently noticed, not only 
 in the old, but even in the young, where sometimes it pro- 
 duces a predisposition to tuberculosis. I have seen one girl 
 who was really murdered by a curate, although no Court of 
 Justice could have laid the crime at his door. He paid atten- 
 tions to her, led her to believe that he was going to marry 
 her, then suddenly forsook her and married another. Grief 
 at this action depressed the circulation of the poor girl he 
 had deserted, brought about a condition of malnutrition, she 
 got phthisis, and died in less than a year. 
 
 It is possible that an abnormally low blood pressure may 
 sometimes be a precursor of phthisis, and give earjy warning 
 of danger. I have seen one case in which an abnormally 
 low pressure was accidentally found in an apparently healthy 
 man, who developed phthisis several months afterwards. 
 
 Fatty Degeneration. Another very frequent cause of 
 weakened cardiac action is degeneration of the muscular 
 structure itself, fibrous or fatty. This occurs very often in 
 diphtheria, typhoid fever, and other infective diseases. It 
 may also occur from altered nervous supply, and Eichhorst 1 
 observed fatty degeneration in the heart of fowls, and Was- 
 silieff in that of rabbits, 2 after section of the vagi. Probably 
 the great weakness of the heart after diphtheria is due in 
 some cases to a double action, viz., (i) to the effect of the 
 toxin in causing degeneration of the cardiac muscles, and (2) 
 to its effect in producing paralysis of the vagus nerves, just 
 as it does of the nerves going .to the pharynx. This paralysis 
 is shown by the extreme rapidity of the pulse, which may 
 come on during the height of the disease and continue for 
 months afterwards. 
 
 Fatty or fibrous .degeneration of the muscular fibers nat- 
 urally produces feeble action of the heart, and such degenera- 
 tion is commonly consequent upon interference with the circu- 
 
 1 Eichhorst, Die trophischen Besiehungen der Nervi Vagi sum Herz- 
 muskel, Berlin, 1879, p. 18. 
 - Wassilieff, Ztsch. f. klin. Med., 1881, iii., 316.
 
 io6 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 lation through the coronary arteries. Here we must distin- 
 guish between the two sides of the heart, because although 
 both coronary arteries may be affected, yet occasionally we 
 find one affected and not the other. The symptoms due to 
 affection of the two sides we shall have to consider later on. 
 
 FIG. 136. Shows the effect of warm clothing in dilating the arterioles, quickening the 
 pulse, and reducing the high tension of i to the low tension of 3. (After Marey.) 
 
 Pulse-rate. The rate of the heart, the rapidity or infre- 
 quency with which it beats, depends upon many factors. In 
 healthy animals increased blood pressure slows the heart by 
 its action upon the vagus roots, but when these nerves are 
 divided increased pressure has a variable action on the heart; 
 
 FIG. 137. Effect of fever. 
 
 sometimes slowing it, sometimes quickening it, but the con- 
 ditions, upon which such retardation or acceleration depend 
 have not yet been fully ascertained. Heat as a rule acceler- 
 ates the pulse-rate and cold retards it, the effect of heat being 
 to fender the heart more excitable, so that (i) stimuli are 
 generated more quickly in the venous sinus and auricles, and
 
 PULSE-RATE EXOPHTHALMIC GOITRE IO/ 
 
 (2) also pass more quickly to the ventricle. The effect of 
 cold on the isolated heart is exactly the opposite. Moreover, 
 heat tends to dilate the vessels, and thus to lessen the resis- 
 tance the heart has to overcome, while cold has an opposite 
 effect. The circulation in fevers, therefore, is usually rapid, 
 and a warm room sometimes appears to cause such vascular 
 dilatation that in delicate people faintness comes on and a 
 tendency to syncope; the dilatation probably occurring- chiefly 
 in the splanchnic area, in which the blood accumulates, as it 
 does after section of the splanchnics. (Cf. Fig 1 . 10, p. 12.) 
 
 The normal pulse-rate in men is from about 60 to 80 per 
 minute. Its rate when the vagi are paralyzed is about 120. 
 This is known from the fact that large doses of atropine or 
 belladonna paralyze the vagus; and in cases of poisoning by 
 these substances in man the pulse-rate has gone up to 120 or 
 upwards. 1 In very nervous people, especially some women, 
 the pulse-rate may rise a good deal above this, but such quick- 
 ening is only temporary. 
 
 The pulse of 120 occurs very frequently as a temporary con- 
 dition in fever, and may occur more or less permanently from 
 paralysis of the vagi after diphtheria, or from alcoholic 
 neuritis. 
 
 Exophthalmic Goitre. In cases of exophthalmic goitre 
 the internal secretion of the thyroid appears not only to quicken 
 the heart but to dilate the vessels, and in this disease the pulse 
 frequently rises to 130 or 140 beats per minute, or even more. 
 It would thus appear that not only is the vagus paralyzed, but 
 that the accelerators are stimulated. That this effect upon the 
 circulation is partly though not entirely due to the action of 
 the actual secretion of the gland itself, is shown by the fact 
 that thyroid, when taken by the mouth too frequently and 
 too long, is cases of myxcedema, will produce these effects 
 upon the circulation. 
 
 1 Atropine probably stimulates the accelerators as well as paralyzes the 
 inhibitory nerves of the heart.
 
 LECTURE IV 
 
 Paroxysmal Tachycardia Bradycardia Intermittent Pulse Palpitation 
 Shock Syncope Embolism and Thrombosis Claudication Angina 
 Pectoris Raynaud's Disease Chilblains, Urticaria, Angio-neurotic (Ede- 
 ma Migraine Sensitiveness of Arteries Sensitiveness of the Heart 
 Valvular Diseases of the Heart Aortic Obstruction Aortic Regurgita- 
 tion Failing Compensation Mitral Incompetence (Functional). 
 
 Paroxysmal Tachycardia. There is a nervous affection 
 of the heart known as paroxysmal tachycardia, in which the 
 pulse suddenly becomes quick and continues so for a length 
 of time, varying from minutes to hours, and then returns sud- 
 denly to the normal. It is usually accompanied by feelings 
 of great discomfort, sometimes like those of angina pectoris. 
 The cause of it is obscure. It is generally associated with 
 some disease of the walls of the heart, especially with fatty 
 degeneration. 
 
 Bradycardia. Another condition, just the opposite of this, 
 is extreme slowness of the heart, or bradycardia. In this 
 condition the pulse may fall as low as eighteen per minute. 
 Napoleon's pulse is said to have been only forty per minute 
 during the whole of his life. The slow pulse may be either 
 apparent or real. In some cases an apparent slowness is due to 
 the fact that some beats of the heart are so feeble that the 
 ventricle never opens the aortic valves, and no pulse reaches 
 the wrist. Sometimes alternate beats are weak and strong, so 
 that for a heart beating eighty times per minute only forty 
 radial pulses are felt. (Fig. 138.) In other cases, however, 
 there are no small beats but only slow pulsations. Weakness 
 of the heart leading to this condition may occur from tempo- 
 rary feebleness after fevers, and especially infective fevers 
 such as diphtheria, enteric, pneumonia, and rheumatic fever, 
 or from general debility, or from fatty or fibroid degeneration 
 of the cardiac walls. It sometimes occurs when the resistance 
 
 1 08
 
 SLOW PULSE INTERMITTENT PULSE ICK) 
 
 which the left ventricle has to overcome is very great, as in 
 Bright's disease and lead poisoning. It also may happen from 
 increased resistance to the action of the right ventricle in em- 
 physema. It may be due to irritation of the vagus center in 
 the medulla, either by (i) central influence, or by (2) reflex 
 stimulation of peripheral origin. Among the central causes 
 
 FIG. 138. Tracings from the left ventricle and aorta showing a slow pulse in the 
 aorta due to each alternate beat of the ventricle being too weak to overcome the 
 pressure within the aorta and left the aortic valves. The upper tracing, VG, is from 
 the left ventricle. The lower, A, is from the aorta. N is the level which the pres- 
 sure within the ventricle must attain in order to raise the aortic valves. (After 
 Marey.) 
 
 are pressure upon the brain by tumor; by effusion of blood, 
 as in apoplexy; by chronic inflammation, as in general paral- 
 ysis; as well as in mental affections, mania, and melancholia, 
 and disease or injuries of the medulla itself, and of the cervical 
 cord. It may be brought about by reflex irritation from the 
 sexual organs, from the skin, from the liver, or from the 
 stomach, as in chronic dyspepsia, gastric ulcer, and cancer. 
 (Fig. 139.) It occurs in poisoning by bile-acids, in jaundice, 
 the action here being probably exerted on the muscular fiber. 
 Other agents, such as tobacco, coffee, digitalis, and sometimes 
 alcohol may cause it, partly by their action upon the cardiac 
 muscle, and partly upon its nervous supply. 
 
 Intermittent Pulse. Both in tachycardia and bradycardia, 
 although the rate of the pulse* is disturbed, its rhythm remains
 
 no 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 regular. Intermission of the pulse is a frequent condition. 
 In it one beat is occasionally dropped. This may happen once 
 in three times, so that two regular beats come followed by a 
 pause, or it may occur in four, five, or more beats which are 
 quite regular, or it may happen at irregular intervals; for 
 example, once after three, next time after five, next after 
 seven, and then again after two. Such irregularity may pos- 
 sibly be a portion of a very large recurring rhythm, but in 
 most cases if such a rhythm exists it is difficult or impossible 
 
 Cerebrum 
 
 Larynx >^> 
 
 Gall bladder 
 Stomach 
 
 Kidney and ureter. .yC- 
 
 Intestine 
 
 Uterus -_ 
 Bladder 
 Vesical nerves 
 
 Medulla- 
 Spinal cord. 
 
 Vagus trunk. 
 
 Thoracic branches. 
 
 Splanchnics. 
 Gall duct. 
 
 Renal nerves. 
 
 Mesenteric nerves. 
 
 Uterine nerves. 
 
 FIG. 139. 
 
 to make it out. In the case of a man recovering from digi- 
 talis poisoning, I had occasion many years ago to observe 
 the form of irregularity shown by the pulse. 1 At first the 
 beats were very rapid with occasional slow ones interspersed, 
 
 'Lauder Brunton, "On Digitalis," etc., Inaugural Thesis, 1866. Re- 
 printed in Collected Papers on Circulation, First Series, pp. 100 and 101.
 
 IRREGULAR PULSE DIGITALIS 
 
 II I 
 
 then it became slow with an occasional rapid beat or two, and 
 finally slow and regular. (Figs. 140 to 144.) 
 
 In poisoning by tobacco the irregularity is sometimes very 
 extraordinary ; one slow, strong beat followed by a number of 
 
 FIG. 140. Pulse tracing from a case of poisoning by digitalis, showing quick pulse 
 with slow beats interposed. 
 
 FIG. 141. Same case. Recovering from the effects of the poison, and showing slow 
 pulse with occasional quick beats. 
 
 FIG. 142. Same case. Slow pulse, with beat interpolated at b. 
 
 FIG. 143. Same case. Pulse regular, but quickened by food. 
 
 FIG. 144. Same case. Recovering; pulse slow and regular. 
 
 very quick ones. This condition may also occur quite apart 
 from tobacco, and may persist for many years without really 
 affecting the patient's health. It is impossible to give, with 
 certainty, any explanation at present of the exact cause of 
 these forms of irregularity. Some of them, such as irregular 
 bradycardia or occasional intermission of a beat, are explained 
 by supposing that the conduction in the muscular fibers con- 
 necting the auricle and ventricle is less perfect than usual, so 
 that a block occurs, as in Gaskell's experiments. The cases 
 of tachycardia with an admixture of very rapid and slow beats, 
 are less easy to explain, on the assumption that cardiac rhythm 
 is entirely a function of its muscular fibers, and I am inclined
 
 I I 2 THERAPEUTICS OF THE CIRCULATION 
 
 to think that the true explanation can only be given on the 
 assumption that the nervous system also plays a part in the 
 cardiac rhythm, and that sometimes the nervous and muscular 
 rhythms interfere with one another. In my first lecture I 
 mentioned some of my grounds for this belief, and since it 
 was delivered, details of experiments by von Basch and Froh- 
 lich have been published which tend to substantiate the ac- 
 curacy of the views that I then brought forward. 1 
 
 Palpitation. Palpitation of the heart is a very troublesome 
 symptom, and its causation is very obscure. Sometimes it 
 appears to be almost a purely subjective sensation, as the 
 patient has a sensation of the heart beating strongly, yet the 
 hand applied to the apex beat does not perceive anything un- 
 usual. In other cases the force of the apex beat, as felt by 
 the hand, is distinctly increased. I have noticed such an 
 increase take place in animals poisoned by digitalis. In my 
 thesis on the action of this drug, I discussed the mechanism of 
 palpitation, and arrived at the conclusion that it was probably 
 due to increased power of the heart in proportion to the resis- 
 tance it had to overcome, so that the ventricular contraction 
 occurred rapidly, and the apex therefore struck forcibly against 
 the chest wall. 2 What seems to confirm this opinion is, I 
 think, the fact that palpitation is frequent in states of debility, 
 but that when the heart is hypertrophied and the tension is 
 high, so that, despite its abnormal strength, the heart cannot 
 contract quickly, palpitation is frequently, indeed one may say 
 generally, absent. 
 
 Effect of Position on Palpitation. One would naturally 
 expect that a constantly recurring rhythmic blow upon the 
 heart at each pulsation would increase its action, and, as a 
 matter of fact, this appears to be the case. The heart is a 
 mobile organ and moves considerably to the left when a person 
 lies on that side. The apex, therefore, tends to strike more 
 
 ^on Basch and A. Frohlich, Centralbldtt f. Physiologie, Bd. xviii. ; 
 Litcratur, 1904, p. 693. 
 
 2 Lauder Brunton, "On Digitalis," etc., Collected Papers on Circulation 
 and Respiration, First Series, p. 52. London: Macmillan & Co.
 
 SHOCK SYNCOPE I I 3 
 
 forcibly against the chest wall and as the effect of this is 
 similar to that of a blow on the heart at each beat, many people 
 are unable to lie on the left side in consequence of the palpi- 
 tation which then comes on. 
 
 Shock. Another important condition in which both heart 
 and vessels appear to be affected is that of shock. Here the 
 heart may become slow and feeble, but this does not appear to 
 be all, for the general depression is out of proportion even to 
 the feebleness of the heart's action. Shock is especially apt 
 to come on from a blow upon the abdomen, and Goltz in his 
 famous experiment showed that if a frog be suspended in the 
 upright position and its heart exposed, a blow upon the 
 intestines has a twofold action. It (i) stops the heart reflexly 
 through the vagus; but after this effect has passed off (2) the 
 heart beats again, but is empty and sends on no blood into the 
 vessels, because the blow has caused dilatation of the ab- 
 dominal vessels and all the 
 blood becomes stored up in 
 them, so that none reaches the 
 heart (Fig. 145). It is not 
 improbable that a similar effect FIG. i 4S . Diagra^o illustrate Goitz's 
 mav occur from irritants inside ex P e ments - a > Norma ; heart in the 
 
 * upright position; b, heart in same posi- 
 
 tllC StOinacll Or intestine, be- tion after shock; c, heart as in b, but in 
 
 , , .... recumbent position, showing it full, so as 
 
 cause when large quantities of to keep up circu i a tion, though the veins 
 alcohol have been swallowed at are sti11 dilated - 
 a draught, death has occurred almost instantly, and the mecha- 
 nism of its production was probably the same as in Goitz's 
 experiment. Severe pain from irritation of nerves in other 
 parts of the body may stop the heart, but under ordinary 
 circumstances it also causes contraction of the abdominal ves- 
 sels, and thus keeps up the blood pressure and maintains the 
 circulation. If the pain be very excessive, it is quite possible 
 that an opposite effect may be produced, and thus fatal syn- 
 cope may ensue. 
 
 I think also that in surgical operations if anaesthesia is 
 imperfect, reflex stoppage of the heart may occur without 
 9
 
 I 14 THERAPEUTICS OF THE CIRCULATION 
 
 reflex contraction of the vessels, and thus fatal shock may be 
 produced, whilst perfect anaesthesia would have abolished any 
 reflex action on the heart as well as on the vessels, and thus 
 prevented any danger. 
 
 Syncope. The remarkable difference between shock and 
 
 FIG. 146. To show the contraction of the vessels produced during the process of 
 multiplying 245 by 15. S, Volume of left arm. A marks the point at which the 
 calculation was commenced; after this point the pressure falls. R, Respiratory move- 
 ment of chest. X, Abscissa. T, Time line; every upright marks an interval of five 
 seconds. 
 
 syncope is that usually in shock the brain remains clear, but 
 in syncope the person becomes suddenly unconscious. The 
 pathology of syncope has not been thoroughly made out, but 
 it appears to be due to sudden anaemia of the brain. The 
 brain requires a large supply of blood when it is functionally 
 active, so that blood is withdrawn from the limbs, and they 
 
 FIG. 147. Tracing from the brain. A, In upright posture; B, with the head 
 inclined forwards. 
 
 become smaller. This is shown by Mosso with the aid of 
 the plethysmograph (p. 69). When measured by this instru- 
 ment, the volume of the arm was found to become much 
 smaller when the person thought hard, as the blood required 
 by the increased functional activity of the brain was with- 
 drawn from the arm. (Fig. 146.) When the body is up-
 
 EMBOLISM THROMBOSIS I I 5 
 
 right, the pressure of blood in the brain is less, but it becomes 
 greater when the head is lowered. (Fig. 147.) The recum- 
 bent position is therefore the best to restore a fainting person, 
 and the tendency to faint may sometimes be averted by plac- 
 ing the head on the hands between the knees. (Fig. 148.) 
 Before the introduction of anaesthetics it was a frequent 
 custom to perform operations in a state of syncope, which 
 was induced by laying the patient flat on the ground for a 
 short time and then raising him very suddenly to the upright 
 position by several strong men. A curious observation was 
 made by John Hunter on the flow of blood during syncope. 
 In a lady who was being bled, the 
 blood issued from the vein slowly and 
 was black, but the moment she fainted 
 the blood rushed out quickly and be- 
 came of a bright color. This phe- 
 nomenon is exactly what is seen in the 
 condition of the submaxillary gland 
 when its arterioles dilate on irritation 
 
 FIG. 148. Attitude to pre- 
 
 of the chorda tympani. As the blood vent fainting, 
 
 from the veins at the bend of the arm 
 
 comes to a great extent through the muscles, we are, I think, 
 justified in believing that, in some cases of syncope at least, 
 the vessels of the muscles undergo sudden dilatation, and thus 
 the blood pressure becomes enormously and instantly reduced. 
 Embolism and Thrombosis. When the blood-vessels be- 
 come obliterated, the supply of blood to the parts to which 
 they are distributed may become so insufficient that the tissues 
 die and gangrene ensues. This obliteration may be due to 
 embolism or thrombosis ; as, for example, when a clot or vege- 
 tation becomes detached from the heart and is carried onwards 
 by the circulation until it is stopped in an artery through which 
 it cannot pass, and which it consequently plugs. Sometimes 
 the arterial wall undergoes atheromatous degeneration, and 
 this may either lead to thrombosis occurring at the spot where 
 the wall is narrowed, or the atheromatous matter may become
 
 Il6 THERAPEUTICS OF THE CIRCULATION 
 
 dislodged and produce embolism further on. In old persons, 
 the arterial walls may become degenerated and contracted to 
 such an extent that senile gangrene of the extremities appears. 
 Before such a stage as this is reached, however, an inability for 
 exertion comes on. This was noticed by Sir Benjamin Brodie, 
 and his description is so good that I cannot do better than 
 quote it : 
 
 Claudication. " Such patients," he said, " walk a short 
 distance very well, but when they attempt more than this, the 
 muscles seem to be unequal to the task, and they can walk no 
 further. The muscles are not absolutely paralyzed, but in a 
 stage approaching to it. The cause of all this is sufficiently 
 obvious. The lower limbs require sometimes a larger and 
 sometimes a smaller supply of blood. During exercise a larger 
 supply is wanted on account of the increased action of the 
 muscles : but, the arteries being ossified or obliterated and thus 
 incapable of dilatation, the increased supply cannot be ob- 
 tained." 
 
 Angina Pectoris. " This state of things is not peculiar to 
 the lower limbs. Wherever muscular structures exist, the same 
 cause will produce the same effect. Dr. Jenner first, and Dr. 
 Parry, of Bath, afterwards, published observations which were 
 supposed to prove that the disease which is usually called 
 ' angina pectoris ' depends on ossification of the coronary 
 arteries. . . . When the coronary arteries are in this condi- 
 tion they may be capable of admitting a moderate supply of 
 blood to the muscular structure of the heart; and as long as 
 the patient makes no abnormal exertion, the circulation goes 
 on well enough; when, however, the heart is excited to in- 
 creased action, whether it be during a fit of passion, or in 
 running, or walking upstairs or lifting weights, then the ossi- 
 fied arteries being incapable of expanding so as to let in the 
 additional quantity of blood, which, under these circumstances, 
 is required, its action stops and syncope ensues ; and I say 
 that this exactly corresponds to the sense of weakness and
 
 RAYNAUD'S DISEASE ANGIO-NEUROTIC OEDEMA 1 17 
 
 want of muscular power which exists in persons who have 
 the arteries of the legs obstructed or ossified." 1 
 
 Raynaud's Disease. Temporary contraction of the artery 
 and anaemia of the tissues occurs in a disease described by 
 Raynaud, and which bears his name. In this disease the 
 arteries contract spasmodically, and I have seen first of all the 
 tips of the fingers become cold, bloodless, and shrunken like 
 the fingers of a corpse, and this condition gradually extended 
 up the hand in the course of five or ten minutes. Sometimes 
 only one finger is affected, sometimes the whole hand, some- 
 times the toes, the tips of the ears or the nose, and occasionally, 
 though rarely, the arms and legs. The internal arteries appear 
 also to undergo a similar contraction, especially those of the 
 kidneys and brain, because this disease is frequently associated 
 with hsemoglobinuria and sometimes with epileptic symptoms 
 and transient hemiplegia. The condition is very much like 
 what occurs after immersion of a hand in very cold water, 
 and just as after the hand has been withdrawn it usually be- 
 comes swollen, hot and red, so the extremities after the spasm 
 has passed off in Raynaud's disease become red and hot. In 
 very cold days we notice that the whiteness of the skin which 
 indicates both arterial and venous contraction, is succeeded by 
 arterial contraction with venous dilatation, so that the surface 
 becomes blue instead of white. The same thing occurs in the 
 severer cases of Raynaud's disease, and the term of local as- 
 phyxia has been given to the condition. In extremely severe 
 cases the contraction has letd to complete stoppage of the blood 
 supply, and consequent gangrene, like that which occurs in 
 senile degeneration of the vessels. 
 
 Chilblains, Urticaria, Angio-neurotic CEdema. A con- 
 dition which is very much allied to this, but much milder, is 
 the common one of chilblains. Another ailment which is very 
 troublesome and where there is a local vascular dilatation with 
 effusion of lymph, is urticaria. The wheals characteristic of 
 
 1 Lectures on Pathology and Surgery, by Sir Benjamin Brodie, London, 
 1846, p. 360.
 
 u8 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 this complaint are very much like those which are produced by 
 a stinging nettle. They may occur without visible cause, but 
 in some persons with an irritable vascular system they may be 
 produced by simply scratching the skin, so that the patient's 
 name may be written on his back with the finger-nail. In 
 
 FIG. 149. Diagram of the carotid, 
 temporal, and occipital arteries in the 
 normal state. 
 
 FIG. 150. Diagram of arteries dur- 
 ing migraine, showing dilatation of 
 the carotid and spasmodic contrac- 
 tions of the temporal arteries. 
 
 so-called angio-neurotic oedema, instead of mere wheals 
 occurring, the patient may become affected by rapid and in- 
 tense cedema over a large portion of the body. I have seen 
 in half an hour one side of the patient's face become so much 
 swelled that the left eye was almost closed, and the left side 
 of the face was like that of a patient suffering from advanced 
 renal dropsy, whilst the other side- of the face remained per- 
 fectly healthy. The pathology of this condition has not been 
 made out, but the cause of the trouble probably is that there 
 are toxic substances in the blood, for urticarial rashes are very 
 common after the injection of diphtheria antitoxin, and I have 
 seen universal oedema, resembling that of advanced renal 
 dropsy, brought on by the injection of anti-streptococcic serum. 
 The one-sided character of the affection in the case I have 
 just mentioned shows that the nervous system is also deeply 
 concerned in the disease.
 
 PATHOLOGY OF MIGRAINE 
 
 Migraine. Sensitiveness of Arteries. In the conditions 
 of which I have just been speaking the small arterioles and 
 capillaries are chiefly affected, but arteries of moderate size, 
 such as the temporal artery, and even large arteries like the 
 carotid, may undergo very considerable alterations in their 
 caliber, either in the way of contraction or dilatation. A good 
 deal of discussion has taken place in regard to the pathology 
 of sick headache or migraine. Du Bois Reymond described 
 the temporal artery in his own case as being much contracted 
 during the headache, and therefore concluded this was a 
 general condition; while others 
 have described this artery as 
 widely dilated and throbbing, 
 and have supposed this condition 
 to be constant. I have unfortu- 
 nately had only too many oppor- 
 tunities of repeating these obser- 
 vations on my own head, and I 
 have found that, as is often the 
 case, both parties are right and 
 both parties are wrong; that the 
 condition described by each 
 occurs, but that it does not ex- 
 tend to all parts of the artery at 
 the same time. Sometimes, for 
 example, during a fit of migraine 
 I have found my temporal artery 
 widely dilated and throbbing (Fig. 151), at other times I have 
 found it hard and contracted, like a piece of whip cord (Fig. 
 150) ; but when it was dilated, if I followed it onward towards 
 the periphery I ascertained that the ascending temporal branch 
 was contracted like a bit of piano wire. (Fig. 151.) On 
 most occasions, if I followed the contracted temporal artery 
 backwards towards the heart, I found that the carotid on that 
 side appeared to be as thick as my thumb, distended to three 
 times its normal diameter, and pulsating violently. The con- 
 
 FIG. 151. Diagram of arteries dur- 
 ing migraine, showing dilatation of 
 the carotid and temporal arteries, and 
 spasmodic contraction of an ascend- 
 ing frontal branch of the anterior 
 temporal artery.
 
 120 THERAPEUTICS OF THE CIRCULATION 
 
 elusion I came to, therefore, in regard to the pathology of 
 migraine, is that there is peripheral contraction and central 
 dilatation of the arteries. Arteries are sensitive, as was known 
 in the old days before the introduction of anaesthetics, because 
 patients complained of pain when the arteries were ligatured. 
 That the pain in migraine is to a great extent due to the 
 stretching action exerted on the contracted temporal artery by 
 the blood which tries to pour into it from the dilated carotid, 
 is shown by the fact that if pressure be exerted upon the caro- 
 tid so as to stop the pulse in the temporal artery, the headache 
 will frequently disappear instantly. Unfortunately, however, 
 it is almost impossible to compress the carotid without also 
 pressing upon the vagus, and the sense of oppression on the 
 chest which this produces is so great that one is generally 
 obliged to stop the compression after a few seconds, although 
 the moment the finger is removed the pain in the head comes 
 back with a rush of peculiar intensity. Megrim is often re- 
 garded as a neuralgic condition, but the observations upon my 
 own head which I have just detailed have convinced me that, 
 although the vascular disturbance which occurs in it, is almost 
 certainly due to an altered action of the vaso-motor nerves, 
 yet the pain is to a great extent like that of colic, where we find 
 intense pain due to spasmodic contraction of one part of the 
 intestine with dilatation or distension of another. 
 
 Sensitiveness of the Heart. Like the vessels, the heart is 
 probably sensitive and capable of originating pain of a most 
 intense character. Pressure from the outside is not felt, as 
 Harvey discovered in the case of young Lord Montgomery, in 
 whom a congenital defect of the sternum exposed the heart. 
 But pressure from without, unless very excessive, does not 
 produce pain in hollow muscular organs such as the stomach, 
 intestines, urinary bladder, gall-bladder, gall-duct, or ureter, 
 yet distension from within causes pain of the most intense 
 character in all of those organs. All these are liable to dis- 
 comfort without pain, and the heart, too, frequently feels
 
 SENSITIVENESS OF THE HEART 121 
 
 discomfort without pain. The sense of oppression which is 
 felt from grief or anxiety is, I think, due to the effect of the 
 vagus nerve, because I have noticed in my own case that grief 
 has produced a sensation of oppression in the chest which 
 has persisted after the emotion which had given rise to it had 
 passed away. We know that this feeling of oppression can 
 be produced by mechanical irritation of the vagus; for Pro- 
 fessor Czermak had a small exostosis on one of his cervical 
 vertebrae, and by compressing his vagus between it and his 
 finger he was able to stop his heart, but the pressure at the 
 same time caused this feeling of oppression or, as he termed 
 it, " Beklemmung " in the chest. 1 
 
 In angina pectoris there are frequently two sensations, or 
 perhaps even more: one of intense oppression, and one of 
 extreme pain. That of extreme pain I am inclined to regard 
 as similar to colic in the intestine, and as depending upon 
 spasmodic contraction of the heart against resistance which it 
 can not properly overcome. It is very difficult to make obser- 
 vations in angina pectoris ; because when the attack comes on, 
 the apparatus for observation is generally not at hand, and 
 even if it is, one is so much taken up with trying to relieve the 
 patient that one does not care to trouble him with the applica- 
 tion of instruments. In 1866 and 1867 I had an opportunity 
 of making observations in a case of angina pectoris, in which 
 the attacks occurred every night and lasted two or three hours. 
 During the attack the pulse was very rapid and the arterioles 
 were contracted, as is shown by the very slow fall of the 
 arterial tension during the cardiac diastole. But even with 
 everything at hand I only once succeeded in making one ob- 
 servation, and that a very imperfect one, of the commencement 
 of an attack, which showed that as the pain came on the 
 
 1 When Professor Czermak described this feeling he supposed that the 
 vagus was compressed between his finger and an enlarged gland, but I was 
 informed by the late Professor Sharpey that what Czermak supposed to be 
 a gland was afterwards discovered to be an exostosis on one of the cervical 
 vertebrae.
 
 122 THERAPEUTICS OF THE CIRCULATION 
 
 tension rose. I was able to make numerous observations re- 
 garding the end of an attack, and found that as the tension 
 fell the pain disappeared. 1 
 
 VALVULAR DISEASES OF THE HEART 
 
 Aortic Obstruction. We may now pass on to an impor- 
 tant class of cases, namely, those of valvular disease of the 
 heart. The aortic orifice sometimes becomes inflamed during 
 foetal life, and becomes narrowed in consequence, but more 
 usually the aortic valves become either stiff with advancing 
 years, or vegetations, frequently calcareous, form on them and 
 lessen the diameter of the orifice. 
 
 We must distinguish carefully between " stenosis " and 
 mere " obstruction," because a small atheromatous mass may 
 obstruct the orifice and give rise to a loud systolic murmur, 
 but yet may practically have little or no effect in lessening 
 the lumen of the vessel, and consequently will produce no 
 practical change in the circulation or in the condition of the 
 pulse. In many cases, especially of elderly people, the aorta 
 becomes atheromatous and rough, so that a systolic murmur 
 occurs in it, but unless the valves are affected, no regurgita- 
 tion results. (Fig. 153.) 
 
 Aortic Regurgitation. \Vhen the valves are diseased, gen- 
 eral incompetency as well as obstruction occurs, and during the 
 diastole blood flows back into the ventricle as well as onwards 
 towards the periphery. (Fig. 153.) Slight degrees of pure 
 stenosis have little or no effect upon the circulation, but as the 
 work which the ventricle has to do in order to expel the blood 
 is increased by the resistance in front, it usually becomes hy- 
 pertrophied. As the amount of blood it has to send into the 
 
 1 Since these lectures were delivered I have had an opportunity of 
 watching a case of severe angina pectoris daily for many weeks, and have 
 been unable to satisfy myself that although rise of tension, quick pulse, and 
 cardiac pain usually came on together, yet each might occur separately 
 without the others. A feeling of anxiety often accompanied the pain, but 
 anxiety might occur without pain, and vice versa.
 
 AORTIC REGURGITATION 
 
 I2 3 
 
 aorta is not more than usual, its cavity does not increase, or, 
 in other words, does not undergo dilatation. When there is 
 regurgitation as well as stenosis, blood pours into the ventricle 
 from both ends, from the auricle and from the aorta, so that 
 the amount of blood it is called upon to hold is greater than 
 usual. Its cavity becomes dilated, and at the same time, in 
 order to send this large wave of blood onwards, its walls re- 
 quire to be stronger than usual. 1 They become thicker, or in 
 other words, both dilatation and hypertrophy occur. So long 
 as this compensatory hypertro- 
 phy is sufficient to enable the 
 ventricle to do its work, there 
 may be no symptoms at all, and 
 I have seen patients engaged in 
 arduous physical labor, carrying 
 heavy hods of bricks up ladders 
 many times a day, without know- 
 ing that there was anything the 
 matter with them. Not infre- 
 quently one may notice that the 
 face has a peculiarly pale, waxy 
 look, and the arteries show a 
 peculiar irritability and tendency 
 to rhythmical contraction which, 
 as I mentioned in my previous 
 lecture, may be easily demon- 
 strated by drawing the finger 
 across the forehead. 
 
 Failing Compensation. But the enlarged heart requires 
 an extra supply of blood, and the coronary arteries may by 
 and by become insufficient to supply this, and then commenc- 
 ing cardiac failure sets in. When this is the case, symptoms 
 of defective supply of blood to the brain occur (Fig. 10), 
 such as giddiness, tendency to faint, or actual fainting; and 
 symptoms also referable to the heart, such as palpitation, 
 cardiac uneasiness, or anginal pain. 
 
 For pulse tracing of aortic regurgitation, vide Fig. 115, p. 90. 
 
 FIG. 152. Diagram to show the 
 usual position of the murmur which 
 indicates atheroma of the aorta. It 
 is generally heard best over the right 
 half of the sternum, opposite the sec- 
 ond rib or first intercostal space, but 
 it may be lower down or higher up. 
 It is sometimes very limited, but is 
 frequently transmitted upwards along 
 the innominate, while an anaemic 
 murmur is transmitted usually hori- 
 zontally to the left
 
 124 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Mitral Incompetence (Functional). So long as the mi- 
 tral valves remain competent, the symptoms remain limited to 
 those parts of the body supplied by the aorta. But when the 
 
 Carotid artery (full) 
 
 Aorta tense ... 
 Veins tense and 
 moderately full 4- 
 
 Blailder (fall) 
 
 J- Carotid artery (empty). 
 
 Aorta lax. 
 
 Veins lax and full. 
 
 Bladder (empty). 
 
 FIG. 153. Diagram to illustrate the tendency to syncope in aortic regurgitation. 
 In a the aortic valves are healthy and prevent regurgitation. The carotid and its 
 branches are shown as full. In b there is aortic regurgitation, the blood flows out 
 of the arterial system through the capillaries and into the heart. The carotid and its 
 branches are shown as empty. In c the condition is the same as in b, but the 
 patient is supposed to be in the recumbent posture, and the carotid and its branches 
 remain full. 
 
 heart dilates so far that the mitral valves no longer close the 
 auriculo-ventricular orifice and the blood pours back into the 
 
 FIG. 154. Diagram of healthy 
 heart in diastole. The aorta 
 is full of blood under pressure, 
 as indicated by the shading, 
 but the ventricle and auricle 
 are protected from pressure by 
 the sigmoid valves. 
 
 FIG. 155. Diagram of a heart 
 with incompetent aortic valves. 
 The ventricle as well as the 
 aorta is under pressure during 
 diastole, but the auricle is 
 protected by the auriculo- 
 ventricular valves. 
 
 FIG. 156. Diagram of a 
 heart with incompetent 
 aortic and mitral valves. 
 The auricle and veins, as 
 well as the ventricle and 
 aorta, are under pressure 
 constantly. 
 
 left auricle and pulmonary veins, symptoms of pulmonary en- 
 gorgement develop. 
 
 Incompetency of the mitral valves may be brought about 
 either by the orifice becoming too large for the valves, or the
 
 MITRAL INCOMPETENCE 
 
 valves too small for the orifice. It was shown by Ludwig 
 that, when the ventricle contracts normally, the muscular 
 
 FIG. 157. After Dr. Th. Schott. Photograph by the Rontgen rays, showing the 
 heart in a healthy man before exertion. 
 
 fibers around the auriculo-ventricular orifice lessen it to such 
 an extent that even imperfect valves might close it; but when 
 
 FIG. 158. After Dr. Th. Schott. Skiagraph of the heart of the same man as Fig. 157, 
 after violent exertion, showing temporary dilatation. 
 
 the heart is dilated, the orifice becomes so large that the valves 
 w r ill not close it, however healthy they may be.
 
 126 THERAPEUTICS OF THE CIRCULATION 
 
 Cardiac Strain. Such dilatation occurs as a sequence to 
 aortic regurgitation, but it also occurs from violent strain in 
 healthy people (Fig. 158), and also from cardiac weakness. 
 Indeed this happens not infrequently in cases of anaemia and 
 debility, such as occur after acute disease. We then find that 
 a systolic murmur, indicative of mitral regurgitation, becomes 
 very evident, but as the heart gains power, the murmur com- 
 pletely disappears. One such murmur I watched with great 
 interest in a girl, who was able to play lawn tennis without 
 any injury whatever, but every time that she went to a dance, 
 the combination of late hours and emotional excitement with 
 active exercise brought on a marked systolic murmur. 
 
 Regurgitation may also occur from irregular action of the 
 musculi papillares, as I observed in some experiments which 
 I made during the year 1865 upon the action of digitalis, and 
 where I noticed a regurgitant murmur occur in the heart of 
 a dog which had been poisoned by digitalis, although post- 
 mortem examination showed the heart to be perfectly healthy. 1 
 Roy and Adami have also described a similar condition. 
 When the mitral valves become incompetent, the reflux of 
 blood at each beat of a powerful ventricle tends to distend 
 the auricle and the pulmonary veins from which the normal 
 stimulus to ventricular contraction ought to start, and in con- 
 sequence of this the cardiac rhythm is apt to be disturbed, 
 and an irregular pulse will result. For this reason the irregu- 
 larity of the pulse is more frequent in mitral than in any other 
 form of cardiac disease. 
 
 1 Lauder Brunton, Collected Papers on Circulation and Respiration, 
 p. 114.
 
 LECTURE V 
 
 Mitral Regurgitation (Organic) Mitral Obstruction Cardiac Dyspnoea 
 Venous Engorgement Other forms of Cardiac Disease Vicious Circle 
 Methods of Treatment in Valvular Disease Uses of Treatment Rest 
 Position Use of Massage Effect of Flatulence on the Heart Use of 
 Drugs in Cardiac Disease Cardiac Nutrients Digitalis and its Congeners 
 Resume of the Action of Digitalis. 
 
 Mitral Regurgitation (Organic). Incompetence of the 
 mitral valves occurs from distortion of the valves by inflam- 
 mation, or by vegetations on their surfaces which prevent them 
 from closing, even more frequently than from dilatation of 
 the auriculo-ventricular orifice. The result, however, is the 
 same. Whenever the valves are incompetent the ventricle 
 drives the blood at each systole back into the auricle and pul- 
 monary veins, as well as forward into the aorta, and during 
 systole the pressure in the auricle and in the pulmonary veins 
 must be nearly, if not quite so high, as that in the aorta. In 
 consequence of this, the auricle becomes hypertrophied. As 
 there are no valves in the pulmonary veins, it seems extraordi- 
 nary that the pulmonary vessels do not suffer more than they 
 do, and it appears to me not improbable that the contractile 
 power of the pulmonary veins, which Sir Joseph Fayrer and I 
 rediscovered, 1 may take the strain off the capillaries in the 
 lungs, and thus prevent, to some extent, the tremendous con- 
 gestion that might otherwise take place. 
 
 Mitral Obstruction. When the mitral valves are much in- 
 flamed, they not unfrequently become adherent to one another, 
 and the mitral orifice is thus so much narrowed that sometimes 
 it will hardly admit the point of the finger. Great hypertrophy 
 of the auricle then occurs, while the ventricle may be smaller 
 than normal. In such a condition the pressure within the 
 pulmonary veins and the auricle tends to be more or less con- 
 
 1 Cf. P . 18. 
 
 127
 
 128 THERAPEUTICS OF THE CIRCULATION 
 
 stantly high, while that in the ventricle becomes low after the 
 systole is over. 
 
 I mentioned before, when speaking- of the physiology of the 
 heart, that dilatation of the apex of the frog's heart by pres- 
 sure from within would act as a stimulus to this portion of the 
 ventricle, and cause it to beat rhythmically when it would 
 otherwise remain perfectly still. The application of this con- 
 stant pressure to the pulmonary veins and left auricle, while it 
 is absent from the left ventricle, naturally tends to disturb the 
 rhythm, and consequently irregularity of the pulse is more fre- 
 
 FIG. 159. Tracing of pulse from a case of mitral incompetence. (After Marey.) 
 
 quent in mitral obstruction than in any other form of cardiac 
 disease. 1 
 
 Cardiac Dyspnoea. Involuntary muscular fiber seems to 
 have less power of withstanding strain when it is constant than 
 when it is intermittent, and it is in mitral obstruction that we 
 most frequently find the pulmonary capillaries giving way be- 
 fore the strain and haemoptysis occurring. 
 
 Backward pressure in the pulmonary circulation, of course, 
 retards circulation through the lungs; less blood can pass 
 through in a given time, and consequently both in mitral re- 
 gurgitation and in mitral obstruction, shortness of breath is 
 a prominent symptom. A patient may be perfectly comfort- 
 able while at rest, but there is no reserve power, and exertion 
 
 1 Luchsinger (Arch. f. d. ges. Physiol., xxvi., p. 451, 1881) and Schiff 
 (ibid., xxvi., p. 456) found that the rhythmical contraction in veins observed 
 by Wharton Jones (Phil. Trans., 1852, p. i) depend on the pressure inside 
 the veins; being well marked when the pressure is high, and absent when 
 the pressure is low. Cf. p. 17, observations of Brunton and Fayrer on 
 "Rhythmical Pulsation of the Vena Cava and Pulmonary Veins"; for 
 if this observation holds good for these veins, the pressure may excite 
 stimuli in the pulmonary veins whose rhythm may still further interfere 
 with that of the other cavities of the heart.
 
 VENOUS ENGORGEMENT I 29 
 
 at once brings on quickened breathing and distress, which may 
 sometimes be very severe. In consequence of this obstruction 
 to the pulmonary circulation, the right ventricle has more 
 resistance to overcome, it is obliged to contract with more 
 force, and on account of the increased work tends to become 
 hypertrophied. As a rule, its working power becomes more 
 and more taxed until the maximum is reached, and then it 
 begins to dilate, so that the tricuspid valves become incompe- 
 tent and the blood pours back into the auricle and the venae 
 cavae. 
 
 Venous Engorgement. Dilatation and hypertrophy of 
 the auricle occur in the same way as on the left -side, but there 
 being no valves in the venae cavae the whole venous system is 
 likely to become engorged. The first indication of venous en- 
 gorgement is shown in those parts of the body where the 
 venous pressure is highest, namely, in the feet and ankles, 
 because in these places there is not only the backward pressure 
 which exists in the vena cava itself, but the weight of the 
 column of blood between the feet and the heart. It is this 
 extra weight that determines the yielding of the venous capil- 
 laries and the exudation of fluid. This is shown by the fact 
 that when the weight of blood is taken off the feet by keeping 
 them raised upon a high stool or chair during the day, or by 
 putting the patient to bed, the oedema as a rule disappears. 
 Next the liver and portal system suffer. The liver becomes 
 congested and enlarged, and flatulence both in the stomach and 
 intestine becomes a troublesome symptom. As the congestion 
 increases the liver may be felt hard, smooth, and large, reach- 
 ing down sometimes to the iliac crest, and water exudes into 
 the abdominal cavity, producing ascites. The kidneys also 
 become congested. The increased venous pressure lessens the 
 circulation through the glomeruli, the urine becomes scanty 
 and loaded with lithates, and then albuminuria appears. 
 
 Other Forms of Cardiac Disease. It is obvious that all 
 the conditions I have just described may result as consequences 
 of aortic regurgitation, but the number of these conditions will 
 
 10
 
 I3O THERAPEUTICS OF THE CIRCULATION 
 
 be greater or less in other forms of cardiac disease, according 
 to the point in the circulation where the lesion 'occurs. Thus, 
 we may have all the symptoms of venous engorgement from 
 weakness of the right ventricle and inability to drive the blood 
 through the lungs. This weakness may be absolute, due to 
 fatty degeneration of the cardiac muscle, consequent upon 
 atheroma of the right pulmonary artery; or it may be rela- 
 tive, due to greater resistance to the circulation in the lungs 
 themselves, as, for example, in chronic bronchitis and emphy- 
 sema. A very instructive experiment in regard to this is that 
 which goes by the name of Valsalva. If one breathes out 
 against resistance as, for example, by closing the mouth and 
 nostrils forcibly, or, what is even more instructive, by blowing 
 against the mercurial column in a manometer it is found 
 that the pulse will stop entirely when the pressure within the 
 lungs reaches a certain point. As a young man I have fre- 
 quently tried this, and could stop my pulse completely. So far 
 as I can recollect, the height to which I raised the mercury 
 before this occurred was somewhere between six and eight 
 inches, but I have not repeated the experiment for a long time, 
 and do not care to do so now, because it is not altogether with- 
 out risk. In efforts of coughing, expiration is, of course, 
 made against raised pressure caused by the closure of the false 
 vocal cords, 1 which yield in an explosive manner after the pres- 
 sure has become raised to a certain extent, and mucus is carried 
 out by the forcible stream of air issuing from the lungs. In 
 violent coughing, the effect of raised pressure in the pulmo- 
 nary alveoli upon the pulmonary circulation becomes very evi- 
 dent. The face becomes congested, and if the coughing be 
 long continued, becomes more or less livid, and the jugular 
 veins stand out largely upon the neck. In people who are 
 otherwise healthy, the ventricle recovers itself when the cough- 
 ing ceases, but prolonged strain, as in chronic bronchitis or 
 spasmodic asthma, tends to cause permanent dilatation of the 
 right side of the heart with all its attendant evils. 
 
 1 Brunton and Cash, Journ. of Anat. and Physiol., vol. xvii., 1882-83.
 
 REST IN TREATMENT OF VALVULAR DISEASE 13! 
 
 Vicious Circle. As in many other things, the conditions in 
 cardiac disease form a vicious circle. The disordered circula- 
 tion disturbs the functions of other organs, and these in turn 
 make the circulation worse. The condition, indeed, reminds 
 one of Shakespeare's lines in regard to sorrow : 
 
 " Sorrow's weight doth heavier grow 
 Through debt that bankrupt sleep doth sorrow owe." 
 
 The disordered circulation interferes with the functions of 
 the lungs, liver, stomach, intestines, and kidneys. On account 
 of the difficulty of breathing, exercise becomes impossible, and 
 thus all the accessory aids to circulation given by the muscles 
 and fasciae during movement 1 are done away with. Appetite 
 becomes lessened and flatulence increases; the elimination of 
 waste products by the kidneys is interfered with, and distension 
 of the abdomen either by flatulence alone or by flatulence with 
 ascites presses the diaphragm up, encroaches upon the breath- 
 ing space in the lungs, and tilts the heart up, thus still further 
 increasing its difficulties. In such cases it is evident that the 
 patient is bound to die, and to die a somewhat painful death, 
 unless medical art can afford him assistance. It is very 
 fortunate, however, that in such cases medical art can do so 
 much. 
 
 TREATMENT OF VALVULAR DISEASE 
 
 Uses of Treatment. Rest. There is perhaps no kind of 
 disease in which the results of treatment are so striking and 
 so encouraging as in cardiac disease. If we can break the 
 vicious circle at one point, we allow recovery to commence; 
 and one of the most important agents, I think I ought to say 
 the most important agent, in the physician's power is absolute 
 rest. It is very hard indeed to make patients understand what 
 one means by absolute rest. They are inclined sometimes to 
 take the expression as meaning that they shall stay in the 
 house, but that they may go up and down stairs as often and 
 as quickly as they please. Now, few people have any idea 
 of the amount of work involved in going up stairs. The 
 
 1 Vide p. 7.
 
 132 THERAPEUTICS OF THE CIRCULATION 
 
 weight of the body is so evenly distributed upon the muscles 
 of the legs that we hardly feel the exertion in health, but if we 
 suppose that we had fixed upon the bannisters of the stairs on 
 the bedroom floor a strong pulley provided with rope and 
 basket, and that the patient weighing, let us say, 150 Ibs., is 
 put into the basket on the ground floor, and that we had to 
 pull him up by means of the rope, we will then understand 
 the number of foot-pounds involved in the amount of exer- 
 tion required to bring him from the dining-room floor to his 
 bedroom. The weight is the same and the height is the same 
 when the patient is drawn up in a basket and when he walks 
 up himself. By putting the position before a patient in this 
 way I have sometimes succeeded in convincing him that the 
 work involved in walking upstairs was really great, and more 
 than his enfeebled heart could stand. But it is not merely in 
 walking upstairs that the heart has extra work to do. Even 
 in getting into bed, work requires to be done, and unfortu- 
 nately, as in the case of a patient whom I saw immediately 
 after giving my third lecture here, the exertion of getting into 
 bed may prove fatal. 
 
 Rule regarding Rest for Patients. The advice I give to 
 patients is, that they shall not take one beat out of their heart 
 that can possibly be avoided; that they shall not do one thing 
 for themselves which anybody else can do for them. Nobody 
 else can breathe for them, nobody else can swallow for them, 
 nobody can evacuate for them ; but with these exceptions every- 
 thing else should be done for them. When they wish to sit 
 up in bed, they should be raised up by others ; when they wish 
 to turn, others should move them ; when they wish to evacu- 
 ate, a bed-pan should be placed under them. There are certain 
 people who seem to be unable to evacuate either the rectum or 
 bladder in the recumbent position, and for these I am accus- 
 tomed to recommend that a platform should be made of 
 rough deal, of such a height as to raise a commode to the 
 level of the bed, and that the patient should be slewed on to 
 it and off it in such a manner that the pelvis always remains
 
 POSITION IN TREATMENT OF VALVULAR DISEASE 133 
 
 in the same plane, and is never either raised or lowered, the 
 only change being in the relative position of the trunk and 
 limbs. 
 
 Position. But here we are met at once with the great 
 objection that in these severe cases the patient cannot lie down 
 on account of difficulty in breathing. The cause of this diffi- 
 culty of breathing while in the recumbent position is prob- 
 ably of twofold origin. In the first place, when the patient 
 is supine, the contraction of the diaphragm at each inspiration 
 has to raise the abdominal 
 viscera (Fig. 160), while in 
 the upright position it has 
 only to push them horizon- 
 tally forward. (Fig. 161.) 
 Another cause, as Leonard 
 Hill has pointed out, is prob- 
 ably the extra tension in the 
 right side of the heart, which 
 occurs when the heart is 
 
 brought down to a level with the splanch- 
 nic area, and the comparative ease which 
 occurs in the upright position is due to the 
 blood remaining in the abdomen and 
 limbs, so that the tension in the right side 
 of the heart becomes less (cf. Figs. 10 and 
 153). In some cases the facts that when 
 the legs are raised, the venous tension in 
 the cava becomes somewhat greater than 
 when they are dependent, and also that 
 when the thighs are swollen there is a 
 little extra pressure exerted on the abdo- 
 FIG. 161. Diagram to men ma k e ft necessary that the patient 
 
 show the horizontal mo- 
 tion of the abdominal con- should be allowed to sit and not be con- 
 tents in the upright posi- fined to bed But j f he is s ft ting? he 
 
 should be kept always in the same posi- 
 tion; he should not get up at all, and he should have not an 
 
 FIG. 160. To show the lifting of the 
 abdominal contents during inspiration in 
 the supine position.
 
 134 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 ordinary chair but a night-stool, so that the evacuations may 
 be removed without disturbing him. Various beds have been 
 devised upon which patients can lie comfortably and have their 
 bodies and limbs placed at any angle that is desired without 
 any exertion whatever on the part of the patient ; but although 
 these are theoretically very useful, they are not so much used 
 in practice as I think they might be. 
 
 Use of Massage. It is evident that when the patient is 
 resting completely, either in bed or in a chair, all the acces- 
 sory means of circulation in the limbs of which I have already 
 spoken are absent, and not un frequently one finds that the 
 feeble circulation in the muscles, and the consequent accumula- 
 tion of waste products, give rise to feelings of heaviness in the 
 limbs, discomfort, and restlessness which are very trying to 
 
 FIG. 162. Diagram of artery and nerve in a sheath of connective tissue to illustrate 
 self-massage of the artery and nerves. A, lymphatics. B, sheath. C, nerve. 
 
 the patient. In health, the arteries which run in the same 
 sheath as the nerves exercise a kind of massage upon them by 
 the alternate contraction and expansion in the same way as on 
 the veins (Fig. 162), but when the pulse is feeble the nerves
 
 ACTION OF MASSAGE 
 
 135 
 
 suffer in consequence. 1 The indication for treatment here is 
 to replace the natural accessories to circulation as far as pos- 
 sible by artificial ones, and this we are able to do to a certain 
 
 CO 
 
 2.2 
 
 2.0 
 
 1.8 
 
 1.6 
 
 1.4 
 
 1.2 
 
 1.0 
 
 .8 
 
 .6 
 
 .4 
 
 .2 
 
 ^abo. ab 
 111 IV 
 
 "T^ ^ 
 
 II 
 
 c^ ab 
 r VI 
 
 ^ 2J 
 V 
 
 ) S 
 
 Ul 
 
 11 
 
 be ato 
 X "I 
 
 c at 
 -A 
 
 c. t 
 
 J V 
 
 ic at 
 
 r w 
 
 5 al 
 
 1 Jl 
 
 jc a 
 
 1" ; 
 
 be a 
 
 ^ ' 
 
 IV* * 
 
 i 
 
 jc abc 
 
 v ' ' w* 
 
 n im 
 
 i n 
 
 FIG. 163. Diagram to show the effect of massage on the flow of blood through 
 muscle, a shows the amount of blood in cubic centimeters which flowed from a 
 muscular vein when it was simply opened. b, During massage. c, After massage. 
 In VI. the rate of flow was increased threefold. Brunton and Tunnicliffe. 
 
 extent by skilful massage. Massage is one of the most power- 
 ful agents in the treatment of such cases. It is a therapeutic 
 agent of very great power and value; but, like opium, which 
 
 FIG. 164. To show the relief from fatigue produced by massage. After Maggiora 
 and Vinaj. Bldt. f. Klin.: Hydrotherapie, 1892, p. 6. i. The fatigue curve of the 
 left hand raising a weight of 3 kilogrammes every two seconds. 2. The fatigue curve 
 of the left hand. 3. The fatigue curve of the left hand after five minutes' massage. 
 4. That of the right hand without massage. This tracing is taken by Mosso's 
 sphygmomanometer. (Fig. 93, p. 72.) 
 
 from its utility has been termed God's greatest gift to man, 
 it is liable to abuse, and on account of its abuse it is often 
 looked upon askance. But just as we cannot afford to throw 
 
 1 Vide p. 6.
 
 136 
 
 THERAPEUTICS OF THE CIRCULATION
 
 USE OF REST AND MASSAGE 
 
 137 
 
 opium aside as a medicine because it is liable to abuse, so we 
 must employ massage if we are to do the best for our patients, 
 and at the same time we must guard, as far as possible, against 
 any chance of abuse. By slow, firm, upward strokes along 
 
 FIG. 1 66. Mosso's ergograph. It consists of a clamping apparatus in which the 
 arm is firmly held; a weight suspended by a string which runs over a pulley, and ends 
 in a loop, into which one finger is put. In the middle of the string a small point 
 is fixed which works upon a revolving cylinder covered with soot, so that each mark 
 of the tracer can be distinctly seen. The finger is then contracted so as to raise the 
 weight at intervals of two seconds. The amount of contraction is shown by the 
 height of the up stroke, and as the exercise goes on the contraction becomes shorter 
 and shorter till at last exhaustion becomes complete. 
 
 the legs and arms the venous blood is forced onwards towards 
 the heart, and the fluid which has accumulated in the inter- 
 cellular tissue is driven on into the lymphatics. Thus the 
 resistance which the flow of blood through the arterioles 
 and capillaries has to overcome is lessened, and the work of 
 the heart lightened. The weariness, the weight, and the dis- 
 comfort of the limbs are removed, and the restlessness and 
 irritability of the patient lessened. (Figs. 163-164.) 
 
 The combined effect of rest and massage is that the heart 
 beats more slowly, beats more easily, has a longer period of 
 repose between each beat, and less work to do at each systole, 
 and thus the process .of repair is allowed to begin. 
 
 The lessened resistance allows each cavity to contract more 
 perfectly, the longer pause allows each cavity to become more 
 full of blood, the larger pulse-wave sent into the vessels at
 
 138 THERAPEUTICS OF THE CIRCULATION 
 
 each ventricular contraction increases the amplitude of the 
 pulse in the arteries, and thus brings about a more efficient 
 self-massage in the arterial walls, and consequently a more 
 efficient return of blood and lymph from the veins and lym- 
 phatics, which accompany the arteries in their sheaths. 1 
 
 The heart itself, by means of its more efficient self-massage, 
 'gets rid of its waste products, is better supplied with blood, 
 and gradually becomes stronger and stronger, until finally 
 many patients who seemed moribund recover under the in- 
 fluence of rest and massage to such an extent that they may 
 become practically well and remain so for years. 
 
 But it is not only on the heart and vessels that the in- 
 fluence of rest and massage and the consequent improvement 
 of the circulation is noticed. On account of the increased 
 circulation through the muscles, waste products are more 
 thoroughly oxidized, and, the massage taking the place of 
 exercise, a better appetite for food is produced, whilst the 
 
 FIG. 167. Pulse tracing, showing the effect of massage and graduated movements. 
 Each tracing is taken partly with a slow and partly with a quick movement of the 
 sphygmograph. The upper shows high tension and a feeble heart; the lower shows 
 less tension and a stronger heart. These tracings I owe to the kindness of Dr. 
 Gustav Hamel, to whose treatment I had recommended the patient. 
 
 diminished congestion of the liver, stomach, and intestines 
 improves digestion, and thus lessens flatulence. Massage to 
 the abdomen aids this process : it tends to cause expulsion of 
 gas from the stomach and intestines, and thus decreases the 
 mechanical interference which the abdominal distension exerts 
 upon the lungs and heart. The freer circulation tells upon 
 1 Fide Fig. i, p. 6.
 
 EFFECT OF, FLATULENCE ON THE HEART 
 
 139 
 
 the kidneys also. The urine becomes more abundant in quan- 
 tity, albumen disappears, waste is more freely eliminated, 
 and absorption goes on both from the inter-cellular tissue and 
 serous cavities, so that the oedema of the limbs and accumula- 
 tion of fluid in the peritoneal or pleural cavities become ab- 
 sorbed, and the oedema, ascites, or pleural effusion disappears. 
 Pleural effusion is, of course, a very serious complication in 
 valvular disease, encroaching as it does upon the available 
 breathing space, and its appearance should always be carefully 
 watched for, more especially as its occurrence is often in- 
 
 -CEREBELLUM 
 
 'MEDULLA 
 
 OBLONCATA 
 
 \-AFFEHENT 
 I NERVES 
 
 - -I- -STOMACH 
 ~ 1 WSO-INHIBlT'.l- 
 I NERVES 
 
 - I INTESTINAL 
 VESSELS 
 
 FIG. 168. Diagram to show the nervous mechanism by which the action of the 
 heart may be depressed by irritation of the stomach. The reflex irritation of the 
 vagus may render the heart's action simply weak, or slow and weak. 
 
 sidious. It is, however, less common and less disturbing than 
 abdominal distension by gas or water, or both. 
 
 Effect of Flatulence on the Heart. Flatulent distension 
 without ascites is very common indeed, and so is flatulent 
 distension with ascites; but ascites without flatulence is rare. 
 The relief which patients with cardiac disturbance feel when 
 flatulence escapes from the stomach is very marked, not only 
 in cases of valvular disease, but in cardiac weakness and in 
 angina pectoris. The modus operandi of gastric distension in 
 disturbing the action of the heart is probably twofold. It may 
 depress it reflexly (Fig. 168) or mechanically (Fig. 169.)
 
 140 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 The heart rests upon the upper surface of the stomach, with 
 only the thin diaphragm between, and if the stomach is dis- 
 tended it tends to tilt the heart up by altering its position; 
 it brings the apex close to the chest wall, and may thus cause 
 
 FIG. 169. Diagram to show the effect of flatulence on the heart. The heavy lines 
 show the normal position of the viscera. The dotted lines show their position when 
 the stomach is over-distended. 
 
 palpitation. Not only so, but it seems also, by altering the 
 axis, to interfere with the heart's action, and may produce dis- 
 tress or even death. Several years ago I saw a notice of a 
 man who died suddenly, and on post-mortem examination he 
 was found to be perfectly healthy, but the stomach was dis- 
 tended with a mixture of potatoes and milk. This had begun 
 to ferment, and the pulpy mass being of an adhesive character, 
 the gas was unable to escape from it, and caused such dis- 
 tension of the stomach that death occurred. 
 
 The mechanism here is, of course, uncertain, because the 
 acute distension may have produced reflex stoppage of the 
 heart, but in all probability the mechanical effect had a great 
 deal to do with it. A year or two ago I saw another similar 
 case recorded, \vhere death was put down to tea. In this 
 instance the bread and tea had apparently formed a mass like
 
 USE OF DRUGS HI 
 
 the potatoes and milk in the former case, and had a similar 
 effect. In former times one mode of punishing by death 
 was to make the condemned person drink bull's blood warm 
 from the vessels of the slaughtered animal. 1 Blood in itself is 
 not a poison, but as the criminal had to drink it in large 
 quantities it coagulated in the stomach and formed a solid clot 
 which, either reflexly or mechanically, caused death. 2 Under 
 ordinary circumstances distension of the stomach, unless 
 extreme, will not displace the heart and encroach upon the 
 lungs, because the abdominal walls will yield, and the intes- 
 tines, partially distended as they usually are with gas, will 
 become compressed before any displacement of the heart can 
 occur. But if the abdomen is distended by fluid, or if it is 
 constricted by a belt or by corsets, flatulent pressure, being 
 prevented from exerting its force in a downward or outward 
 direction, will push the heart up, and death may result. For 
 this reason, as was shown by the Hyderabad Chloroform Com- 
 mission, tight-lacing is dangerous during the administration 
 of anaesthetics. 3 It tends to increase the liability to palpita- 
 tion, and explains the efficacy of the common practice of at 
 once loosening the corsets in case of fainting. 
 
 Massage and Diet Use of Drugs in Cardiac Diseases. 
 But useful and important as rest and massage are in the 
 treatment of cardiac disease, they are not the only instru- 
 ments for treatment in the hands of the physician. We pos- 
 sess many drugs which have a powerful action on the heart 
 and vessels, and are of the utmost service in cardiac disease. 
 We may divide such into (i) cardiac nutrients, (2) cardiac 
 tonics, (3) cardiac stimulants, (4) cardiac depressants, (5) 
 vascular contractors, and (6) vascular dilators. In addition 
 to these, we have a number of drugs which have a less direct 
 action upon the heart and vessels themselves, but rather affect 
 
 1 Marx, Gtftlehre, vol. i., p. 268. Herodotus, Book III., Thalia, cap. 15. 
 "This explanation was known to Pliny, Hist. Nat. L., xi., c. 38, sect. 90, 
 quoted by Marx. 
 3 Lancet, 1890, vol. i., p. 662.
 
 142 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 170. Ludwig and Coats' frog-heart apparatus. A is a reservoir for serum. 
 B, a stopcock to regulate the supply to the heart. C, a piece of caoutchouc tubing 
 connecting A and D. D, a glass cannula in the vena cava inferior. D r , another in 
 the aorta. E, a manometer. F, a piece of tubing closed by a clip, to allow of the 
 escape of serum. G, a fine pen, floating on the mercury in E. H, the frog's heart. 
 J, a sealed glass tube, passed through the oesophagus K, and firmly held by a holder 
 L. M, a nut which allows L to be moved up and down. N, a second holder to sup- 
 port A. P, a stand with upright rod. S, a flap of skin to cover the heart and pre- 
 vent drying. V, the vagus.
 
 CARDIAC NUTRIENTS 143 
 
 tissue change, and influence the heart indirectjy through other 
 organs. The best cardiac nutrient is, of course, well aerated 
 blood with a proper proportion of nutrient matter and little 
 waste product. The nutrient materials have been investigated 
 one by one in experiments at first upon the frog's heart (Fig. 
 170), and latterly upon the mammalian heart. The method 
 of keeping isolated organs alive by artificial circulation was 
 invented by Ludwig, and in the first experiments which he 
 and his scholars made upon the frog's heart they used a simple 
 solution of common salt of about .5 to .6 per cent., that is to 
 say, about 2^ grains to the ounce. When this was circu- 
 lated artificially through the frog's heart it continued beating 
 for a length of time, but gradually the pulsations became 
 slower and feebler, and at length ceased altogether. The ad- 
 dition of diluted blood usually made the heart beat more 
 strongly for a longer period, and when it stopped the stoppage 
 was not due to exhaustion of the nutrient material, but the 
 accumulation of waste. This was shown by the fact that a 
 frog's heart when apparently dead may be revived, and again 
 commence to beat when the waste products are washed out 
 by perfusion with normal saline solution containing a minute 
 quantity of sodium hydrate. 1 
 
 Cardiac Nutrients. An interesting and important dis- 
 covery was made by Ringer, who found that when the saline 
 solution was made with tap-water it maintained the action of 
 the heart for a very much longer time than when made with 
 distilled water. On investigating the cause of this, he found 
 it was the lime in the tap-water which had a stimulating effect 
 upon the heart, and he was able to produce the same effect by 
 adding lime in small quantities to saline solution made with 
 distilled water. 2 
 
 We know that a fire when allowed to burn without attention 
 will often go out before the whole of the coal is consumed, 
 because it is smothered in its own ash, and that if we heap 
 
 1 Gaule, Arch. f. Anat. u. Physiol., physiol. Abt., 1878, s. 294. 
 'Ringer, Jour, of Physiol., iv., p. 29.
 
 144 THERAPEUTICS OF THE CIRCULATION 
 
 a be 
 
 FIG. 171. After Ringer. Tracings showing the effect of simple NaCl solution 
 in weakening the pulsations of the apex of the frog's heart. The tracing a was taken 
 soon after the blood was replaced by NaCl solution; b, after a longer period; and 
 c after a still longer time. 
 
 FIG. 172. After Ringer. Shows the effect produced upon the beat of the frog's 
 heart fed with NaCl solution by the addition of a trace of calcium chloride. The 
 beats in this case are induced by an induction shock. 
 
 FIG. 173. Tracing showing enormous contraction of the gastrocnemius of the frog 
 by a solution of caffeine.
 
 DIGITALIS AND ITS CONGENERS 145 
 
 ashes on the fire we tend to put it out. But the result is 
 different if we use cinders instead of ash; and although cin- 
 ders represent half-burned coal, they are sometimes very 
 useful in keeping up a fire or in helping it to burn when it 
 is low. In the same way the ashes, as we may term them, 
 of the tissues tend to smother the vital fires, and to prevent 
 the tissues from performing their proper functions; but the 
 vital cinders, that is, substances which are derived from albu- 
 mens and are on the way to urea or uric acid, may be very 
 useful. Amongst these we have a series of bodies to which 
 the term of purin bodies has been applied xanthine, hypo- 
 xanthine, methylxanthine, dimethylxanthine or theobromine, 
 and trimethylxanthine or caffeine. All these bodies are prob- 
 ably injurious in large quantities, but just as a few cinders 
 may help a fire, so when used in small quantities they are 
 often very useful. Beef-tea and extracts of meat have little 
 or no nutritive action, and life cannot be sustained upon them, 
 but they are useful stimulants, as was shown by Parkes in the 
 Ashanti campaign; 1 and in disease they act as cardiac stimu- 
 lants, although hardly as cardiac nutrients. Amongst the 
 most powerful cardiac nutrients appears to be glucose; for 
 Locke found in his experiments that the addition of glucose, 
 even in very small quantity, to a saline fluid greatly increased 
 its nutritive effect upon the isolated mammalian heart. Other 
 sugars have less action. Their nutritive effect apparently runs 
 parallel with their susceptibility to fermentation, glucose stand- 
 ing far ahead of the others. Caffeine in large doses acts as 
 a muscular poison, and tends to cause strong contraction, end- 
 ing in rigor of the muscle. Its effect in small doses upon the 
 heart appears to be that it increases the muscular contraction, 
 and strengthens the ventricular beats. 
 
 Digitalis and its Congeners. The most important drug 
 of all, however, in the treatment of heart disease is digitalis. 
 Although this drug has been used for a long time, yet it is 
 only within the last forty years or so that its action has really 
 
 1 Parkes. 
 1 1
 
 146 THERAPEUTICS OF THE CIRCULATION 
 
 become generally understood. Even when I was a student, 
 digitalis was looked upon as a cardiac depressant to be used 
 with great care in enfeebled hearts, whereas now it is uni- 
 versally regarded as a cardiac tonic. Although Blake in 1839 
 showed that digitalis injected into the arterial system greatly 
 raised the blood pressure, yet the physiological action of the 
 drug was not further investigated until Traube made his ex- 
 periments in 1862 on the mammalian circulation, and Fagge 
 and Stevenson on the frog's heart. In 1865 I wrote my 
 Thesis on Digitalis, and, I think, for the first time, brought 
 into relation the double action of digitalis both on the heart 
 and the vessels, as well as giving the first definite proof that 
 the cardiac action in mammals was actually strengthened and 
 not weakened by this drug. 1 
 
 Digitalis is an example of a very widely distributed group 
 of poisons, many of which are used in various parts of the 
 world for poisoning arrows, either for use in the chase or in 
 war. Those which are most commonly used in medicine are 
 the strophanthus hispidus and squill (Scilla maritima). 
 Amongst those occasionally but less frequently employed are, 
 casca or sassy bark (Erythrophlosum gmnenense} , lily of the 
 valley (Convallaria majalis}, Canadian hemp (Apocynum 
 cannabinum}, pheasant's eye (Adonis vernalis}, and Christ- 
 mas rose (Helleborus niger}. Other plants having a similar 
 action, but not used, are Antiaris toxicaria (upas), Nerium 
 oleander, Acocanthera (oubain), Thevetia grandiflora, and 
 Coronilla. A poison having a similar action is obtained from 
 the skin of toads. It is called phrynin, and though not em- 
 ployed much in medicine, it has proved useful. The story 
 is told that the husband of an Italian woman was dying of 
 heart disease, with dropsical limbs and all the usual accompani- 
 ments. As his death was so slow, his good wife thought she 
 
 'Brunton, "On Digitalis," pp. 28, 31. Churchill, London, 1868. Re- 
 printed in Collected Papers on Circulation and Respiration, pp. 52, 55. 
 Macmillan, London, 1906. This paper was presented as a graduation 
 thesis to the University of Edinburgh in 1866, but was not published until 
 1868. This paper also gives the early literature of the subject.
 
 ACTION OF DIGITALIS ON THE FROG S HEART 
 
 147 
 
 would quicken his journey into the other world, and accord- 
 ingly she went into the garden, where she found several toads. 
 These she dropped into the wine her husband was to drink; 
 but instead of his dying forthwith, as she expected, he began 
 immediately to get well, the phrynin from the toad's skin 
 having had upon him the same beneficial effect that a course 
 of digitalis would have had. 
 
 Resume of the Action of Digitalis. Digitalis acts on the 
 cardiac muscle, the intrinsic cardiac nerves, and the vagus 
 center in the medulla. It also affects the arterioles, causing 
 them to contract, and probably it has upon them also a two- 
 fold action, as on the heart, and stimulates both the contractile 
 muscular walls and the nerves which go to them. The action 
 
 OU. C. 
 
 FIG. 174. Diagram to show the action of digitalis in the frog's heart; a is the 
 normal heart in which both auricle and ventricle are filled with blood during the 
 diastole; b is the heart with the ventricle becoming contracted and showing the yielding 
 pouches; c is the heart fully under the influence of digitalis with the ventricle firmly 
 contracted so that it will not admit any of the blood which distends the auricle. 
 
 upon the heart of the frog is very marked and characteristic, 
 and the action here is less complicated than in mammals, 
 inasmuch as the heart itself is less under the control of the 
 central nervous system, and is less readily affected by altera- 
 tions which may occur in the vessels. When the excised heart 
 of a frog is either laid in a solution containing the active 
 principles of digitalis or is connected with an apparatus by 
 which serum containing these principles may be circulated 
 through it, changes are observed, which may be divided into 
 changes in rate of pulsation and changes in character of pulsa- 
 tion. The heart first of all begins to pulsate more slowly,
 
 148 THERAPEUTICS OF THE CIRCULATION 
 
 and at the same time more powerfully; the contractions 
 become gradually stronger, and the relaxation or diastole 
 becomes less perfect, so that finally the heart stands still 
 altogether in a state of complete contraction. If the heart 
 which is thus standing still be forcibly dilated, by passing 
 fluid into its interior under pressure, pulsation will recom- 
 mence. Occasionally during the process of contraction small 
 points on the surface of the heart may be observed, which re- 
 main dilated, and look like small purple pulsatile pouches on 
 the surface of the organ. 1 The nature of these pouches has 
 not been definitely ascertained, but it is not improbable that 
 they are due to slight injury of the muscular fiber in the proc- 
 ess of removing the heart from the body of the frog. When 
 the heart of a frog is lift in situ, and is merely exposed to 
 view by opening the thorax of the animal, and dropping a 
 solution of digitalis upon it, the same phenomena are observed. 
 They are unaltered by the use of atropine, and are supposed 
 to be due to the action of the drug upon the muscular fibers 
 of the heart itself. 
 
 1 Fagge and Stevenson, Roy. Soc. Proc., xiv., p. 270.
 
 LECTURE VI 
 
 Action of Digitalis in Mammals Uses of Digitalis Action of Digitalis 
 on (Edema Toxic Action of Digitalis Action of Digitalis on Arterioles 
 Stages in the Action of Digitalis Difference between Digitalis and other 
 Cardiac Tonics Action of Strychnine on the Heart Action of Caffeine 
 and other Purin Bodies Drawbacks to the Action of Digitalis and other 
 Cardiac Tonics Removal of these Drawbacks by Combination Vaso- 
 dilators : amyl nitrite, isobutyl nitrite, hydroxylamine, nitroglycerine, nitro- 
 erythrite, nitromannite, sodium, and other nitrites. 
 
 Action of Digitalis in Mammals. In mammals, digitalis 
 causes increased contraction of the muscular fibers, both (i) 
 in the heart and (2) the arteries. This increased contraction 
 appears to be partly due to the action of digitalis on the mus- 
 cular fibers themselves, but its effect upon the muscle is greatly 
 modified by its action upon the nervous system. Its action 
 is exerted especially upon the medulla oblongata, and it appears 
 to affect first the inhibitory center of the vagus and the vaso- 
 motor center for the vessels. When small doses are given, 
 the effect appears to be limited to these centers, but when the 
 administration is carried to the extent of poisoning, the ad- 
 jacent respiratory and vomiting centers are also affected. 
 From stimulation of the vagus center, the pulse becomes slow, 
 and the diastole more complete, while at the same time the 
 stimulation of the muscular fibers of the heart makes its con- 
 tractions more powerful. Its beats thus become much more 
 efficient; the longer intervals between them afford the heart 
 time for recuperation; the more complete diastole allows a 
 larger quantity of blood to accumulate in its cavities, the more 
 powerful systole drives this onward, the self-massage of the 
 heart becomes more complete, and all the good effects which I 
 have mentioned as occurring from this are noticed after the 
 action of digitalis. One consequence which is of special in- 
 terest is its diuretic action. This is partly due to the rise in 
 blood pressure which it produces, and which raises the pres- 
 
 149
 
 ISO THERAPEUTICS OF THE CIRCULATION 
 
 sure in the glomeruli, drives the blood more quickly through 
 the kidneys, and causes a more rapid secretion of urine. At 
 the same time it is probable that digitalis has a certain stimu- 
 lating effect on the secreting structures in the kidneys them- 
 selves, a stimulation which may extend also to other parts of 
 the genito-urinary tract. This effect, however, is not so 
 great as that produced by caffeine, and the diuretic action of 
 digitalis is probably exerted chiefly through the circulation. 
 When digitalis acts upon a healthy man so as to produce 
 diuresis, the drain of fluid becomes so great that, as I have 
 found in my own experiments, the thirst it induces becomes 
 intolerable, and water must be taken in order to allay it. 1 
 
 In cardiac diseases with oedema, or accumulation of fluid in 
 the serous cavities, such drinking is unnecessary, as the fluid 
 drained away from the blood by the kidneys is supplied by 
 absorption from the subcutaneous tissue or from the serous 
 cavities. 
 
 Uses of Digitalis. Not only does the circulation in the 
 tissues generally improve under digitalis, but the nutrition of 
 the heart is increased by more efficient circulation through the 
 coronary vessels; dilatation is lessened; the muscular rings 
 around the auriculo-ventricular orifices contract more strongly, 
 the mitral and tricuspid valves close them more efficiently, and 
 regurgitation is lessened. In cases where the valvular incom- 
 petency is solely due to dilatation and not to changes in the 
 valves themselves, the incompetency may be completely cured. 
 
 The arteries likewise benefit, as the slower and stronger 
 beats of the heart increase the self-massage of the artery in its 
 sheath, and the same increased pulsation aids the circulation in 
 the veins, as already described. The venous circulation is 
 farther aided by increased suction-power of the heart (Fig. 
 125, p. 96), which contracts more rapidly and completely. 
 Diminished regurgitation combines with increased circulation 
 in the veins to lessen venous congestion, and thus tends to 
 
 1 Lauder Brunton on "Digitalis," Collected Papers, p. 83. Macmillan & 
 Co., London, 1906.
 
 DIURESIS USES OF DIGITALIS 
 
 increase the secretion of urine. For venous congestion in the 
 kidneys tends to compress the arterioles and tubules in the 
 
 FIG. 175. Heart fully distended, showing insufficiency of the valves to close the mitral 
 and tricuspid orifices. 
 
 organ, and thus lessen secretion; and digitalis, therefore, in 
 cases of venous congestion probably acts as a diuretic in four 
 
 FIG. 176. Heart in full 
 systole, showing the mitral 
 and tricuspid orifices so di- 
 minished by the muscular con- 
 traction that the valves close 
 them easily. 
 
 FIG. 177. The same heart 
 as in Fig. 176, from another 
 point of view. 
 
 ways (i) it increases the blood pressure in the glomeruli; 
 (2) it lessens the resistance which the pressure of the dis-
 
 152 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 tended venous radicles in the kidney opposes to secretion; (3) 
 it probably acts as a stimulant to the secreting cells of the 
 kidney; and (4) it increases the volume of blood, and some- 
 what alters its composition by causing absorption from cedem- 
 atous tissues and serous cavities. When it causes absorp- 
 tion of ascitic fluid from the abdominal cavity it may act as 
 a diuretic in a fifth way, viz., by lessening the resistance op- 
 posed to the secretion of urine by the pressure of the ascitic 
 fluid on (a) the kidney itself, and (b) on the ureters. From 
 this manifold action of digitalis as a diuretic it is evident that 
 when its action is once fairly established in a water-logged 
 
 FIG. 178. Diagram to show the effect 
 of venous congestion and of obstruction of 
 the ureter or tubules on the kidney. A, 
 normal kidney, with artery in the center 
 of the hilus. The artery ends in a. 
 glomerulus from which a urinary tubule 
 passes into the ureter, which is shown 
 passing out of the hilus below the artery. 
 The renal vein is shown above the artery 
 in the hilus. B shows congestion of the 
 vein, with consequent compression of the 
 artery and tubule. C shows obstruction of 
 the ureter and tubules. 
 
 FIG. 179. Diagrammatic section 
 of the abdomen: A, in the normal 
 state; B, in advanced dropsy, where 
 the ascitic fluid compresses the kid- 
 ney itself and also the ureter, so 
 that the secretion of urine is hind- 
 ered in two ways: (i) by pressure 
 on the outside of the kidney, and 
 (2) by pressure on the inside of the 
 kidney from the tension in the 
 urinary tubules. 
 
 patient, the amount of urine secreted for some days may be 
 enormous. 
 
 Action of Digitalis on CEdema. As I have already men- 
 tioned, the diuretic action of digitalis may cause so much water 
 to be withdrawn from the blood that it produces a consuming 
 thirst in a healthy man. 1 In a dropsical one, the fluid lost 
 through the kidneys is made up by absorption from the tissues, 
 and this is one way in which digitalis reduces oedema. But it 
 
 'Lauder Brunton on "Digitalis," Notes of March 17 and 19, 1865. 
 Collected Papers on Circulation and Respiration, p. 83.
 
 ACTION OF DIGITALIS ON (EDEMA 
 
 153 
 
 is probably not the only one. For digitalis stimulates the vaso- 
 motor nerves, and in this way tends to prevent the exudation 
 of fluid from the blood-vessels, which produces oedema. It is 
 
 ARTER/ES 
 
 FIG. 1 80. Diagram of Ranvier's experiment on dropsy. The vena cava is 
 ligatured, and in the left leg the trunk of the sciatic has been divided so that both 
 the motor and vaso-motor nerves contained in it are paralyzed. On the right side the 
 motor roots of the sciatic alone are divided and the vaso-motor left uninjured. 
 There is thus motor paralysis on both sides, but vaso-motor paralysis and dropsy only 
 on the left side. 
 
 universally acknowledged that venous obstruction tends to 
 produce oedema, but at the same time oedema may occur with- 
 out any obvious venous obstruction, as in angio-neurotic 
 cedema. Moreover, venous obstruction may exist without 
 oedema, as was shown by Ranvier, who tied the vena cava in 
 a dog, and found that although venous congestion was thus 
 produced in both legs, no oedema occurred in the leg where 
 the vaso-motor nerves were left intact, but occurred in the 
 other where the vaso-motor nerves were divided. 
 
 Another benefit resulting from diminished venous conges-
 
 154 THERAPEUTICS OF THE CIRCULATION 
 
 tion is improved digestion and assimilation. The liver, which 
 under increased venous pressure may have become so swollen 
 as to reach even below the umbilicus, returns more or less to 
 its normal size, and the obstacle which had existed to the re- 
 turn of venous blood from the stomach and intestines, nearly 
 
 FIG. 181. Diagram to show the return of venous blood from the stomach and in- 
 testines through the liver. 
 
 all of which has to pass through the liver, is removed (Fig. 
 181). The circulation through these organs becomes better, 
 digestion and absorption improve, flatulence is lessened, and 
 the patient's nutrition improves. 
 
 Toxic Action of Digitalis. All these are the advantages 
 which we gain from the proper administration of digitalis;
 
 TOXIC ACTION OF DIGITALIS 
 
 155 
 
 but when carried too far, a toxic action occurs, and one of the 
 first symptoms is nausea and vomiting. This may be due 
 simply to extension of the irritation in the medulla from the 
 vagus and vaso-motor centers to the vomiting center, but it 
 .may be due also, to some extent, to a local irritation of the 
 stomach by the digitalis being secreted into it in the same way 
 as tartar emetic, or the toxins of cholera. In medical practice, 
 gastric irritation is usually one of the first indications that 
 the physiological effect of digitalis is passing into its toxic 
 action. Sometimes, however, the pulse becomes abnormally 
 slow, even before sickness occurs. If the warning given 
 either by sickness or by the pulse is attended to, and the ad- 
 ministration of the drug is stopped, usually no further dis- 
 advantage occurs : but if these warnings be unheeded, exces- 
 
 FIG. 182. Diagram to show the relation between blood pressure and the secretion 
 of urine after the administration of erythrophlceum. The lower tracing shows the 
 blood pressure in millimeters of mercury. The upper shows the secretion of urine 
 in minims per ten minutes. It may be noted that when the blood pressure rises to 
 its maximum of 200, the secretion of urine falls to zero. 
 
 sive vomiting may set in, collapse may occur, and the secre- 
 tion of urine may be entirely arrested. The secretion of urine 
 may cease at the time when the blood pressure is at its maxi- 
 mum, as I found along with Mr. Power in the case of digi-
 
 156 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 talis, and along with Mr. Pye in the case of strophanthus. 
 The stoppage of secretion is exactly like that which occurs 
 from ligature of the renal artery, and in all probability it is 
 
 100 
 
 90 
 
 80 
 
 70 
 
 60 
 
 FIG. 183. Tracings to show the first stages of the action of digitalis. Brunton 
 and Meyer Tracing of the oscillations of blood pressure in a dog. There are nearly 
 5 beats of the heart in the tracing and the pressure falls to 55 mm. of mercury and 
 rises to 94. 
 
 due to spasm of these arteries stopping the circulation through 
 the kidney. As the pressure begins to fall and the arteries 
 relax, urine is again secreted, but it is often albuminous, 
 
 FIG. 184. Tracing from same animal after the administration of digitalis. The slow- 
 ing of the heart is very marked, the pressure is somewhat raised. 
 
 exactly like the urine secreted after the arteries have been 
 ligatured and then released.
 
 ACTION OF DIGITALIS ON ARTERIOLES 
 
 157 
 
 Action of Digitalis on Arterioles. The rise of blood pres- 
 sure which digitalis produces was attributed by Traube and 
 
 no 
 
 FIG. 185. Tracing from the same animal when the action of digitalis is more pro- 
 nounced. The difference between this and the previous tracing does not consist so 
 much in any further slowing of the pulse but in the smaller oscillation and the rise 
 in tension. 
 
 von Bezold to increased action of the heart, and they left the 
 arterioles altogether out of account as a factor in its produc- 
 
 tic. 1 86. Tracing of the blood pressure of a dog during arrest of the heart by 
 electrical stimulation of the vagus before injection of digitalis. It will be noticed 
 that during the stoppage the blood pressure falls to within 1.5 cm. of the abscissa. 
 
 tion. In my thesis, presented to the Edinburgh University 
 in 1866, I pointed out the importance of the arterioles, and 
 in the winter of 1867-68 I obtained, in conjunction with A.
 
 I$8 THERAPEUTICS OF THE CIRCULATION 
 
 B. Meyer, experimental evidence of this action. 1 We noticed 
 that after the injection of digitalis into the veins of a dog, 
 the pressure in the arteries not only rose higher than before, 
 but it fell more slowly during diastole. Had the arterioles not 
 been contracted, the higher pressure would have driven the 
 blood more quickly through them in diastole, and so the fall 
 would have been quicker than before, instead of being slower, 
 as we found it to be. In order to obtain more certain proof 
 of this, however, I then took up the question along with Dr. 
 Tunnicliffe, and instead of using the normal systole of the 
 heart we prolonged it greatly by irritation of the vagus. The 
 
 FIG. 187. The same experiment as in Fig. 186, but after the injection of digitalis. 
 Although the arrest of the heart is longer than in the previous experiment, the blood 
 pressure only falls to within 3 cm. of the abscissa instead of to 1.5 cm. 
 
 results we arrived at entirely confirmed my previous observa- 
 tions ; for, although the pressure was considerably raised in 
 the arteries by the administration of digitalis, it fell very much 
 more slowly than in the normal animal, while the heart was 
 standing still from irritation of the vagus. I need not enter 
 further into the discussion of this point, as Tunnicliffe and I 
 have gone fully into it in our paper. 2 
 
 Stages in the Action of Digitalis. The action of the drug 
 
 1 Brunton and Meyer, Jour, of Anat. and Physiol., vol. vii., 1873, and 
 reprinted in Collected Papers, p. 141. 
 
 2 Lander Brunton and Tunnicliffe, Journ. of Physiol, 1896, vol. xx., p. 354.
 
 STAGES IN THE ACTION OF DIGITALIS 
 
 159 
 
 may be divided into several stages. These stages have been 
 variously described, so that the stages of different authors do 
 not correspond. The essential part of the division is that in 
 the first stage there is increased power, both of those parts 
 of the nervous system connected with the heart and vessels 
 and of the muscular fibers in them, while in the later stages 
 
 FIG. 188. Tracings of blood pressure showing the action of digitalis. The first is 
 normal; the second, slow pulse with rise of pressure; third, paralyzed vagus with con- 
 tracted arterioles; fourth, vessels relax. 
 
 more or less complete paralysis of these structures occurs. 
 
 We might, then, take as the 
 
 1st stage, that in which there is increased action in all the 
 nerves and muscles of the circulation ; as the 
 
 2d, that in which the nervous system of the heart begins 
 to fail, while muscular power and the whole vascular apparatus 
 are still intact; as the
 
 I6O THERAPEUTICS OF THE CIRCULATION 
 
 3d, that in which the muscular fiber of the heart begins to 
 fail; and as the 
 
 4th, that in which the vessels become enfeebled. 
 
 In the first stage we have a rise of blood pressure and 
 usually a slowing of the pulse, this slowing being due to the 
 action of the drug both on the vagus roots and ends in the 
 heart. Although the pulse is slow, the systole of the heart is 
 not prolonged, and there is, therefore, a much longer diastole 
 during which the heart is able to rest. The blood pressure in 
 the kidneys is increased as well as in the other organs, and the 
 urinary secretion is therefore augmented. In the second stage, 
 while the blood pressure continues high, the vagus becomes 
 partially paralyzed, and therefore the pulsations become at first 
 irregular and afterwards very rapid. In this condition spasm 
 of the renal vessels may occur, and the urinary secretions may 
 entirely cease. When this occurs in man, the condition of the 
 patient is dangerous. In the third stage the heart becomes 
 feebler, and may again become regular, from failure either of 
 the muscular fiber itself or the intrinsic ganglia. The arterioles 
 now relax, the blood pressure begins to fall, and the urine may 
 again become copious. In the fourth stage, the vessels dilate 
 generally, blood pressure falls very greatly, and the heart stops 
 sometimes in systole, as in the frog, but very frequently in 
 diastole. 
 
 Difference between Digitalis and other Cardiac Tonics. 
 The differences which have been observed between the ac- 
 tion of digitalis and its congeners are that, while digitalis 
 affects both heart and vessels, the action of strophanthus 
 appears to be exerted more especially upon the heart, increas- 
 ing its power; while that of erythrophlceum appears to be ex- 
 erted more upon the vessels. 
 
 Action of Adrenaline on the Heart and Vessels. This 
 substance when injected into the circulation causes a contrac- 
 tion of the vessels and rise of blood pressure, such as almost 
 no other substance, except nicotine, p. 167, will produce. It 
 is also a powerful stimulant of the heart. Unfortunately, its
 
 STRYCHNINE CAFFEINE OTHER PURIN BODIES l6l 
 
 action is transient, and when given by the mouth, its action 
 is much less than when given hypodermically, 
 
 Action of Strychnine on the Heart. Another drug be- 
 longing to quite a different class, and yet most useful in cardiac 
 disease, is strychnine. Its action is exerted slightly, if at all, 
 upon the muscular fiber, but it greatly increases the reflex 
 excitability of nerve centers. This is more especially marked 
 in those of the cord and medulla, but it also stimulates peri- 
 pheral ganglia, and Cash and I found that when applied to the 
 heart it prevented the slowing or stoppage of the ventricle, 
 which usually occurs from the application of a ligature be- 
 tween the venous sinus and the ventricle. 1 In some books on 
 Pharmacology the action of strychnine as a cardiac stimulant 
 is to a great extent ignored; but I think that in medical prac- 
 tice the use of this drug as a cardiac stimulant has of late 
 years become more and more general, and it is justified by the 
 good effects observed from it, and explained, partly at least, 
 by the action on the heart which Cash and I found it to have. 
 Under its use we frequently notice that a pulse which was 
 previously feeble, irregular, or intermittent, becomes steady, 
 strong, and regular. No doubt, the conditions which regu- 
 late the pulse are very complicated in health, and still more 
 in disease, so that it is difficult or impossible to be absolutely 
 certain of the exact mode of action of strychnine; but at the 
 same time its good effects are, I think, undeniable, and the 
 explanation that I have given is at any rate feasible. 
 
 Action of Caffeine and other Purin Bodies. While 
 strychnine exerts its beneficial effect almost entirely through 
 the nerves, caffeine and allied bodies probably exert it, more 
 especially, through their action upon the muscular fiber of the 
 heart and arteries and upon the secreting cells in the kidneys. 
 This is not entirely the case, however, for all the plants which 
 contain either caffeine or theobromine are used dietetically as 
 
 1 Brunton and Cash, " On the explanation of Stannius's experiment, and 
 on the Action of Strychnia on the Heart," St. Bartholomew's Hospital 
 Reports, vol. xvi., 1880, reprinted in Collected Papers, p. 556, cf. p. 21.
 
 1 62 THERAPEUTICS OF THE CIRCULATION 
 
 nervous stimulants; tea, coffee, and chocolate being the most 
 commonly employed, but kola and guarana being also largely 
 used in Africa and South America. Like digitalis, caffeine 
 stimulates the vaso-motor center in the medulla and raises the 
 blood-pressure by causing contraction of the vessels; but this 
 rise, instead of being accompanied by a slow pulse, as in the 
 case of digitalis, usually goes along with an acceleration of the 
 heart beats. The reason of this probably is that the cardiac 
 muscle is rendered by caffeine more irritable, so that its rhyth- 
 mical stimuli follow one another more quickly, while at the 
 same time its contraction becomes more powerful. The effect 
 upon the kidneys is to produce a considerably increased flow 
 of urine, and the increase of water is accompanied also by an 
 increase in the solids, the total effect being chiefly due to stimu- 
 lation of the secreting cells. Theobromine differs from caf- 
 feine in having much less effect upon the vaso-motor center 
 and more effect upon the kidney itself. It therefore acts more 
 powerfully as a diuretic than caffeine. It is sparingly soluble 
 in water, but is rendered more soluble by trisodium phosphate, 
 and several synthetic compounds have been introduced into 
 medicine. One is called diuretin, which is said to be a sali- 
 cylate of sodium and theobromine ; agurin, which is an acetate 
 of sodium and theobromine; an iodide of sodium and theo- 
 bromine; and uropherin, which is a salicylate of lithium and 
 theobromine. Another substance, also found in tea and coffee, 
 theophyllin, has been made synthetically, and is sold under 
 the name theocine. All these substances are useful diuretics, 
 and may be given either alone or in combination with digitalis, 
 strophanthus, or other drugs having a similar action. 
 
 Drawbacks to the Action of Digitalis and other Cardiac 
 Tonics. All the drugs of which we have hitherto been speak- 
 ing have a tendency to cause contraction of the vessels. This 
 tendency may interfere with their beneficial effects by caus- 
 ing contraction of the renal arteries, and thus checking the 
 secretion of urine; but a greater drawback sometimes is that, 
 by contracting the vessels generally, they raise the blood pres-
 
 DRAWBACKS TO CARDIAC TONICS 163 
 
 sure and thus increase the resistance which the heart has to 
 overcome, and consequently the work it has to do. If the 
 heart is very feeble it may even become unable to overcome 
 the increased tension, and sudden and fatal syncope may ensue. 
 Fatal syncope has not un frequently resulted from the exces- 
 sive use of digitalis, and it appears to be more apt to come 
 on when the person rises to micturate. The sudden change 
 from a recumbent to an upright position lessens the pressure 
 of blood in the cerebral arteries, while, at the same time, by 
 emptying the bladder the intra-abdominal pressure is lessened, 
 and the blood is retained in the splanchnic area. But the cases 
 in which the heart is most likely to be stopped by digitalis are 
 those in which the arterial pressure is already high, as in 
 advanced Bright's disease, and where the heart has already 
 become fatty. In such cases digitalis must be used with great 
 caution, for there is a double risk. On the one hand, there is 
 the danger just alluded to of stopping the heart, and on the 
 other, there is the risk of causing apoplexy by the arterial 
 tension rising so high as to burst a vessel in the brain. 
 
 Removal of these Drawbacks by Combination. Yet in 
 many such cases we sadly want the steadying and strengthen- 
 ing effect of digitalis or strophanthus upon the heart, and we 
 are able to obtain the result we desire by combining these 
 drugs with others belonging to an entirely different class, 
 namely, that of vaso-dilators. 
 
 Vaso-dilators. The first vaso-dilator investigated was 
 nitrite of amyl. Its power of causing flushing of the face was 
 noticed by Guthrie in 1859, and Dr. B. W. Richardson ob- 
 served that it caused dilation of the capillaries in the frog's 
 foot; but it was Dr. Arthur Gamgee who first discovered its 
 power of lowering the blood pressure. It was under his direc- 
 tion that I had been carrying out my experiments on digitalis 
 in the late Professor Douglas Maclagan's laboratory, and I 
 used to submit myself to Dr. Gamgee for experiments upon 
 the effect of nitrite of amyl on my own pulse, from which he 
 made sphygmographic tracings, and these experiments nat-
 
 164 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 urally rendered me thoroughly conversant with its physio- 
 logical action on the pulse. The numerous observations I had 
 
 189. Tracing showing the ac- 
 tion of isobutyl nitrite on blood pres- 
 sure. The indications in the tracing 
 are the same in Fig. 190. 
 
 FIG. 190. Tracing showing the ac- 
 tion of amyl nitrite on the blood pres- 
 sure. The point where the administra- 
 tion was begun is marked by a cross; 
 the point where it was discontinued, by 
 a small arrow. The horizontal double- 
 headed arrow indicates the zero point 
 of pressure; the single-headed arrow in- 
 dicates the direction in which the trac- 
 ing is to be read. 
 
 made upon my own pulse 1 naturally made me rather expert 
 in the use of the sphygmograph ; and when resident in the 
 
 1 Lauder Brunton on " Digitalis," Inaugural Thesis, 1866, and Collected 
 Papers on Circulation and Respiration, First Series, pp. 129-136.
 
 FIRST USE OF AMYL NITRITE 
 
 i6 5 
 
 Royal Infirmary at Edinburgh I made a number of observa- 
 tions upon a case of angina pectoris which was at that time 
 in the wards. I found that during every attack the tension 
 of the pulse became greatly increased, and as the pain passed 
 off the tension fell. Every remedy had been tried in vain, 
 and the patient was just going out of the hospital when it 
 occurred to me that if one could lower the pressure in his 
 vessels one would very probably relieve 
 the pain. I therefore kept him in one 
 day longer to try the experiment, and 
 promised him that if it should fail he 
 should go out next day. To my de- 
 light the experiment proved a complete 
 success. As I administered the nitrite 
 of amyl, which my friend Dr. Gamgee 
 had given me, the patient's face became 
 flushed, the pulse, instead of being 
 small and thready, became full and 
 bounding, and the pain almost instan- 
 taneously disappeared. (Figs. 204- 
 214, p. 190.) Nitrite of amyl still 
 holds its place in medical practice as 
 the most rapid and powerful vascular 
 dilator, but other nitrites or nitrates 
 having a slower but more lasting action 
 have now come into more general use. 
 In 1876, along with Mr. Tait, 1 I 
 discovered that nitroglycerine had an 
 action upon the circulation similar to 
 that of nitrite of amyl, but I used to get such an awful head- 
 ache from working with it that I hesitated to give it to 
 patients, and while I was still hesitating Dr. Murrell employed 
 it in a case of angina with great success. It has now be- 
 come the stock remedy for lowering arterial tension, and has 
 been introduced into the British Pharmacopoeia in the form 
 
 1 St. Bartholomew's Hospital Reports, 1876, p. 144. 
 
 FIG. 191. Action of 
 hydroxylamine hydrochlor- 
 ate on blood pressure.
 
 1 66 THERAPEUTICS OF THE CIRCULATION 
 
 of tablets containing a hundredth of a grain in chocolate. 
 These may be either taken at once, or a little bit of them 
 may be nibbled and the nibbling carried on until the pain 
 passes off. If one is not sufficient, more may be used. 
 Whilst working in Professor Ludwig's laboratory in 1869, I 
 found that sodium nitrite had a similar action to amyl nitrite, 
 but not so marked. This observation was not published, and 
 the action of sodium nitrite was described some years later 
 by Dr. Hay. In 1876 and 1877 I made also a large num- 
 ber of experiments, along with the late Dr. Gresswell of 
 Melbourne, on the action of other nitrites, but owing to vari- 
 ous circumstances these results also have not been published. 
 A very interesting research by Professors Cash and Dunstan 1 
 on various nitrites shows that they are all alike in the nature 
 of their action, though differing somewhat in degree. The 
 same is the case with a substance differing entirely from them 
 chemically, namely, hydroxylamine, which Mr. T. J. Boken- 
 ham 2 and I found to dilate the vessels, and produce a fall in 
 the blood pressure almost identical with that caused by nitrite 
 of amyl. 
 
 A most interesting discussion of the drugs belonging to the 
 nitrous group is contained in the lectures of the late Professor. 
 Leech, whose death was a loss to the whole scientific world, 
 and a great personal grief to everyone who knew him. Nitro- 
 erythrol is another substance which is almost more useful than 
 any of the other nitrites, because its action, though less 
 powerful, is more prolonged than theirs, and in cases where 
 we wish to keep the blood pressure constantly low, it is very 
 convenient, an eighth to half a grain or even more being taken 
 every two, four, or six hours, more or less as the case re- 
 quires. Nitromannitol may also be used in doses of one grain 
 or more. Where the pulse is very quick, aconite or colchicum 
 may be given and general bleeding may be required. 
 
 1 Cash and Dunstan. 
 
 2 Brunton and Bokenham, Roy. Soc. Proc., 1889, vol. xlv., p. 352.
 
 LECTURE VII 
 
 Nicotine Tobacco Smoking Attractions of Smoking Results of Ex- 
 cessive Smoking Aconite Local Modification of the Circulation: Inflam- 
 mation General Bleeding Local Bleeding Treatment of Cardiac Dis- 
 eases : Treatment of Palpitation Diet and Regimen Graves's Disease 
 Tachycardia from Strain Paroxysmal Tachycardia. 
 
 Nicotine. Another drug which has a very powerful in- 
 fluence upon the blood pressure and cardiac action, is nicotine. 
 Both in frogs and mammals nicotine produces, first convul- 
 sions and then paralysis. When applied in small doses to the 
 frog's heart, it causes the beats at first to become slow and 
 afterwards quick. If the dose be large, no primary slowing 
 may be observed. In animals it causes slowing of the heart, 
 with enormous rise of blood pressure. The rise of blood 
 pressure is so great that I have never seen it equalled after the 
 injection of any drug, with the exception of suprarenal extract. 
 The rise of pressure is chiefly due to contraction of the arteri- 
 oles. This contraction is partly dependent upon stimulation 
 of the vaso-motor center in the medulla oblongata, but partly 
 also to a local action upon the arterioles themselves, as it may 
 be produced by injection of the drug even after the medulla 
 has been destroyed. The pulse-rate in mammals is first 
 slowed and afterwards quickened, just as in the frog. The 
 slowing is due partly to stimulation of the vagus center in the 
 medulla oblongata, and partly to the stimulation of the in- 
 hibitory apparatus in the heart itself. The subsequent in- 
 crease in the pulse-rate is due to paralysis of these ganglia. 
 In consequence of this double action of nicotine, if the vagus 
 be divided during the period of slow pulse, the pulse becomes 
 somewhat quicker, but still remains slower than normal. 
 When, however, the dose has been sufficiently large to quicken 
 the pulse, no stimulation of the vagus will slow the heart, as 
 its terminal branches in the heart are paralyzed by the drug. 
 
 167
 
 1 68 THERAPEUTICS OF THE CIRCULATION 
 
 This action is the same in the heart of the frog, so that after 
 a large dose of nicotine, stimulation of the vagus has no effect 
 upon the heart, but stimulation of the venous sinus itself will 
 slow the heart. The reason of this probably is, that, although 
 the inhibitory ganglia in the heart are paralyzed, the inhibitory 
 neurons which proceed from them are still intact, and are 
 affected by local stimulation. 
 
 Formerly, tobacco enemata were used as a means of caus- 
 ing vascular and general relaxation, but they were far from 
 being without danger and are never employed now. But, 
 although tobacco is not used as a remedy for disease, its em- 
 ployment is so universal that its action requires very careful 
 consideration. Nicotine alone is only taken into the body 
 when tobacco is used by chewing or by snuffing. When it is 
 chewed, most of the juice is expectorated, but a small portion 
 is probably swallowed. When tobacco is used in the form of 
 snuff, small quantities of it find their way into the naso- 
 pharynx and they are swallowed. The tobacco used for chew- 
 ing or snuffing contains, as a rule, but very little nicotine, and 
 so symptoms of poisoning from either of those habits are rare. 
 
 Tobacco Smoking. Usually, tobacco is employed by smok- 
 ing, either in the form of cigars or cigarettes, or in a pipe. 
 \Vhen used in any one of these forms it is not pure nicotine 
 which reaches the mouth, but really the products of the dry 
 distillation of tobacco, containing a large quantity of pyridine 
 and picoline bases. 1 Probably nicotine in greater or less quan- 
 tity is also present. The proportions of. the pyridine and 
 picoline bases in the tobacco smoke vary according to the mode 
 in which it is burnt. In a cigar there is a freer access of air, 
 so that much collidine and little pyridine are formed, while 
 in a pipe much more pyridine is produced, and thus stronger 
 tobacco can be smoked in a cigar than in a pipe. So much is 
 this the case, that tobacco which in the form of a cigar would 
 produce no disagreeable effect, may cause giddiness and vomit- 
 
 1 Vohl and Eulenburg, Arch. Pharm. [2], cxlvii., 130-166. Abstracted 
 by Lander Bi;unton in Journ. Chem. Soc., 1871, New Ser., vol. ix., p. 1075.
 
 ATTRACTIONS OF SMOKING 169 
 
 ing if smoked in a pipe. The smoke from a pipe or cigar 
 usually passes simply into the mouth and out again, either 
 through the mouth or the nostrils; but when smoked in a 
 huka or .narghileh, the smoke is inhaled into the lungs, and 
 this is frequently done also by people who smoke cigarettes. 
 When a huka or a narghileh is used, the smoke passes through 
 water before being inhaled, and it is thus deprived of most of 
 its poisonous constituents; but this is not so with the smoke 
 of cigarettes, and, as absorption occurs very rapidly from the 
 pulmonary mucous membrane, cigarette smoking is sometimes 
 very injurious. There is another reason, however, why ciga- 
 rette smoking is frequently more harmful than smoking a 
 pipe or cigar, and it is that cigarettes are small and can be 
 smoked in a few minutes, so that many more cigarettes than 
 pipes or cigars are consumed in the course of the day, and 
 the total quantity of tobacco used is thus much greater in the 
 form of cigarettes. 
 
 Smoking in moderation does not seem to be injurious to 
 grown-up people, but there appears to be a general consensus 
 of opinion that it is very distinctly harmful to growing lads. 
 
 Attractions of Smoking. In adults, smoking appears to 
 have a double action. It will stimulate the brain to increased 
 
 FIG. 192. Tracing to show the increased rapidity of circulation in the carotid of 
 horse during mastication. (After Marey.) 
 
 activity, and it will also produce a soothing effect in conditions 
 of excitement. Its stimulating effect upon mental activity is 
 probably partly due to the local irritant action of smoke upon 
 the mouth, causing reflex dilation of the vessels which supply 
 the brain in somewhat the same way as mastication (Fig. 192).
 
 I/O THERAPEUTICS OF THE CIRCULATION 
 
 Its action as a sedative is probably partly due to the necessity 
 of breathing rhythmically while smoking, and the soothing 
 effect of watching the smoke as it issues from the lips or 
 nostrils, especially when it is blown out in the form of rings. 
 This is by no means an unimportant factor, for many people 
 derive but very little pleasure from smoking in the dark. 
 
 Results of Excessive Smoking. One of the commonest 
 results of excessive smoking is chronic pharyngitis, with irrita- 
 
 FIG. 193. Pulsations of the fontanelle (F) in an infant six weeks old while sucking. 
 R shows a simultaneous tracing of the thoracic respiration. The breast was offered 
 to the child at the beginning of the tracing. At the time indicated by the third 
 respiratory wave, which has a flattened top, the child began to take the breast. It 
 will be noticed that the line of the tracing F rises, indicating increased circulation 
 on the brain. (After Salathe.) 
 
 bility of the throat, cough and hoarseness, and sometimes the 
 irritation also affects the tongue. Weakness of vision, nervous 
 tremor, and giddiness frequently result from tobacco-smoking. 
 It is difficult to decide how far these are due to the direct action 
 of the tobacco smoke upon the nervous system, and how far 
 they are caused through alteration in the circulation. The 
 circulation becomes much affected ; palpitation and pain in the 
 cardiac region are common results. Sometimes, though rarely, 
 the cardiac pain may be so great as to simulate angina pectoris. 
 Irregularity of the heart is very common, and it appears to me 
 that this irregularity is more frequently found from a common 
 kind of tobacco known as " pig-tail " than from better-class 
 tobaccos. When I was a house physician I met with it very 
 frequently, and the cardiac rhythm might be represented some- 
 what in this way :
 
 ACONITE I / 1 
 
 a pause, followed by one or two heavy beats, then a succession 
 of quick, small beats, and then a pause again. With better- 
 class tobaccos I have not observed this irregularity so fre- 
 quently, but I have more often seen the patient simply fall 
 down unconscious, as if he had been shot. These unpleasant 
 symptoms, as well as the nervous symptoms which accompany 
 them, may sometimes cease upon lessening the amount of 
 tobacco used, but not un frequently a very small quantity 
 appears to keep up the condition after it has once been es- 
 tablished : and complete abstinence from tobacco, occasionally 
 for a period of several months, is required before it can be 
 resumed without causing a recurrence of the symptoms. 
 
 Aconite. Aconite is a drug which may be looked upon as 
 a typical cardiac depressant. Its most characteristic physio- 
 logical action is that of causing numbness and tingling when 
 applied to the tongue in small quantities, and this test is much 
 more delicate than any chemical reaction. When adminis- 
 tered to mammals in small doses, it slows the heart very 
 greatly, and this effect is entirely due to its action upon the 
 vagus center. Its effects are precisely similar to those pro- 
 duced by stimulation of the vagus, the heart being rendered 
 slow and the blood pressure falling. In larger doses it para- 
 lyzes the ends of the vagus in the heart, so that the pulse 
 becomes suddenly very rapid and at the same time irregular. 
 It appears to have also a local action on the cardiac muscle, 
 but this is of a very complex nature, and is probably con- 
 nected with stimulation and paralysis of some sensory mechan- 
 ism in the heart itself, to which the cardiac pulsations are 
 partly due. That such a reflex mechanism actually exists in 
 the heart itself appears to be shown, amongst other things, by 
 the experiments of Von Basch and A. Frohlich 1 upon the ac- 
 tion of cocaine on the heart. They found that when the sur- 
 face of the heart was stimulated by a Faradic current, which 
 caused an extra beat and compensatory pause, this effect 
 
 1 Von Basch and A. Frohlich, Centralblatt fiir Physiologic, Band xviii. ; 
 Literatur, 1904, p. 693.
 
 172 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 diminished rapidly when cocaine was applied to the surface 
 of the heart. This action was not due to any effect of cocaine 
 upon the cardiac muscle, but only to its local action on the 
 epicardium. It is not improbable that the effect of aconite 
 upon the heart may be due to an action upon the sensory 
 mechanism in it somewhat analogous to that of cocaine. One 
 effect of aconite is to disturb the rhythm very greatly, so that 
 
 foSD MOTOR CENTRE 
 /N MEDULLA. 
 
 VASO MOTOR 
 FOR THE VESSELS 
 OF THE EAR 
 
 ASO MOTOR NERVES 
 ) FOR OTHER PARTS 
 OF THE BODY 
 
 FIG. 194. Diagram of the vaso-inotor nerves of the rabbit's ear. 
 
 in the frog's heart the normal beats and peristaltic action may 
 alternate. 
 
 The chief use of aconite is in local inflammations accom- 
 panied by general febrile disturbance. Small doses of this drug 
 appear occasionally to be exceedingly useful ; for example, in 
 tonsillitis and in febrile colds. In nervous flutterings of the 
 heart, aconite in small doses appears to quiet the circulation, 
 but how it does so I cannot at present explain. Very small
 
 USES OF ACONITE 
 
 173 
 
 FIG. 195. Blood vessels in normal condition. (After Lister.) 
 
 FIG. 196. Same vessels after the application of an irritant and commencement of 
 inflammation. (After Lister.)
 
 174 THERAPEUTICS. OF THE CIRCULATION 
 
 doses are sufficient, and often seem to slow the pulse more than 
 larger ones. One minim of the pharmacopoeial tincture every 
 hour is frequently sufficient, although the dose given in the 
 British Pharmacopoeia is 2 to 5 minims, frequently repeated, or 
 5 to 15 minims when given at longer intervals. In cases of 
 persistent high tension with attacks of angina pectoris, aconite 
 is sometimes useful. Its action should be regulated by a 
 sphygmomanometer. 
 
 Local Modification of the Circulation inflammation. 
 We have various methods of modifying the circulation locally. 
 In local inflammations, as I have just said, aconite seems to be 
 useful, and during its administration the local inflammation 
 frequently subsides, the pain disappearing, the redness, swell- 
 ing, and heat of the part diminishing. We may modify the 
 local circulation in inflammation either by heat or cold. If 
 
 FIG. 197. Diagram to show the effects of heat and cold in lessening the pain of 
 inflammation. The diagram is supposed to represent the end of the ringer. The 
 small star indicates the point of irritation, e. g., a prick by a thorn. The line in 
 the center of each figure is intended to represent the nerve going to the injured part; 
 and at the side of each figure is an artery and vein connected by a capillary network. 
 In a the capillary network around the seat of irritation is seen to be much congested; 
 the nerve-filaments are thus pressed upon, and pain is occasioned; b represents the 
 condition of the finger after the application of cold to the arm or hand. In con- 
 sequence of the contraction of the afferent arteries the finger becomes ansmic; no 
 pressure is exerted on the nervous filaments, and pain is alleviated; c represents the 
 finger after it has been encased in a warm poultice; the capillary network at the 
 surface of the finger is dilated, and the blood is thus drawn away from the seat of 
 irritation, and the pain therefore relieved. 
 
 the inflammation be situated in a place where the tissues are 
 yielding, heat frequently relieves it most, but if the tissues are 
 unyielding, as, for example, where the inflammation occurs at 
 the root of a tooth or under a hard fascia, heat increases the
 
 LOCAL MODIFICATION OF THE CIRCULATION 
 
 pain while cold relieves it. The explanation of this is obvious. 
 Heat tends to cause local dilation of the vessels, and if the 
 nerves which run alongside them are in an unyielding sheath, 
 the dilated vessels press more upon them and increase the 
 pain; whereas if the tissues are yielding all round, the col- 
 lateral circulation is increased, and the pressure of blood in 
 the inflamed area is lessened. If the nerves and vessels are 
 both confined in an unyielding sheath, the application of cold 
 tends to cause contraction of the vessels, and, by diminishing 
 their caliber, to lessen pressure upon the nerves and ease the 
 pain. The local application of heat may induce a pretty ex- 
 tensive dilatation of the vesels; for, on putting my feet into 
 a bath of hot water, I have sometimes observed increased 
 pulsation of the femoral arteries. The local application of 
 cold in the case of an artery will cause it to contract, and 
 lessen the circulation in the distal part; so that if a cold band- 
 age be applied over the middle of the arm, the radial artery 
 will beat less strongly. By putting on a cold bandage covered 
 with oil-silk a gentle warmth of the surface is produced, which 
 seems to have a quieting effect upon the circulation and lessens 
 the pain from inflammation, as is evident from its use in 
 various local lesions, and perhaps most markedly when ap- 
 plied to the throat in cases of pharyngitis and tonsillitis. A 
 large wet compress of this sort applied to the abdomen is 
 sometimes very useful in cases of sleeplessness, as it tends 
 to draw away the blood from the brain and allow the nerve 
 cells to become quiet. Warmth to the inside of the stomach 
 has a similar action, and warm food will often tend to pro- 
 duce sleep. The food must, however, not be too warm, as 
 otherwise the heat will pass through the diaphragm, and by its 
 local stimulating action on the heart will increase the force of 
 the pulse, and by driving more blood to the brain, lessen the 
 tendency to sleep instead of increasing it. 
 
 General Bleeding. Bleeding from the arm is a remedy 
 which is now too little used. In the case of angina pectoris, 
 in which I used nitrite of amyl for the first time, small bleed-
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Vessels of thoracic wall 
 
 FIG. 198. 
 
 Vaso-motor centre. 
 
 Vessels of body generally. 
 
 Dilated vessels of lung. 
 
 Diagram to show congestion of the lung. The pulmonary vessels are shown 
 dilated, and those of the thoracic wall contracted. 
 
 Dilated vessels of 
 thoracic wall 
 
 Blister 
 
 Vaso-motor centre. 
 
 Vessels of body 
 generally. 
 
 Contracted vessels 
 of lung. 
 
 FIG. 199. Diagram to explain the action of counter-irritation. A blister or other 
 counter-irritant is shown applied to the chest-wall. The stimulus which it causes is 
 transmitted up the afferent nerves to the vaso-motor center; it is thence reflected down 
 the vaso-motor nerves to the pulmonary vessels, causing them to contract, while it is 
 reflected down vaso-dilating fibers to the vessels of the thoracic wall, and probably of 
 other parts of the body also, causing them to dilate, and thus lessening the pulmonary 
 congestion by withdrawing blood from the lungs. (Compare with Fig. 198.) 
 
 FIG. 200. Showing the effect of cold upon the arteries. A shows the normal 
 sphygmogram from the radial artery. B is the same after the application of a cold 
 compress above the elbow. (After Winfernitz.)
 
 LOCAL BLEEDING 177 
 
 ings of three or four ounces were the only thing which eased 
 the pain before the nitrite was employed, and even after its 
 employment bleeding from the arm benefited the patient. 1 
 In engorged conditions of the right side of the heart, whether 
 due to mitral incompetence or pulmonary affections, blood- 
 letting not only relieves the symptoms, but may save the 
 patient's life. 
 
 Local Bleeding. A means of influencing the circulation 
 locally, which was formerly much employed, but has now to a 
 great extent fallen into disuse, is the application of leeches 
 and cupping. The relief which is obtained by the application 
 of half a dozen leeches to the side, in cases of severe pleurisy, 
 is very extraordinary; and it is difficult indeed to see how 
 the comparatively small quantity of blood which they extract 
 should relieve the patient so much, but there can be no doubt 
 about the fact that the relief they afford is enormous. Their 
 application over the mastoid process in severe headache or in 
 meningitis, and over the cardiac area in pericarditis or the 
 liver in hepatitis, especially if accompanied with perihepatitis, 
 is very useful. Wet cupping over the kidneys in acute 
 nephritis and over the back in suffocative bronchitis, is 
 sometimes attended with marked amelioration of the symp- 
 toms. It is not simply the removal of blood that produces 
 this effect, because dry cupping, where no blood is removed, 
 is frequently of service. In dry cupping the beneficial result 
 may be partly due to the withdrawal of blood to the skin and 
 subcutaneous tissue. It may also be due to a reflex effect of 
 the stimulus upon the circulation, both local and general, and 
 it may possibly be, to some extent, a form of serum therapeu- 
 tics, as the fluid which exudes into the tissues after the appli- 
 cation of the cups may undergo some alteration which imparts 
 to it a curative action after its reabsorption. Any explanation 
 of the mode of action, however, is at present hypothetical, and 
 we are obliged to be content with knowing what the effects are 
 
 1 Lauder Brunton, Clinical Society Reports, vol. Hi., 1870; and, Collected 
 
 Papers, First Series, p. 186. 
 
 13
 
 1/8 THERAPEUTICS OF THE CIRCULATION 
 
 without understanding how they are produced. The same 
 may be said of the marked benefit which results from local 
 applications over the cardiac region. When the heart is ex- 
 cited by emotion, the natural tendency is to place the hand 
 over the heart, in order, as the phrase goes, " to still its beat- 
 ing." The pressure of the hand over the cardiac region cer- 
 tainly tends to quiet palpitation, and the same result is ob- 
 tained, even to a greater extent, by permanent pressure from 
 the application of a plaster over this region. The plaster may 
 be simply adhesive; but I think the use of extract of bella- 
 donna is something more than a prejudice, and a belladonna 
 plaster, I think, really has a more powerful action as a cardiac 
 sedative than a merely adhesive plaster. A good deal depends 
 upon the way the plaster is applied. It is best not to have it 
 too small, and in the case of women it ought to be cut like 
 the pattern which I show you, so that it may fit 
 over the breast. An india-rubber bag, filled with 
 crushed ice, applied over the cardiac region some- 
 times quiets excessive cardiac action ; or, in place 
 of it, a tube of india-rubber, coiled round and round, so as to 
 form a flat plate through which cold water may be passed in 
 a continuous stream, may have a similar action. When the 
 action of the heart is feeble, a bag filled with hot water, or a 
 warm poultice, a warm fomentation, or a turpentine stupe, may 
 stimulate its action. In one case of cardiac disease I have 
 seen ammonia liniment rubbed over the cardiac region for the 
 relief of pain bring on such palpitation as to cause very great 
 inconvenience to the patient, and to necessitate the relinquish- 
 ing of the remedy. 
 
 TREATMENT OF CARDIAC DISEASES 
 
 Treatment of Palpitation. We may pass now from the 
 consideration of the therapeutic means at our disposal to the 
 treatment of definite disorders of the circulation. First of all, 
 we may take palpitation. The first thing to be done is, of 
 course, to try and find out its cause, and relieve it if possible.
 
 TREATMENT OF PALPITATION 
 
 In cases where it depends upon the excessive use of alcohol, 
 tobacco, tea, or coffee, these articles should either be dimin- 
 ished or, if necessary, cut off entirely. The use of a bella- 
 donna plaster I have already mentioned, and here the distinc- 
 tion between gentle, steady pressure and hard pressure is ob- 
 vious, because, although the slight pressure of the plaster or 
 
 RECTUM AND H^EMORRHOIDAL PLEXUS. 
 
 FIG. 201. Diagram of the veins forming part of the portal circulation. The 
 pancreatic and splenic veins, although most important, have been omitted for the sake 
 of clearness. 
 
 hand tends to quiet the heart, yet the harder pressure pro- 
 duced by lying upon the left side frequently aggravates the 
 palpitation, so that patients are obliged to lie upon the right
 
 ISO THERAPEUTICS OF THE CIRCULATION 
 
 side. In some cases they are obliged to lie upon their back ; 
 but, as a rule, lying on the back is disadvantageous. In many 
 people it appears to disturb the circulation to such an extent 
 as to cause a nightmare, frequently of such a kind as to indi- 
 cate interference with the circulation through the lungs, be- 
 cause the dream which makes the patient awaken is that of 
 being chased by an animal or subjected to some other sudden 
 strain, and when he does awake he has the same sensation of 
 oppression, and his heart is beating just as if he had been 
 running away from a mad bull or undergoing some other vio- 
 lent exertion. 
 
 When palpitation depends upon distension of the stomach 
 by flatulence pushing the heart up, and thus bringing its apex 
 against the chest wall, immediate relief is afforded by carmina- 
 tives to bring the flatulence away, and I give here two pre- 
 scriptions, which may serve as examples : 
 
 $ Sodii Bicarb gr. v 
 
 Spt. .Ether Co HI v 
 
 Spt. Chlorof niv 
 
 Tinct. Cardamom. Co TTl x 
 
 Aq. Menth. Pip ad Jj 
 
 M. mitte 3viij 
 
 Sig. One-eighth part to be taken alone, or with water, every ten or fif- 
 teen minutes until the flatulence is relieved. 
 
 $ Spt. Ammon. Aromat Tl xv 
 
 Spt. Chlorof ni x 
 
 Tinct. Carminativ Til x 
 
 Aqua ad 3ss 
 
 M. mitte 3 V J 
 
 Sig. One-twelfth part to be taken alone, or in water, every few minutes 
 until the flatulence is relieved. 
 
 Another useful plan is to give about one-third of a tea- 
 spoonful of sodium bicarbonate in a claret glassful of water 
 or peppermint water, and to let the patient slowly sip as 
 much of this as is necessary. But, in order to relieve the 
 palpitation permanently, the digestion must be put right and 
 fermentation in the stomach stopped. We must remember 
 here that the blood from the stomach has to pass through the
 
 FLATULENCE IN HEART DISEASE l8l 
 
 liver (Fig. 181, p. 154) before it reaches the general circula- 
 tion, and that the liver and bowels require attention as well 
 as the stomach. We very frequently are able to relieve palpi- 
 tation far more by medicines which act only on the digestive 
 canal, than by drugs which affect the heart and vessels directly. 
 One of the best remedies that I know for functional irritation 
 of the heart is one which my old teacher, Dr. Warburton 
 Begbie, used to call the " pulvis mirabilis." Its composition 
 was as follows : 
 
 IJ Bismuth Subnit gr. x 
 
 Sodii Bicarb gr. x 
 
 Pulv. Nuc. Vom gr. ss-jss 
 
 Pulv. Rhei gr. j-iij 
 
 Pulv. Cinnamom. Co gr. iij 
 
 M. ft. pulv. 
 
 The great disadvantage of this powder was its filthy taste, 
 but this can be got over by putting the nux vomica and 
 rhubarb in a cachet, and giving the other ingredients in a 
 mixture, along with some carminative and flavoring sub- 
 stance. Both the mixture and cachet are taken at the same 
 time, and, as they mix in the stomach, one gets the effect one 
 desires without the patient perceiving the taste. When the 
 heart is feeble, three or four minims of tincture of strophan- 
 thus or of digitalis may be added to the mixture with advan- 
 tage; and if the patient be anaemic, some preparation of iron 
 may be either given along with, or separate from the medicine. 
 Diet and Regimen. Of course, a large quantity of food 
 which would distend the stomach mechanically should be 
 avoided; and, if required, the meals should be small in quan- 
 tity and more frequently repeated. Articles of diet that tend 
 to cause flatulency, such as cabbage, pastry, and sugar, should 
 also be avoided, or anything else that seems to disagree with 
 the patient. The eating must be slow, and mastication 
 thorough. In addition to the nature of the food, the manner 
 in which solids and liquids are taken must be carefully attended 
 to. When much fluid is drunk with a meal it tends to dilute
 
 1 82 THERAPEUTICS OF THE CIRCULATION 
 
 the gastric juice, and this lessens digestion in the stomach, so 
 that digestion must be finished in the intestine. When little 
 fluid is taken with a meal the digestion in the stomach is more 
 perfect, and consequently less digestion requires to be carried 
 on in the intestine. People who have a tendency to flatulence 
 should therefore take little or no liquid with their meals. But, 
 it is evident that as the body contains so much water, water 
 must be taken in some form or another during the day. The 
 best form in which to take it is that of simple hot water, as 
 hot as can be comfortably drunk, with a slice of lemon floating 
 on the surface to relieve the insipidity of the hot water itself. 
 The water should not be drunk in large draughts, but should 
 be slowly sipped. The best time for taking the water is when 
 digestion in the stomach is finished, that is to say, three or 
 four hours after a meal. Thus, if breakfast be taken at 8, 
 some hot water may be sipped between n and 12. If lunch 
 be taken at I some hot water may be sipped between 4 and 5. 
 
 At this time the water may be either sipped alone or it may 
 be slightly flavored with tea, or the water may be sipped first 
 and a cup of ordinary tea drunk afterwards. The water alone 
 is best, because the cup of tea sometimes gives rise to acidity 
 and flatulence ; but its refreshing power is so great that in some 
 cases it may be allowed, and if so, it ought to be China tea. 
 If hot water or tea be disliked, the water may be simply 
 flavored with some kind of meat extract, or thin broth, juli- 
 enne soup, or beef-, mutton-, or chicken-tea may be substituted, 
 but it must not be strong. Water should again be sipped be- 
 fore going to bed. 
 
 Water taken in this way not only supplies the needs of the 
 body, but it tends to wash the contents of the stomach out 
 after each meal, so that no food is left behind to ferment. 
 When the stomach is not cleaned out, remnants of food are apt 
 to undergo fermentation, and the portion of each meal that is 
 left behind tends to start fermentation in the next meal, so 
 that a state of indigestion is set up which may remain for a 
 length of time.
 
 USES OF WATER WHEN TO TAKE IT 183 
 
 In order that digestion should be perfect the food must be 
 thoroughly broken up, as otherwise it will not be dissolved by 
 the gastric juice. Many people are apt to chew their food very 
 imperfectly and wash it down with liquid, either water, tea, 
 coffee, wine, or spirits, during the meal. When no liquid is 
 taken with the meal, this becomes almost impossible. The 
 food must then be broken up thoroughly and mixed with 
 saliva. One great rule in indigestion of all sorts, therefore, is 
 to take no liquid during meals. When liquid is drunk towards 
 the end of a meal, the danger of imperfect mastication is 
 lessened, but much liquid taken at this time will still interfere 
 with digestion in the stomach, by diluting the gastric juice and 
 so weakening its digestive power. If the patient is able to take 
 exercise, a moderate amount of gentle exercise in the open 
 air is advisable; and where the patient seems too weak for 
 much exercise, massage may take its place to a considerable 
 extent. If other means fail and the palpitation is very dis- 
 tressing, the patient may be put to bed and kept there steadily 
 regular Weir Mitchell treatment, in fact, being adopted. 
 
 Palpitation is very apt to be associated with some disturb- 
 ance in the pelvic organs, and anything wrong with these ought 
 to be attended to, and any excitement of them should be care- 
 fully avoided. 
 
 In cases where palpitation is associated with debility, 
 strychnine or nux vomica is of great service, and may be given 
 as in the prescription for the " pulvis mirabilis," shortly before 
 or after meals. Its action is complex, because it affects the 
 whole nervous system, stimulating the brain, the medulla, and 
 the heart. In most cases it can be borne even in large doses, 
 but there are some where it does harm rather than good, more 
 especially in patients of a highly nervous temperament, and 
 where there is a tendency to excessive sensibility of the pelvic 
 organs. 
 
 Graves's Disease. In Graves's disease we frequently meet 
 with very considerable palpitation, associated with excessive 
 rapidity of the heart, and sometimes we find these conditions
 
 184 THERAPEUTICS OF THE CIRCULATION 
 
 present without any protrusion of the eyeballs. As I men- 
 tioned before, palpitation may be caused by a too prolonged 
 administration of thyroid gland. The best treatment for 
 Graves's disease is undoubtedly prolonged rest in bed, and one 
 of the most successful cases I ever had was a lady who, luckily, 
 became pregnant shortly after the onset of the disease. She 
 was kept constantly in bed for nine months, and made a per- 
 fect recovery. As such patients are usually very emotional, 
 bromides of potassium, sodium, ammonium, or strontium, 
 either singly or combined, are often beneficial, quieting the 
 nervous irritability and removing the restlessness and sleep- 
 lessness which sometimes are present. I have frequently used, 
 and I think with benefit, calcium chloride, and suprarenal ex- 
 tract. Kocher thinks that phosphates should be given freely. 1 
 
 Tachycardia from Strain. Excessive exercise appears to 
 be sometimes followed by a rapid action of the heart, which, 
 instead of passing after the exercise is over, may continue for 
 days or even weeks. In all probability such cases are due to a 
 certain amount of cardiac strain, and ought to be treated as 
 such. 
 
 Paroxysmal Tachycardia. In paroxysmal tachycardia, 
 the beats of the heart, which may previously have been per- 
 fectly normal, suddenly become excessively rapid, as much as 
 three or four times as quick as before. It would almost seem 
 in these cases as if each cavity of the heart was capable of 
 giving an independent stimulus to the contraction of the whole, 
 so that a pulse of 60 might suddenly jump up to a pulse of 240. 
 We do not know the pathology of such cases, but they are not 
 unfrequently associated with a certain amount of fatty degen- 
 eration in the heart. They are benefited during the attack by 
 cold applications over the heart, sometimes by drinking iced 
 water, so as to get the effect of cold directly upon the heart 
 through the stomach, and sometimes by a powerful stimulant 
 such as strong coffee. The attack may sometimes be cut 
 short by the administration of an emetic such as 20 grains of 
 
 1 Common salt in drachm doses, with plenty water, three times a day, 
 is sometimes useful.
 
 PAROXYSMAL TACHYCARDIA 
 
 I8 5 
 
 sulphate of zinc, or mustard and water may be employed. 
 During the interval, small doses of strophanthus, digitalis, 
 strychnine, and eserine may be useful in steadying the heart. 
 If they are associated with high tension, vascular dilators must 
 be employed ; and if they occur in gouty people, the diet should 
 be, to a great extent, non-nitrogenous. In some cases the 
 
 FIG. 202. Case of exophthalmic goitre, St. Bartholomew's Hospital Journal, 
 December, 1897. 
 
 attack of tachycardia appears to be due to reflex irritation 
 from the stomach, and bismuth, sodium bicarbonate, pepsin, or 
 other digestive ferments are of service by lessening dyspepsia, 
 while bromides diminish reflex irritability, and dilute hydro- 
 cyanic acid acts as a local gastric sedative.
 
 LECTURE VIII 
 
 Bradycardia Stokes-Adams Syndrome Irregularity of Pulse Angina 
 Pectoris Treatment of an Attack of Angina Pectoris Diet and Regimen 
 in Angina Cardiac Asthma Sleeplessness Aortic Disease Mitral Re- 
 gurgitation Nauheim Treatment Oertel's Treatment Treatment of 
 Venous Stasis Graduated Exercises Elimination Milk Diet Chloride- 
 free Food Tapping Surgical Treatment of Cardiac Diseases Senile 
 Rise of Pressure Senile Decay Prolongation of Life. 
 
 Bradycardia. The opposite of tachycardia is brachycardia, 
 or, as it is often termed, bradycardia. In some cases of brachy- 
 cardia the slow pulse is associated with syncope. This con- 
 dition is known by the name of Stokes-Adams syndrome. In 
 these cases the patient is affected sometimes as much as three 
 or four times a day by giddiness, insensibility, or epilepsy, and 
 this condition is probably due to atheroma of the vessels in the 
 medulla. In some people the pulse is naturally very slow. 
 In Napoleon, as I have remarked, it was said to have been 
 only 40 per minute, and in a fellow-student of mine was only 
 42 per minute. This man came from Demerara, and I do not 
 know whether malarial affection had anything whatever to do 
 with it or not. Extreme slowness of the pulse is probably due 
 to excessive action of the inhibitory nervous mechanism, either 
 in the medulla oblongata or in the heart itself. Sometimes 
 the latter may be excited by irritation of the vagus trunks or 
 branches of the vagus in the cardiac plexus, just as slowness 
 of the pulse may be produced experimentally by irritation of 
 the vagus in animals. Slowness of the pulse sometimes occurs 
 in women after childbirth, but the explanation of it is un- 
 certain. It is very apt to occur when the heart is feeble, as 
 during convalescence from infective diseases such as acute 
 rheumatism, diphtheria, pneumonia, and typhoid fever ; in gen- 
 eral weakness due to anaemia, chlorosis, and diabetes; and in 
 permanent weakness of the cardiac walls due to fatty or fibroid 
 
 1 86
 
 BRADYCARDIA 
 
 18; 
 
 degeneration. It is seen also in typhoid fever even while the 
 temperature is high, and in this case it is probably due to the 
 effect of a toxin which stimulates the inhibitory mechanism 
 either in the medulla or the heart, and prevents the pulse 
 from rising above 96 even when the temperature would lead 
 
 <, -CEREBELLUM 
 T"/- -'MEDULLA 
 \ / OELONCATA 
 
 -AFFERENT 
 NERVES 
 
 INTESTINAL 
 VESSELS 
 
 FIG. 203. Diagram to show the nervous mechanism by which the action of the 
 heart may be depressed by irritation of the stomach. The reflex irritation of the 
 vagus may render the heart's action simply weak, or slow and weak. 
 
 one to expect a pulse of 120. In the convalescence from diph- 
 theria the slowness of the pulse is not improbably due to some 
 neuritis of the vagus, which, in severe cases, leads to complete 
 paralysis with exceedingly rapid pulse. Other poisons, such 
 as those which occur in uraemia, and also alcohol, coffee, digi- 
 talis, lead, and tobacco, may cause a very slow pulse. It is 
 frequent in jaundice, and its occurrence here appears to be 
 due to the bile acids which weaken the cardiac muscle and 
 render it more easily affected by the inhibitory nerves. 1 The 
 medullary center of the vagus may be stimulated and a slow 
 pulse produced reflexly from the stomach, as in dyspepsia, 
 cancer, or ulcer, from the intestines, or from the skin or sexual 
 organs. (Fig. 216.) It occurs also when there is pressure 
 within the cranium, as from cerebral abscess, aneurysm, 
 haemorrhage, or tumor; in meningitis, either simple or tuber- 
 
 1 Wickham Legg, Bile, Jaundice, and Bilious Disorders, London.
 
 1 88 THERAPEUTICS OF THE CIRCULATION 
 
 cular; in epilepsy, general paresis, mania, sunstroke, melan- 
 cholia, and injuries of the medulla or cervical cord. It is also 
 brought about when the pressure which the heart has to over- 
 come is abnormally high, either in the pulmonary circulation, 
 as in emphysema, or in the general circulation, as in chronic 
 interstitial nephritis. The variety of causation is so great that 
 the treatment is necessarily very different in many of those 
 cases. Speaking generally, however, we have to remove the 
 cause as far as it is in our power. If due to toxins, we must 
 try to lessen their formation in the stomach and intestines by 
 the use of antiseptics and by free purgation, more especially by 
 the use of mercurial purgatives and salines, so as to clear out 
 the bile, in which toxins are largely contained. Where the 
 slow pulse is due to reflex inhibition from the stomach, we 
 must remove the source of irritation and lessen the reflex ex- 
 citability of the vagus center. We may do this by the use of 
 alkalies and bismuth to soothe the gastric mucous membrane, 
 and bromide of potassium to lessen the nervous irritability. 1 
 In all cases it is advisable to try to strengthen the heart itself, 
 and nux vomica or strychnine with iron are amongst the most 
 useful remedies for this purpose. 
 
 Irregularity of Pulse. Alterations in the rhythm of the 
 heart, alternating tachycardia and brachycardia, so as to give 
 an irregularity or intermittence, are usually due to a combina- 
 tion of the causes that produce either the one or the other. 
 In poisoning by digitalis, for example, we get in its various 
 stages brachycardia, irregularity, and tachycardia, vide p. 149. 
 According to one explanation, this occurs as the inhibitory 
 apparatus is stimulated, or has begun to suffer from more or 
 less complete paralysis. According to another, it depends on 
 the rate of production and conduction of stimuli in the heart 
 itself. The treatment of irregularity and intermission is, there- 
 fore, much the same as that for tachycardia and brachycardia. 
 An irregularity of the pulse may sometimes persist for years. 
 
 1 Vide author's remarks on a case by Dr. Somerville, Practitioner, vol. 
 xvi., p. 1 86.
 
 ANGINA PECTORIS 189 
 
 One patient of mine, who is now seventy-nine years of age, had 
 a bigeminal pulse, that is, two beats in rapid succession fol- 
 lowed by a longer pause, for many years. He is still hale and 
 healthy. A relative of my own died at the age of eighty-four, 
 after having had a very irregular pulse for sixty-seven years. 
 This irregularity of the pulse came on after an attack of rheu- 
 matic fever at the age of seventeen, and continued all the rest 
 of her life. 
 
 Angina Pectoris. One of the most distressing forms of 
 cardiac disturbance is angina pectoris. I have already men- 
 tioned the relationship between this disease and diminished 
 circulation through the coronary arteries, as well as the prob- 
 able causation of the pain. In many cases this is situated about 
 mid-sternum, but it is frequently felt more towards the cardiac 
 apex, and often radiates towards the shoulders and down the 
 arms, especially the left arm. As I have already said, it is 
 probably due to a want of relationship between the power of 
 the cardiac muscle and the resistance it has to overcome. It 
 is brought on by anything that raises the blood pressure 
 quickly, such as exertion or emotion, and especially by the 
 emotion of anger, which, as in John Hunter's case, may bring 
 about a fatal attack at once. Anything that interferes with 
 the action of the heart tends to increase the pain, and thus 
 distension of the stomach by tilting the heart up makes the 
 patient worse, and much relief is afforded by the administration 
 of carminatives, which bring the flatulence away and allow the 
 heart to resume its normal condition. 
 
 During the process of digestion the blood pressure tends to 
 be higher than usual, and immediately after digestion pain is 
 brought on by the slightest exertion with much greater ease 
 than during the fasting condition. 
 
 Treatment of an Attack of Angina Pectoris. The indica- 
 tion for treatment, of course, is to relieve the heart by dilating 
 the vessels, and this is brought about most quickly by the use 
 of nitrite of amyl. 1 Nitrobutyl and other organic nitrites have 
 
 a Lauder Brunton, Lancet, July 27, 1897, and Reports of the Clinical So- 
 ciety, vol. Hi., 1870.
 
 FIG. 204. Normal pulse, 
 right radial. 
 
 Fio. 205. Normal pulse, 
 left radial. 
 
 FIG. 206 Right radial, 
 during angina. 
 
 Fig. 207. Left radial. 
 
 FIG. 208. During severe 
 anginal pain. 
 
 FIG. 209. Pain nearly but 
 not quite gone, a little 
 remaining near the nipple 
 after giving nitiite of amyl. 
 
 FIG. 210. Pain quite gone, 
 but afterwards returned. 
 
 FIG. 211. Pain quite gone, 
 which did not return. 
 
 FIG. 212. Pain coming on 
 at 1, more severe at 2. 
 Most severe at Fig. 213. 
 
 FIG. 213. Pain severe. 
 
 FIG. 214. Pain relieved by 
 nitrite of amyl. 
 
 FIGS. 204 to 214. Tracings of the pulse in angina pectoris.
 
 DIET AND REGIMEN IN ANGINA IQI 
 
 a similar action, but nitrite of amyl seems, upon the whole, to 
 be the most satisfactory. Nitroglycerine acts nearly, though 
 not quite so quickly, and is more convenient. It has also the 
 advantage of dilating the vessels for a longer time than nitrite 
 of amyl. It may be given in solution with a little brandy or 
 ether, or the patient may carry about with him nitroglycerine 
 tablets, each containing one-hundredth of a grain, made up 
 with chocolate ; and the best plan, as a rule, is not to swallow 
 the whole tablet, but to nibble it slowly until the pain has 
 ceased. If half a tablet is sufficient, it is not necessary to take 
 more; but if one is insufficient, then as many more may be 
 taken as are necessary. I have never seen any bad effect from 
 an overdose either of nitroglycerine or amyl nitrite, except 
 headache, giddiness, or transient faintness. When the attack 
 is excessively severe a neuralgic element may be superadded to 
 the physical condition, and I think it is possible that sometimes 
 it may come on independently. At any rate, a subcutaneous 
 injection of a quarter or a third of a grain of morphine may 
 sometimes be necessary, in order to lessen the pain and give 
 the patient relief, and a few whiffs of chloroform will deaden 
 the pain until the morphine has had time to take effect. 
 
 Diet and Regimen in Angina. During the interval the 
 tension should be kept low by diet as nearly as possible vege- 
 tarian, taking care that it is easily digested and that it does 
 not give rise to flatulence. Tea and coffee, and, of course, 
 all meat extracts which contain substances of the purin type 
 and tend to raise the blood pressure, should be avoided. The 
 bowels should be kept freely open, and mercurials should be 
 given, once, twice, or three times a week at night, followed 
 by a saline in the morning, so as to remove from the body 
 all substances likely to raise the blood pressure. Many sub- 
 stances having a poisonous action are absorbed by the liver 
 and excreted in the bile. They are reabsorbed from the duo- 
 denum, again passed to the liver, and again excreted. (Fig. 
 215.) This may go on for a long time in the entero-hepatic 
 circulation, until they either accumulate to such an extent that
 
 192 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 they pass into the general circulation and act upon the nervous 
 system, heart, or other organs, or are cleared out by mercurial 
 purgatives and salines. Nitro-erythrol in doses of half a grain 
 three times a day, or more if required, will sometimes keep a 
 patient, who would otherwise suffer from angina pectoris, per- 
 fectly comfortable for years. 
 
 All such persons, however, should take care to remain quiet 
 for half an hour at least after every meal, and when they get up 
 they should move very slowly until they begin to get warm. 
 When the vessels of the muscles become dilated, patients are 
 
 Liver with bile- 
 
 duct leading into 
 
 the duodenum. 
 
 Portal vein with 
 entero-hepatic cir- 
 culation, showing 
 
 absorption and re- 
 excretion of bile. 
 
 Mesenteric veins. . 
 
 Stomach. 
 
 Small intestines. 
 
 Colon. 
 
 FIG. 215. Diagram to illustrate the entero-hepatic circulation. 
 
 frequently able to walk with perfect comfort even at a rapid 
 pace. Cf. Effect of muscular area, p. 15. 
 
 Cardiac Asthma. When the right side of the heart is 
 enfeebled the symptoms of cardiac asthma are apt to come 
 on. The patient is quite comfortable so long as he remains 
 still, but the least exertion brings on rapid breathing, or even 
 dyspnoea and distress. This condition is largely due to de- 
 generation of the right side of the heart, consequent upon 
 interference with the circulation in the right coronary artery. 
 It may be associated with fatty degeneration of both sides of 
 the heart, but it may also occur in the right side independently
 
 SLEEPLESSNESS 193 
 
 of the left. 1 Nitrite of amyl is not of so much use in this as 
 in ordinary angina, as the pulmonary circulation does not seem 
 to be affected by nitrites to the same extent as the general 
 circulation. Inhalation of 5 minims of iodide of ethyl is 
 sometimes serviceable, but inhalation of oxygen occasionally 
 affords very great relief, and in a case which I recently saw 
 the tension in the radial artery rose under the influence of 
 oxygen to an extent which I should not have believed if I 
 had not seen it. The tension, as tested by Potain's instrument, 
 was only 75 when the inhalation was begun, and in the course 
 of ten minutes' inhalation it rose steadily until it had reached 
 150. 
 
 In cardiac asthma gentle exercises are useful as tending to 
 train the heart, increase its nutrition, and thus accelerate the 
 circulation through the lungs. At the same time, iodide of 
 potassium, strychnine, digitalis, squill, and strophanthus are all 
 useful, as well as Oertel's treatment, which we shall presently 
 have to consider in relation to valvular disease. 
 
 Sleeplessness. Although sleeplessness may occur apart 
 from any disease of the heart, yet it not infrequently occurs 
 along with cardiac disease, and forms one of its most distress- 
 ing symptoms. In many cases the patient is intensely drowsy, 
 but the moment he falls asleep he feels a sensation of intense 
 distress, and awakes with a start. Sometimes this condition 
 appears to be aggravated by flatulent distension of the 
 stomach, or acidity, and it may be somewhat relieved by the 
 use of bicarbonate of soda and carminatives, alone or with 
 rhubarb. A purely milk diet for some days may also be use- 
 ful. The various hypnotics may all be tried. Paraldehyde 
 is sometimes efficacious in drachm doses, trional or sulphonal 
 in 20 or 30 grain doses, and chloral 10-30 grain doses, with 
 bromides of potassium, sodium, or ammonium, or all three 
 mixed, in doses of 30 to 60 grains. As chloral has a some- 
 what depressing action on the heart, one may hesitate to give 
 it if the cardiac action is very weak, but this very action, by 
 lowering the blood pressure, increases its hypnotic effect. The 
 Brunton, Practitioner, June, 1905.
 
 194 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 remedy par excellence in this condition, however, is opium or 
 morphine. The latter may be given either by the mouth or 
 subcutaneous injection, and the former either by the mouth 
 or rectum. A convenient way is to draw 30-60 minims of 
 tincture of opium into a glycerine syringe holding 2 drachms, 
 then draw up water till the syringe is full, and inject into the 
 
 NERVOUS CENTRE 
 , or VOMITIHC /N 
 | THE MEDULLA 
 
 /NTEST1ME- 1-- 
 
 UTERUS -\---J--V 
 
 VESICAL 
 NER VES 
 
 FIG. 216. Diagram showing the afferent nerves by which the vomiting center may be 
 
 excited to action. 
 
 rectum. The advantage this method has over administration 
 by the mouth is that one can be quite sure beforehand that 
 the rectum is empty and that absorption will take place quickly, 
 whereas the stomach may contain a large quantity of food or
 
 AORTIC DISEASE 
 
 195 
 
 fluid with which the opium will be so much diluted that it may 
 have hardly any effect. Sometimes neither opium nor mor- 
 phine seem to produce the desired effect, even when given in 
 full doses, and in such cases a few whiffs of chloroform may 
 be given so as just to allow the narcotic to take effect. And 
 here it may be well to say that I do not think the presence of 
 albumen in the urine contra-indicates the use of either opium 
 or morphine. The susceptibility of patients to these drugs 
 varies so much that it is impossible to 
 fix a dose, but usually one may begin 
 with ]/ or }4 of a grain of morphine 
 subcutaneously, and increase the dose 
 carefully until the desired result has 
 been obtained. Even should there 
 seem to be danger in pushing the nar- 
 cotic, it must be remembered that to 
 withhold it also entails risk, for the 
 exhaustion of the patient by continued 
 insomnia cannot but tend towards a 
 fatal termination. 
 
 Aortic Disease. As I mentioned 
 before, cases of aortic stenosis 
 
 or 
 
 FIG. 217. Diagram to illus- 
 trate the occurrence of syncope 
 in cases of aortic regurgitation. 
 In a the normal heart with full 
 
 aortic regurgitation may continue for carotid and free supply of blood 
 
 , . . r , '.i to the brain is represented; in 
 
 a length of time without giving rise b the carotid is shown empty> 
 to any symptoms whatever, and are ^ that s y nc P e occur from 
 
 . blood flowing back into the 
 
 reCOgmzed Only by a SyStollC murmur ventricle as well as onward into 
 rvupr fh* sr>rta in t1i* racA nf thp the aorta : in c is shown aortic 
 
 over me aorta m tne regurgitation in the rec umbent 
 
 former, and a diastolic murmur in the posture, so that the carotid is 
 
 .., , __ x i i T we H filled and regurgitation into 
 
 case of the latter. Here I think I the hear t is rather less, 
 ought to give a word of caution as to 
 
 the place where the aortic regurgitant murmur is heard. It 
 is usually heard quite markedly over the aortic valves, or per- 
 haps I ought to say rather over the aortic cartilage, and is 
 propagated down the sternum, but sometimes is not heard at 
 all at the base of the heart, and is only audible at the lower 
 end of the sternum more especially to its left side. This con-
 
 196 THERAPEUTICS OF THE CIRCULATION 
 
 dition was impressed upon me by the fact that an old friend 
 of mine in Edinburgh told a lady that she had aortic regurgi- 
 tation. She came up to London and saw the late Sir Andrew 
 Clark, who told her there was nothing the matter with her 
 heart. She went back to Edinburgh and rebuked my old 
 friend very severely for having frightened her unnecessarily. 
 He said he was sorry, but nevertheless she had aortic regur- 
 gitation, and if she would go back and ask Sir Andrew to ex- 
 amine her more carefully, he would find it too. She did so, 
 and on the second examination Sir Andrew found the murmur 
 as my friend had described it, and wrote to him acknowl- 
 edging his error. Now, no one could possibly doubt the great 
 clinical knowledge and exact diagnosis of Sir Andrew Clark, 
 and the reason that he fell into error was simply that his 
 waiting-room was filled with patients, and in order to save 
 time he did not ask the lady to loosen her stays. On listening 
 over the part of the chest above the stays, no murmur was 
 audible, and it was only after the stays were removed that 
 the diastolic murmur at the lower end of the sternum could be 
 distinguished. 
 
 Persons suffering from aortic regurgitation are more liable 
 to sudden death than those suffering from any other form of 
 cardiac disease, except perhaps those who have angina pec- 
 toris ; but so long as the valvular lesion is fully compensated, 
 all that is necessary is to warn the patient against sudden 
 strain. Many of them might walk 25 miles in a day without 
 harm or even with positive advantage, but 20 yards sudden 
 spurt to catch a train might prove fatal. Although sudden 
 death occurs not infrequently in aortic regurgitation, yet per- 
 haps a still more frequent course of the disease is for the left 
 ventricle to yield before the strain, and then the mitral valves 
 become incompetent, so that we get all the consequences which 
 I have previously described from backward pressure on the 
 lungs and right heart. In uncomplicated cases of aortic regur- 
 gitation, digitalis is likely rather to add to the danger they 
 already incur from syncope than to do the patients good. In
 
 MITRAL REGURGITATION 
 
 197 
 
 A O 
 
 FIG. 218. Diagram of the 
 cardiac dulness before and after 
 a bath. A similar effect is pro- 
 duced by gymnastic exercises. 
 The thin line shows the gradu- 
 ated dulness before and the- 
 thick one after. A, Nipple. 
 B, Nipple. C, Ensiform cartil- 
 age. (After Schott.) 
 
 some cases, however, if carefully watched, it may tend, 
 especially when combined with strychnine and caffeine, to keep 
 the left ventricle from yielding, and thus maintain the patient's 
 health. 
 
 But in cases where the ventricle has already dilated and 
 the mitral valves become incompe- 
 tent, we have to treat the patient just 
 as we would an ordinary case of 
 mitral disease, for the danger then 
 arises from impeded pulmonary cir- 
 culation and venous stasis rather 
 than from imperfection of the gen- 
 eral circulation. Such cases, how- 
 ever, as a rule require to be treated 
 rather as cases of advanced mitral 
 disease, with complete rest, than as 
 mild cases where the patient may be 
 allowed to go about. 
 
 Mitral Regurgitation. Mitral incompetence is much more 
 frequent than is usually thought, for people go about with 
 slight mitral leakage and present no symptoms, so that the 
 condition of the valve is only discovered by a medical exami- 
 nation. These patients are usually told, and rightly so, not 
 that they have any disease of their valves, but that their heart 
 is a little weak, and they must be careful to avoid strain. As 
 a general rule, this is all that is necessary; but when shortness 
 of breath or symptoms of venous stasis set in, more active 
 treatment is required, and here digitalis and strophanthus find 
 their proper place. 
 
 Nauheim Treatment. For such cases also the treatment 
 by baths and exercises is useful. The system of applying 
 them has been well worked out by the brothers Augustus and 
 Theodore Schott, at Nauheim, and the treatment is often 
 known now as the " Nauheim " treatment. At Nauheim, the 
 water as it issues from the springs is very highly charged with 
 carbonic acid, but this is allowed to escape, and the water to
 
 198 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 become still, for the baths which are given at first, and it is 
 only in the later baths that the effervescent water is employed. 
 Baths are usually employed every other day during a course of 
 
 FIG. 219. Pulse tracing, showing the effect of massage and graduated movements. 
 Each tracing is taken partly with a slow and partly with a quick movement of the 
 sphygmograph. The upper shows high tension and a feeble heart; the lower shows 
 less tension and a stronger heart. These tracings I owe to the kindness of Dr. 
 Gustav Hamel, to whose treatment I had recommended the patient. 
 
 four to six weeks, or even longer, according to the condition 
 of the patient. The bath at first lasts only about six minutes 
 at a temperature of 95. The duration is then increased to 
 eight or ten minutes, and the temperature is lowered to 92. 
 
 F. 21-10-93. before exercise 31 oz. 
 
 G F 21-IO-B8-. after 'exercise 3roz. 
 
 FIG. 220. Pulse tracing to show the effect of exercises. The upper tracing shows 
 the pulse before and the lower tracing after exercise. 
 
 They are then strengthened further with the mother liquor 
 obtained by evaporating the ordinary water. The duration 
 is gradually increased to fifteen or twenty minutes and the
 
 EFFECTS OF NAUHEIM TREATMENT 
 
 199 
 
 temperature lowered as far as 82. Immediately after the bath 
 the patient must rest for at least an hour, and on alternate 
 days movements may be used. I give here a list of the move- 
 
 G.F. 28-10-98. before I- bath 3so7. 
 
 FIG. 221. Tracing from the pulse of a patient aged 62, with gouty kidney, of a 
 failing heart. This tracing and the three following show the effect of Nauheim baths 
 in increasing the cardiac force and dilating the vessels. 
 
 FIG. 222. Effect of one bath. 
 
 tf> bath & 2 " effervescing bath 3roi. 
 
 FIG. 223. From the same patient. 
 
 G.F. 10-12-98 after 19^ bath 
 
 FIG. 224. From the same patient, after nineteen baths. 
 
 ments, which Professor Schott at Nauheim kindly got his 
 attendant to show me :
 
 2OO THERAPEUTICS OF THE CIRCULATION 
 
 The essential part of these movements is that the movement shall be 
 slow and regular, and that each movement shall be fully carried out. The 
 body should be held upright, the joints should be kept straight, and the 
 resistance applied should not be sufficiently great to cause any tremor of the 
 limbs or shortness of breath in the patient. The resistance may either be 
 applied by the patient himself putting into action the opposing muscles to 
 those which affect the movement, or by an attendant or friend gently 
 opposing the movements. 
 
 I. The arms are to be raised slowly outwards from the side until they 
 are on a level with the shoulder. After a pause they should be slowly 
 lowered. 
 
 II. The body should be inclined sideways as much as possible towards 
 the right, then to the left. 
 
 III. One leg should be extended as far as possible sideways from the 
 body, the patient steadying himself by holding on to a chair. The leg is 
 then dropped back. The same movements are repeated by the other leg. 
 
 IV. The arms are raised in front of the body to a level with the shoulder, 
 and then put down. 
 
 V. The hands are rested on the hips, and the body is bent forwards as 
 far as possible, and then raised to the upright position. 
 
 VI. One leg is raised with the knee straight forwards as far as possible, 
 then brought back. This movement is repeated with the other leg. 
 
 VII. With the hands on the hips, the body is twisted round as far as 
 possible to the right, and then again to the left. 
 
 VIII. With the hands resting on a chair and the back stiff and straight, 
 each leg is raised as far as possible backwards, first one and then the 
 other. 
 
 IX. The arms are extended and the fists supinated. The arms are then 
 extended outwards, next inwards at the height of the body. 
 
 X. Each knee is first raised as far as possible to the body, and then the 
 leg extended. 
 
 XL This movement is the same as IX., but with the fists pronated. 
 
 XII. Each leg is bent backwards from the knee and then straightened. 
 
 XIII. Each arm is bent and straightened from the elbow. 
 
 XIV. The arms are brought from the sides forwards and upwards, then 
 downwards and back as far as they will go, the elbows and the hands being 
 straight. 
 
 XV. The arms are put at a level with the shoulder, and then bent from 
 the elbow inwards and again extended. 
 
 XVI. With the arms in front at the level of the shoulder and the hands 
 stretched, the arms are opened out sideways and then brought together. 
 
 XVII. The arms are bent from the elbow outwards and extended. 
 
 . There should be a pause of half a minute between each successive movement, 
 such as raising the arms and lowering them, and a pause of one or two minutes 
 between the movements of different kinds, such as I. and II. 
 
 After the course is over it is advisable for the patient to go
 
 OERTEL S TREATMENT 2OI 
 
 some place for an after-cure, where he can follow up the treat- 
 ment by graduated exercise. 
 
 Cartel's Treatment. This treatment by graduated exer- 
 cise is often known as Oertel's. The principles upon which it 
 depends are (i) that the cardiac symptoms are due to dis- 
 proportion between the force of the heart and the resistance 
 it has to overcome; and (2) this disproportion is to be rem- 
 edied by dietetics and by exercise, consisting chiefly of gradu- 
 ated walking uphill. 
 
 The dietetic rules are (i) Give such food as will 
 strengthen the cardiac muscle; and (2) diminish the amount 
 of liquid consumed, in order to reduce the mass of circulating 
 blood. 
 
 The exercises are intended to promote elimination of liquid, 
 especially through the lungs and skin, and to increase the nu- 
 trition and activity of the heart. In aortic regurgitation, Dr. 
 Schott considers that the work of the heart is easier when 
 there is abundance of blood to make up for the loss in the 
 general circulation sustained by regurgitation during the 
 diastole. He therefore, advises a very full diet; but in mitral 
 disease, where the patient, on account of breathlessness, can 
 move less than a healthy person, he advises a sparing diet. In 
 chronic myocarditis, where albumen is required, but not nu- 
 clein, butcher's meat should be given sparingly, but milk and 
 plasmon freely. In aortic disease he allows two pints of fluid 
 a day, and as much as three pints if the weather be hot; but 
 if there is any interference with the pulmonary circulation, 
 as shown by shortness of breath, he only allows between a 
 pint and a half and two pints. In mitral disease he only 
 allows about a pint and a quarter to a pint and a half. 
 
 The exercise consists in gentle walking up graduated slopes. 
 The first walk is taken upon a very gentle slope, and only for 
 a short distance. This is increased daily, and when the patient 
 can walk on the level or gentle slope without shortness of 
 breath he walks up a somewhat steeper grade. The steepness 
 is gradually increased as the patient's heart will bear it. Such
 
 2O2 THERAPEUTICS OF THE CIRCULATION 
 
 walks have been well arranged at Llangammarch in this 
 country, and one of the best places abroad is, I think, Baden- 
 weiler, although there are numerous other places where similar 
 walks have been laid out. 
 
 Treatment of Venous Stasis. In cases of well-marked 
 venous stasis, whether it be dependent upon mitral stenosis or 
 regurgitation, or dilatation of the right side of the heart, con- 
 sequent upon bronchitis and emphysema, the best results are 
 certainly afforded by complete rest, in bed if possible, or in a 
 chair if the dyspnoea be so great that the patient cannot stay 
 in bed. In such cases massage comes in most usefully, the 
 hand of the masseur or masseuse supplying, as it were, the 
 place of an auxiliary heart in helping the venous return, and 
 the place of the lymph hearts which we find in batrachians 
 (cf. p. 9). 
 
 Graduated Exercises. Gentle movements are also useful ; 
 for example, the patient may bend one finger gently against 
 resistance the first day or even the first forenoon. In the after- 
 noon he may straighten the same finger against resistance. 
 Next day he may bend two fingers, and in the afternoon 
 extend two fingers and so on, gradually including the wrist, 
 the fore-arm, and even the arm. The resistance should at 
 first be very slight indeed, and may be gradually increased as 
 the patient can bear it. Such gentle movement as simply 
 flexing a finger might seem at first sight to be useless, but 
 if any of you will put your hand upon your biceps and get 
 someone elese to hold your finger while you flex against resist- 
 ance, you will soon discover that it is not merely the muscles 
 of the finger alone that are in action, but that the biceps, and 
 even the muscles of the trunk take part in the movement. The 
 effect of massage and exercise on the pulse is shown by the 
 tracing in Fig. 219, where the high tension with slight move- 
 ment of the radial artery is converted into less tension, quicker 
 contraction of the heart, and more active movement of the 
 vessel increasing the self -massage both of the arteries and the 
 heart.
 
 ELIMINATION 2O3 
 
 Inhalation of oxygen certainly gives great help in some 
 cases, and I think it is possible that occasionally the deep 
 inhalations which patients take when they are inhaling the 
 oxygen may help mechanically by producing self -massage of 
 the heart. 
 
 Elimination. I have already spoken of the action and use 
 of digitalis and its congeners as well as of caffeine in such 
 cases, and have given you the indications for employing them, 
 and also referred to the symptoms which necessitate their dis- 
 continuance. But here, again, you must remember that the 
 imperfect circulation and imperfect respiration tend to pro- 
 duce the products of waste, and we must look to the elimina- 
 tion of these by means of purgatives such as calomel and 
 compound jalap powder. Half a drachm to a drachm of com- 
 pound jalap powder every morning, or every other morning, 
 is a most useful agent in withdrawing water from the body, 
 and thus aiding the action of the kidneys, especially when 
 ascites is present. Its efficacy is, I think, increased by the 
 addition of a drachm of potassium bitartrate to every dose. 
 Another well-tried remedy is the Haustus Scoparii Composi- 
 tus of St. Bartholomew's Hospital. Its composition is as 
 follows : 
 
 Spirit of Juniper 30 minims 
 
 Potassium Tartrate 20 grains 
 
 Decoction of Broom Tops to I ounce 
 
 The action of mercurials is not properly understood, but it is 
 very curious to note how frequently the addition of a little 
 mercury to digitalis increases its beneficial action. The old- 
 fashioned pill of one grain of powdered digitalis, one of 
 powdered squill, and one of blue pill, frequently succeeds when 
 other remedies fail. At St. Bartholomew's we have two grains 
 of extract of hyoscyamus added to this pill, in order to lessen 
 any irritation of the stomach or bowels that the other ingre- 
 dients might produce: whilst in other hospitals the quantity 
 of squill and blue pill is increased to two grains and the 
 amount of digitalis is kept at one grain.
 
 2O4 THERAPEUTICS OF THE CIRCULATION 
 
 Milk Diet and Chloride-free Food. Lately a great deal 
 of attention has been given, especially in France, to the effect 
 of chlorides upon transudation from the vessels into the tis- 
 sues. Chlorides appear to favor this, and therefore, although 
 they may be useful in health, they are disadvantageous in 
 dropsy, and accordingly a diet containing a small quantity of 
 chlorides is used. Calcium and its salts appear to have a con- 
 trary action, and rather to diminish transudation. The 
 amount of chlorides in milk is not great, the quantity of cal- 
 cium is considerable, and the lactose appears to have a diuretic 
 action; so that frequently we notice patients suffering from 
 mitral disease when put to bed with entire rest, with massage, 
 with an entirely milk diet, just as if they were typhoid patients, 
 and with the digitalis and blue pill already mentioned, fre- 
 quently improve with great rapidity. But a milk diet does 
 not always suit ; and consequently, in France, bread made with 
 sugar instead of salt, farinaceous preparations also made with 
 sugar and without salt, and boiled meat without salt, but with 
 sweetened tomato sauce or some such condiment to make it 
 pleasant, and eggs, either boiled without salt or in the form 
 of a sweet omelette, and plasmon, may all be used. I have 
 only tried this in a few cases, but certainly the treatment has 
 appeared satisfactory. 
 
 Tapping. When the oedema becomes very great in the 
 legs or scrotum, it is advisable to let it out, and the way in 
 which this can be done depends to a great extent upon the 
 character of the patient. In some, Southey's or Bartel's tubes 
 may be used to drain the legs or scrotum, but when the patient 
 is restless these are apt to be dragged from their place, and 
 almost the only way is to puncture the legs either with an 
 ordinary sewing needle or with a triangular surgical needle, or 
 make small incisions with the lancet or bistoury, and surround 
 the parts with absorbent cotton wool, which can be frequently 
 changed, and place a waterproof sheet under the part to 
 prevent the bed from becoming soaked. Effusion into the 
 serous cavity of the abdomen or pleura must be removed by 
 tapping, if it reach any great extent.
 
 SENILE RISE OF PRESSURE 2O$ 
 
 Surgical Treatment of Cardiac Diseases. In some cases 
 of cardiac disease treatment may for a time be beneficial and 
 relieve the patient's sufferings, but may be quite impotent to 
 effect a cure or to render the patient fit for any exertion 
 whatever. This is especially marked in mitral stenosis, and 
 I believe that in some cases of this form of cardiac disease 
 surgical treatment may yet effect a cure. 1 
 
 Senile Rise of Pressure. I must not finish my Lectures 
 without drawing attention to one condition which is very 
 common, and which may become still commoner as increasing 
 medical knowledge regarding the prevention of infective dis- 
 ease leads to prolongation of life. In all men with advancing 
 years the arteries tend to lose their elasticity and become more 
 rigid. The time at which this alteration takes place varies in 
 different individuals and in different families, and the saying 
 is a particularly true one that " a man is as old as his ar- 
 teries " ; so that not infrequently we find strong athletic and 
 robust families who are not only powerful both physically and 
 mentally, but apparently free from disease, and who are yet 
 short-lived. I believe that these lives might frequently be 
 lengthened by timely attention to the condition of the arteries, 
 more especially by measurement of the blood pressure, and 
 adjustment of work, of exercise, and of food to the condition 
 that is found. The combination of atheromatous arteries and 
 high blood pressure is very common, and the risks it entails 
 are twofold : ( i ) It may lead to cardiac failure, the heart being 
 unable to overcome the excessive tension, and this is all the 
 more common when it is affected by fatty or fibroid degenera- 
 tion; (2) a vessel may rupture in the brain, and give rise to 
 sudden death, to hemiplegia, or, if the haemorrhage be small, 
 to local paralysis, sensory affections, or mental deterioration, 
 the result depending on the part of the brain affected. Simi- 
 lar results may ensue from blocking of the arteries by ather- 
 oma. These conditions are illustrated by Figs. 225 and 226. 
 
 1 Lander Brunton, "On the Possibility of Treating Mitral Stenosis by 
 Surgical Methods," Lancet, 8th February, 1902.
 
 2O6 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Senile Decay. In the decade for 1891 to 1900 of persons 
 above the age of seventy-five years, no less than 34,822 died 
 from heart disease, and 39,662 from diseases of the blood- 
 
 FIG. 225. Distribution of the arteries in the brain. (After Ross.) 
 
 vessels above that age. Nor does this even cover all the mis- 
 chief done by diseases of the blood-vessels, for apoplexia, 
 paralysis, and senile decay may all be reckoned as secondary 
 
 FIG. 226. Cerebral cortex showing the distribution of function. (After Osier.) 
 
 to disease of the cerebral vessels. In his most instructive book, 
 On the Nature of Man, Metchnikoff mentions that there are 
 two classes of phagocytes in the body, the small or microphags,
 
 SENILE DECAY 
 
 207 
 
 and the large or macrophags. The function of the microphags 
 is to rid us of microbes, that of the macrophags is to heal 
 mechanical injuries, such as haemorrhages, wounds, and so 
 forth. In the brains of old persons and animals a number of 
 nerve cells are surrounded and devoured by macrophags (Fig. 
 227), and Metchnikoff thinks himself justified in asserting 
 that senile decay is mainly due to the destruction of the higher 
 elements of the organism by macrophags. Other parts of the 
 body also are not safe from their attacks, and the kidneys may 
 likewise suffer (Fig. 228). But the function of the macro- 
 phags is not to attack healthy tissues ; it is to remove those the 
 vitality of which is destroyed or impaired, and so long as the 
 
 FIG. 227. Cell from the 
 brain of a woman, aged 100 
 years, being devoured by 
 macrophags. (From Metchni- 
 koff.) 
 
 FIG. 228. Section of a renal tubule in- 
 vaded by macrophags, from the body of 
 an old man, aged 90 years (m = macro- 
 phags). (From Metchnikoff.) 
 
 brain cells are abundantly supplied with blood they will prob- 
 ably be allowed to remain uninjured by the attacks of the 
 macrophags. I think, therefore, that while senile decay may 
 be actually produced by the macrophags, we are justified in 
 believing that it really originates in an alteration of the blood- 
 vessels. 
 
 Treatment of Senile Conditions of the Vessels. Al- 
 though I do not quite agree with him in every respect, I think 
 that my former pupil and old friend, Dr. Haig, has done a 
 very great service by drawing general attention to the injurious 
 effects of a too highly nitrogenous diet. In cases where the
 
 2O8 THERAPEUTICS OF THE CIRCULATION 
 
 arterial tension tends to rise much above the normal, the pro- 
 teids in food should be kept as low as they possibly can, con- 
 sistently with the proper performance with the bodily func- 
 tions. The bowels should also be kept free either by the use 
 of salines or by small quantities of some aperient such as cas- 
 cara, aloes, or rhubarb, along with each meal, so that the 
 natural stimulating effect of food upon the bowels as well as 
 the stomach should be increased. Nor should the occasional 
 use of a mercurial purgative be omitted, and here I may men- 
 tion that the danger of mercury in albuminuria has, I think, 
 been greatly exaggerated, and has sometimes in my own ex- 
 perience been productive of much harm, for I have met practi- 
 tioners who have been so imbued with the fear of mercury 
 that they would not give it in cases of cardiac disease either 
 as a purgative or in combination with digitalis, because albu- 
 men had appeared in the urine. Whereas in these very cases 
 mercury was one of the best things to restore the circulation 
 to its normal condition and cause the albumen to disappear. 
 
 The steady employment of iodides is sometimes most use- 
 ful, and I have found great advantage in a number of cases 
 of high tension from 20 grains of nitrate of potash along with 
 YI to 2 grains of nitrite of sodium given in a tumbler of water 
 or aperient water every morning on rising. This seems to 
 keep the tension from rising too high, and the treatment may 
 be continued with advantage for years. 
 
 Where this is insufficient, it may be supplemented by two 
 or three grains of sodium nitrite in water every four hours, or 
 by nitro-erythrol in doses of y* to 2 grains, or Koo grain nitro- 
 glycerine in tablets or solution. Ammonium hippurate. as 
 recommended by Oliver, may also be useful. 
 
 In very high tension it may be advisable to bleed from the 
 arm. The effect of this in relieving angina was most strik- 
 ingly shown in the patient whom I was afterwards able to 
 relieve by the use of nitrite of amyl (Clin. Soc. Rep., vol. Hi., 
 1870; and, Collected Papers, p. 186). 
 
 By careful estimation of the blood pressure, and by keep-
 
 SENILE CONDITIONS OF THE VESSELS 2CK) 
 
 ing the tension at a proper level by diet regimen and medi- 
 cines, I believe that the cardiac failure or the cerebral apoplexy, 
 which are common causes of death in advanced years, may be 
 averted for years, and the life not only prolonged greatly, but 
 the senile decay or paralysis, which are so trying to the patients 
 themselves and their friends, may be prevented. 
 
 As I mentioned in my first Lecture, the therapeutics of the 
 circulation is a very large subject, and I have been able to 
 treat it only sketchily and imperfectly, but the general outlines 
 I have given may be a guide in further reading on the subject; 
 whilst the prominence I have given to the subjects at which I 
 have worked experimentally is, I believe, in accordance with 
 the general purpose of the University in establishing such 
 lectures.
 
 APPENDIX A 
 
 Functions of Protoplasm. In Lecture (I., page 24), I 
 mentioned that protoplasm can contract independently of 
 nerves, and that partially differentiated protoplasm might pos- 
 sess the functions both of muscle and nerve. It was impos- 
 sible to enter more fully into this subject in the lectures; but 
 as it is one of great interest, I have thought it worth while to 
 deal with it in an appendix, especially as books in which it is 
 discussed are not always of ready access, even to those who 
 are able to consult public libraries. 
 
 Contractility and Conduction of Stimuli by Vegetable 
 Protoplasm. My attention was first directed to this subject by 
 the late Professor J. Hutton Balfour, and in his class of Botany 
 in 1865 I wrote a prize essay on the movements of plants and 
 the action of drugs upon them. The experiments I made on the 
 subject added little to the results already obtained by Marcet, 
 Macaire-Prinsep, Dutrochet, Brucke, Livingston, and Cold- 
 stream, and the essay was not published. I experimented 
 chiefly with the sensitive plant (Mimosa pudica). The leaves 
 of this plant have numerous small leaflets standing out on each 
 side of the midrib, or like the teeth of a double comb. If the 
 swelling at the base of one be touched, the leaflets fold up 
 together, and the irritation spreads to the neighboring leaf- 
 lets, which fold up. If the plant is in good condition, the 
 stimulus affects the whole leaf, which falls down instead of 
 standing out from the stem. Marcet found that chloroform 
 at first acts as an irritant, and causes the leaflets to fall. After 
 a while they recover, but are then insensible to touching. This 
 condition appears to be analogous to the effect of chloroform 
 on animals, in which it frequently produces struggling and 
 afterwards anaesthesia. I found in my experiments that 
 alcohol dropped on the leaves had a somewhat similar, though 
 less marked effect. Perhaps one passage from my unpub- 
 lished essay may not be without interest, and so I give it here ; 
 " When I began to write this essay, I had an inclination to 
 the belief that plants as well as animals have a nervous sys- 
 tem, but I now think that if they do possess something anal- 
 ogous to it, yet it is very different in kind. However, it is
 
 212 THERAPEUTICS OF THE CIRCULATION 
 
 possible that researches on the motions in cells of plants may 
 yet lead to some light on that mysterious part of the animal 
 economy, and help to solve the question which so long has 
 engaged the attention of all medical men, ' How do medicines 
 act?' for most of those are poisons, and if we could only 
 find out how poisons act on the vegetable organism, a great 
 step would be gained towards our knowledge of their action 
 on animals." 
 
 Animal Protoplasm. In the amoeba (Fig. 27, page 26), 
 and in the leucocytes of higher animals, every part of the 
 protoplasm of which they consist appears capable of exer- 
 cising the functions of receiving and conducting stimuli, of 
 contracting, and of secreting. In low organisms, such as 
 
 FIG. 229. Neuro-muscular cells from the fresh-water hydra, a, A neuro-muscular 
 cell seen in profile; b, a three-quarter view; c, a frontal view. (After Ranvier, 
 Lefons d'Anatomie G&n&rale sur le Syst&me Musculaire, Paris, Delahaye & Co., 1880, 
 p. 328.) 
 
 the hydra, differentiation occurs but incompletely, and the 
 same is the case in the embryos of higher animals. 
 
 Neuro-muscular Cells. It has been shown by Kleinenberg 
 and Ranvier that in the fresh-water hydra the protoplasm in 
 some of the cells appears to have the power of receiving 
 stimuli and also of contracting; in fact, of performing the 
 functions of both nerve and muscle. To these cells the name 
 of neuro-muscular has been given. Ranvier's description is so 
 clear that I have translated it almost verbatim. 1 
 
 The body of the hydra consists of a cylindrical tube, open at 
 one end. The body-wall consists of three layers : an inner or 
 endoderm, a middle or mesoderm, and an outer or ectoderm. 
 
 1 Ranvier, Legons d'Anatomie Generate sur le Systcme Musculaire, Paris 
 (A. Delahaye & Co.), 1880, pp. 325 et seq.
 
 APPENDIX A 
 
 213 
 
 The ectoderm is composed of large cells lying adjacent to 
 one another, and forming a protecting layer. Under this is 
 the mesoderm of interlacing fibers. Internal to this is the 
 endoderm, consisting of large cells arranged like epithelium. 
 
 The ectoderm sends into the mesoderm a series of proc- 
 esses. Each of these proceeds from the body of an ecto- 
 dermal cell of which it seems to form a part. Kleinenberg, 
 who first described them, supposes that the ectodermic cell 
 with its mesodermic prolongation constitutes a neuro-muscular 
 element (Fig. 229). The ectodermic cell corresponds to an 
 ordinary nerve-cell, and is receptive, sensory, and excito- 
 motory. The mesodermic prolongation represents a muscular, 
 or at all events, a contractile element. 
 
 In the hydra, then, he supposes that the function of sensa- 
 tion is connected with stimulation of the ectodermic portion of 
 the cell, and motion with its meso- 
 dermic or muscular portion. The 
 three layers in the body of the hydra 
 correspond to the three layers of the 
 blastoderm in a vertebrate embryo. 
 The ectoderm is analogous to the 
 outer layer of the blastoderm, from 
 which not only the integument which 
 covers the exterior of the animal is 
 developed, but also the central ner- 
 vous system, which originates from 
 that part of the layer which is sepa- 
 rated by the involution of the primi- 
 tive groove. The mesoderm of the 
 hydra corresponds to the muscular 
 system of vertebrates, which is de- 
 veloped in the middle layer of the 
 blastoderm, and remains connected 
 on the one hand with the nerve cen- 
 ters which have been separated from 
 the external layer by involution, and 
 on the other with that part which 
 develops into integument. 
 
 In the hydra the ectodermic cells have three functions, viz., 
 (i) they protect the surface; (2) they act as sensory nerves; 
 and (3) as excito-motor agents. 
 
 FIG. 230. Primitive bundle 
 from a mammalian embryo 
 (about the third month), ex- 
 amined in strongly iodized 
 serum. n, Nuclei surrounded 
 by glycogenic substance g; s, 
 striated cortex; p, central cyl- 
 inder of protoplasm. (After 
 Ranvier, Le(ons d'Anatomie 
 Generate sur le Musculaire, 
 Paris, Delahaye & Co., 1880, p. 
 374-)
 
 214 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Amongst animals more completely differentiated, these 
 different qualities, instead of being united in a single ana- 
 tomical element, become associated with special elements 
 whose forms are adapted to their functions. ' 
 
 The hydra when irritated contracts strongly. According to 
 Ranvier, it is very easy to understand this, if its mesodermic 
 cells are contractile. But it can elongate itself as well as 
 contract, and this active elongation Ranvier says is difficult to 
 
 FIG. 231. 
 
 Cells of involuntary muscle from the bladder of the dog, showing traces 
 of striation. (After Schwalbe.) 
 
 understand, and he will not offer an explanation of it. But if 
 we suppose the cells to have the power of contracting trans- 
 versely as well as longitudinally, vide page 45, the explanation 
 is simple enough. In embryonic muscle the fibers are only 
 
 FIG. 232. Purkinje's fibers from a sheep's heart, n, Nuclei; c, protoplasm; f, 
 striated muscular substance. (After Ranvier, Legons d'Anatomie G6n6rale sur le 
 Systtme Musculaire, Paris, Delahaye & Co., 1880, p. 300.) 
 
 striated at the side, and the anterior consists of undifferentiated 
 protoplasm (Fig. 230). 
 
 A slight tendency to striation has been observed by Schwalbe 
 in the involuntary muscle of the bladder in the dog (Fig. 231).
 
 APPENDIX A 
 
 215 
 
 In the cells of Purkinje a striation similar to that in embry- 
 onic muscle (Fig. 230) exists at the periphery of the cell 
 (Fig. 232). _ 
 
 The function of these cells has long been a mystery, but 
 they are now coming to be regarded as the conductions of 
 stimuli from the auricles to the ventricles, and thus maintain- 
 
 Riffht aortic semilunar valve 
 
 ATRIO-VENTRICULAR 
 BUNDLE 
 
 FIG. 233. Atrio-ventricular bundle of Stanley-Kent and His, seen from the right 
 ventricle. (From Morris's Anatomy, after Retzer.) For description, vide, p. 37. 
 
 ing or assisting to maintain, in conjunction with nerves, the 
 coordination of the auricular and ventricular pulsations 
 (page 36). 
 
 Bundle of Stanley-Kent and His. This has been de- 
 scribed in the lectures (page 37), but its position and rela- 
 tions will be more easily understood from the accompanying 
 figure (Fig. 233).
 
 APPENDIX B 
 
 Instruments for Measuring the Blood-pressure in Man. 
 Janeway's has been mentioned (page 81), but may be here 
 described. 
 
 It employs the method of circular compression, introduced 
 by Riva-Rocci and Hill, with the wide armlet, proved essen- 
 tial by v. Recklinghausen. The jointing of the manometer 
 tube is copied from Cook, the use of a Politzer inflater from 
 Erlanger. The apparatus is designed to embody in a portable 
 clinical sphygmomanometer, which shall measure both systolic 
 
 FIG. 234. Janeway's sphygmomanometer. 
 
 and diastolic pressures, every requirement for accuracy and 
 substantiality. 
 
 The sphygmomanometer consists of three essential parts. 
 A, Manometer, of U-tube form, with upper part jointed, fixed 
 to the under side of case lid. The scale is graduated empiri- 
 cally for each manometer, and is accurate. B, Compressing 
 armlets, consisting of a hollow rubber bag 12 by 18 cm. 
 This is attached to an outer leather cuff, which fastens by two 
 encircling straps with friction buckles. C, Inflator, an 8-oz. 
 
 216
 
 APPENDIX B 
 
 217 
 
 Politzer bag with valve. D, Tube connecting the manometer 
 and armlet. E, stopcock with needle valve to allow slow re- 
 lease of pressure. F, A small cock to close the open end of 
 the manometer. G, A rubber joint which is compressed by a 
 block and closes the other end of the manometer when the box 
 is shut. H, is a spring to hold the stopcock in place when the 
 box is shut. It is made by C. E. Dressier & Co., 143-147 
 East Twenty-third Street, New York. It can be obtained 
 from Mr. Hawksley, 357 Oxford Street, London. 
 
 C. J. Martin's new modification of Riva-Rocci's instru- 
 
 FIG. 235. C. J. Martin's modification of Riva-Rocci's sphygmomanometer. 
 
 ment is one of the best of the new instruments which have 
 been introduced since these lectures were delivered. His 
 earlier one is described at page 78. The newer one has all 
 the advantages of the earlier, and has the additional one of 
 being portable. Mercurial manometers, as a rule, are trouble- 
 some, as the mercurial column is apt to break or the mercury 
 to be spilled. The india-rubber caps in this instrument, if well 
 pushed home over the openings of the tubes, prevent this from 
 occurring.
 
 2l8 THERAPEUTICS OF THE CIRCULATION 
 
 Description of Martin's Improved Form of Riva-Rocci's 
 Sphygmomanometer. * 
 
 The apparatus consists of a bag of thin rubber, Hoth of an 
 inch in thickness, 13^/2 inches long, and 4 inches broad, the 
 interior of which communicates with a piece of small-bore 
 rubber tube. The rubber bag is covered on the outside by 
 unyielding leather, and loosely on the inside with soft thin 
 material. This bag is wrapped round the arm over the biceps, 
 so that the ends overlap, and secured by straps, so adjusted as 
 to fit closely to the arm. 
 
 The interior of the bag communicates by rubber tubing on 
 the one hand with a mercury manometer, and on the other with 
 a rubber ball. A side tube near the ball is closed by a screw 
 and leather washer: by loosening this, the air in the system 
 may be allowed to escape. 
 
 The manometer is ff.the ordinary U-tube variety, 12 inches 
 in length, and made of thick glass tube. It is provided with a 
 scale, which is graduated so as to indicate the pressure, in 
 millimeters of mercury. The glass tube is fixed to a piece 
 of wood, which latter fits into a socket on the side of the 
 interior of the box. 
 
 The manometer can be carried in any position, provided the 
 ends be secured with the rubber caps. The whole aparatus is 
 fitted into a box in such a way that there is no danger of 
 damaging the glass tube. 
 
 One millimeter of the scale really indicates 2 millimeters of 
 pressure as the rise of the mercury in one limb of the manom- 
 eter is accompanied by a corresponding fall in the other. This 
 is accounted for in the marking of the scale so that the pres- 
 sure can be read off directly from the numbers on it with- 
 out the necessity for any calculation. 
 
 Directions for Using the Instrument.- Fix the manom- 
 eter in the socket and remove the rubber caps. Wrap the bag 
 evenly round the right arm of the patient, over the biceps, 
 either next to the skin or over soft clothing, so that the ends 
 overlap. (With children the bag can be placed round the 
 thigh.) Secure the bag by means of the straps. 
 
 The arm and hand of the patient must rest upon a table at 
 the level of the heart, and the finger of the observer's left 
 hand be kept upon the pulse. Loosen the brass screw valve 
 1 C. J. Martin, Brit. Med. Journ., April 22, 1905.
 
 APPENDIX B 219 
 
 near the ball, and see that the level of the mercury stands at 
 zero on the scale. If this is not the case, adjust the tube by 
 pushing- it up or down until the mercury is at this level. 
 Attach one end of the tubing to the manometer and the other 
 to the glass tube connection of the bag. Screw the brass out- 
 let-valve tightly home. 
 
 The pressure in the bag is now slowly raised by squeezing 
 the ball with the right hand until the pulse can no longer be 
 felt. At this point the rise of the mercury in one limb of the 
 manometer is read on the scale, and the figure on the scale 
 indicates the maximum systolic pressure at the time. 
 
 Having read off the pressure in the manometer, allow the 
 air to escape by loosening the brass screw near the ball. By 
 allowing the air to escape slowly, the pressure at which the 
 pulse returns can also be observed. 
 
 The diastolic pressure is ascertained by allowing the pres- 
 sure to fall still farther very slowly, and noting the height at 
 which the greatest oscillations of the mercury occur at each 
 pulsation. 
 
 When packing the manometer in its case, remove it from the 
 socket and replace the small rubber caps securely and tightly 
 on the open ends, to prevent the mercury escaping. Then put 
 the manometer in the guides at the bottom of the box, face 
 upward, the scale-end nearest to the handle. Upon this lay 
 the armlet, leather side upward. The tubing, ball, etc., may 
 be distributed about the case. Carry the box by means of 
 the hand-loop at the end. 
 
 The scale on the manometer is immovable, but the glass 
 tube admits of a small movement. Should any of the mercury 
 be accidentally spilled, refill the tube, and bring the surface 
 of the mercury to correspond with the zero on the scale. 
 Spilled mercury may be scooped up with a bent calling card. 
 Care must be taken not to use a silver tea-spoon, which would 
 at once become amalgamated and spoiled. Gold or silver rings 
 or sleeve-links must also be prevented from touching the 
 mercury, or they will be spoiled. 
 
 Note. A fall on the floor, or the jolting in travelling by 
 rail, may separate the two columns of mercury in the manom- 
 eter tube; to rectify this, hold the manometer board by its 
 upper end, and gently swing it in the manner adopted to ad- 
 just the index of a clinical thermometer; leave the rubber 
 caps on the tubes whilst so doing. 1 
 
 1 It is made by Mr. T. Hawksley, 357 Oxford Street, London, W.
 
 220 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Lockhart Mummery's is much like C. J. Martin's, but it 
 has a large reservoir of mercury like Riva-Rocci's original 
 
 FIG. 236. Lockhart Mummery's modification of Riva-Rocci's sphygmomanometer. 
 (Made by Hawksley.) 
 
 instrument (page 78), instead of a U-tube. The mercury 
 
 is retained by india-rubber caps, and the instrument is portable. 
 
 Oliver's New Sphygmomanometer. In this instrument 
 
 FIG. 237. Oliver's new instrument. A, Tap for occluding or releasing air; B, 
 
 tap for augmenting the oscillations of the fluid index; C, rubber connections; D, 
 
 screw for regulating the pressure in the air bag; E, the palpating finger; F, 
 sphygmomanometer. 
 
 the pressure is afforded, as in Hill's smaller one (p. 68), by 
 a fluid index working against a column of compressed air.
 
 APPENDIX B 
 
 221 
 
 It has the convenience of a long scale, so that the oscillations 
 of pressure at every beat of the pulse are very distinct, and 
 the diastolic pressure (page 82) is more easily read than with 
 most other instruments. This is made all the easier by raising 
 or lowering the pressure by the action of a screw, in much 
 the same way as in Gaertner's tonometer (Fig. 95, page 74). 
 Gibson's Clinical Polygraph. This instrument is in- 
 
 FIG. 238. Dr. A. G. Gibson's clinical polygraph. A, Rectangular box, contain- 
 ing driving mechanism and electric time-marker. Outside box Driving cylinder C, 
 cell for strip of paper D. Pillar to hold three tambours and (a second) to carry time- 
 marking tambour. Nos. i, 2, 3, 4, are the writing levers of the four tambours. 
 Each tambour capable of vertical adjustment on its pillar, and an angular adjustment 
 
 by the screws BB are levers for throwing the pens out of action when 
 
 filling with ink or changing the paper. C, Driving cylinder. D, Cell to hold paper. 
 E, The adjustable spring, keeps the paper flat against the driving cylinder when at 
 work. F is the unwound coil of paper in its cell. H, An axle carrying two friction 
 rollers, adjusted for pressure by the screw at side. J, Screw to be removed when the 
 time-marker is to be used. It screws into the " bob " of the pendulum, inside the box, 
 and keeps it in safety when traveling, etc. K, By screwing in, lifts the receiver 
 away from the pendulum and diminishes the force of impact. L is the air tube of 
 the receiver inside the box, which is struck by the pendulum " bob " five times per 
 second. This tube communicates with the writing tambour as shown. The stopcock 
 governs the amount of air passing to the tambour. MM are terminals for the single 
 cell to drive the time-marker. N is an adjusting screw for the time-marker, which, 
 when listened to, should coincide with the ticking sounds of a watch held to the ear. 
 The latter are five to the second. P is an ordinary dry cell. Receivers for the 
 jugular pulse and radial artery are shown in situ. Side tubes and stopcocks are for 
 regulating the air contents of the receivers; i. e., a little more or less air may be 
 wanted in the receivers, and it is easily blown in by the mouth, or let out by the 
 tap. Both Oliver's and Gibson's instruments are made by Hawksley. 
 
 tended to give simultaneous tracings of the apex beat, and 
 respiration of the radial artery and jugular vein. 
 
 A number of other instruments might very well have been 
 described here, but I have no illustrations of them, and without
 
 222 THERAPEUTICS OF THE CIRCULATION 
 
 illustrations a letterpress description is hard to understand. 
 All those instruments mentioned in the lectures, of which the 
 illustration bears the name of Ch. Verdin, can be obtained 
 from his successor, M. Boulitte, 7 Rue Linne, Paris. 
 
 Choice of Instruments for Measuring Blood Pressure. 
 For any one who has only a single instrument, my experience 
 leads me to think that Martin's new form of Riva-Rocci is 
 at once the cheapest and the best. If he has more than one, 
 it is very convenient indeed to use one of Von Basch's or 
 Potain's, as it is so easily applied. If any doubt arises, 
 Martin's instrument, which is, I think, more accurate, can be 
 used to control the figure by Von Basch's or Potain's. The 
 accuracy of either of these can be tested with the mercurial 
 manometer, as shown at page 83, but if Von Basch's instru- 
 ment is employed as supplied by Down Bros., a three-way 
 stopcock must be got also, either from them or from Boulitte 
 or from some other maker.
 
 Exercise in Angina Pectoris. This question came on at 
 a late period in the lectures, when I had to deal with it very 
 briefly, but I discussed it rather fully in my Harveian Oration, 
 from which I may take the following quotation : " The cir- 
 culation through the muscles is indeed a complex phenomenon, 
 and it was shown by Ludwig and Sadler to depend at least 
 upon two factors having an antagonistic action. When a 
 muscle is thrown into action, it mechanically compresses the 
 blood vessels within it, and thus tends to lessen the circula- 
 tion through it, but at the same time the stimulus which is 
 sent down through the motor nerve, and which calls it into 
 
 FIG. 239. After Ludwig and Sadler. The marks along the base-lines indicate 
 seconds; the height above the base-line indicates the amount of blood flowing from the 
 veins of the biceps of a dog during tetanus (T or tet), during rest (Ruhe), or during 
 simple contraction (Zuck). 
 
 action, brings about a dilatation of the vascular walls, and thus 
 increases the circulation throughout the muscle. 
 
 " When the amount of blood is measured before, during, and 
 after stimulation of the motor nerve, it is sometimes found 
 that the flow is diminished, at others that it is increased. This 
 difference depends upon the comparative effect of the mechani- 
 cal compression of the vessels of the muscles just mentioned, 
 and upon the increase of their lumen by the dilatation of their 
 walls. It invariably happens, however, that after the muscle 
 has ceased to act, the flow of blood through the muscle is in- 
 creased. This increase is quite independent of any alteration 
 in the general pressure of blood in the arteries, and it occurs 
 when an artificial stream of blood, under constant pressure, 
 is sent through the muscle. A heart whose nutrition has been 
 
 223
 
 224 THERAPEUTICS OF THE CIRCULATION 
 
 weakened by disease of the arteries, and consequent imperfect 
 supply of blood to the cardiac muscle, is unable to meet any 
 increased resistance, if this should be offered to it, and pain 
 is at once felt. In such cases, unless they be far advanced, we 
 find, precisely as we might expect, that walking on the level 
 usually causes no pain, but the attempt to ascend even a slight 
 rise, by which the muscles are brought into more active exer- 
 tion, brings on pain at once. Yet here again we find, as we 
 should expect, that if the patient is able to continue walking, 
 the pain passes off and does not return. These phenomena 
 would be inexplicable if it were not for Ludwig's observa- 
 tions on circulation through the muscles; but in the light of 
 these observations, everything is made prefectly intelligible. 
 Walking on the flat, by causing no violent exertion of the 
 muscles, produces no mechanical constriction of the vessels, 
 and thus does not increase the blood pressure. The greater 
 exertion of walking up a hill has this effect; but if the patient 
 is able to continue his exertions, the increased dilatation of 
 the vessels a consequence of musclar activity allows the 
 pressure again to fall, and relieves the pain."
 
 APPENDIX D 
 
 NOTES BY PROFESSOR KRONECKER. 
 
 This appendix contains a number of notes which Professor 
 Kronecker has kindly sent me relating to his own work and 
 that of his pupils on the heart. His notes are especially 
 valuable, because they afford such clear evidence of the con- 
 duction of stimuli in the heart by nervous channels, which it 
 is at present rather the fashion to neglect. Conduction of 
 stimuli is by many regarded as a function of muscle only, 
 just as their conduction was regarded as a function of nerves 
 only several years ago. The truth probably lies between the 
 two extreme views, and conduction occurs through both chan- 
 nels as mentioned at p. 33. The question is by no means one 
 of mere scientific interest, because on its correct answer a 
 correct knowledge of the causation and treatment of heart- 
 block depends. I have not been able to use the whole of the 
 material with which he kindly furnished me, for it arrived 
 just as this book was going to press, and to obtain the illustra- 
 tions required would have entailed considerable delay. 
 
 His observations on self -massage of the heart and arteries 
 are also most interesting, for though Briicke (p. 97) indicated 
 the suction action of the cardiac systole, and Ludwig showed 
 the effect of muscular action on the flow of lymph (p. 9), yet 
 it is to Kronecker that we owe the first full discussion of the 
 self -massage of the heart and arteries. 
 
 The Work of the Heart. The heart does not beat at the 
 expense of its own tissues, but only at that of the energy- 
 supplying material with which it is fed. The smaller the 
 quantity of this material, the less is the work done by the 
 heart. No other material enables the heart to beat except 
 serumalbumin, and, to a very slight degree, serumglobulin. 
 Only very minute quantities of this are required, on account 
 of the high energy-value of the albumen. Neither glycogen 
 nor other carbohydrates can supply the place of genuine 
 albumen. Of course, inorganic solutions do not supply energy. 
 Solutions of inorganic salts, as mentioned by Gaule, Binger, 
 Howell, Locke, Schucking, and others, weakens the pulsations ; 
 16 225
 
 226 THERAPEUTICS OF THE CIRCULATION 
 
 but the better they enable the albuminates to be utilized in the 
 heart, the less do they have this effect. Every saline solution 
 gradually exhausts the energy of the heart, but it can be 
 restored by serum. The blood corpuscles and fibrin do not 
 take part in this process, and hence blood is no better than 
 serum as a nutrient. 
 
 Oxygen does not increase the work done by the heart. 
 Blood saturated with carbonic oxide nourishes it just as well 
 as arterial blood. Asphyxial blood is only poisonous on ac- 
 count of the CO 2 it contains. 
 
 Dissolved erythrocytes (laky blood) poison the heart only 
 on account of the poisonous potassium salt set free by their 
 solution. If these are renewed by dialysis, laky blood is 
 innocuous. 
 
 In 1874 Kronecker advanced the following explanation of 
 the ascending staircase (Bowditch's Treppe) : The pulsating 
 heart massages itself. In amphibian hearts, where capillary 
 clefts replace the coronary arteries, each systole presses out the 
 contents of the clefts, each diastole allows the clefts to reopen. 
 By this mechanism the nutritive material is renewed. After a 
 long standstill the products of metabolism remain in the clefts 
 and asphyxiate the heart muscle. Every systole removes a 
 small quantity of the noxious substances, and their place is 
 supplied by nutrient material. In this way we have the para- 
 dox of recovery through work. The descending stair can be 
 artificially produced by washing out the heart with saline 
 solution. 
 
 Bowditch's Law. The amplitude of the heart's beats is 
 absolutely independent of the irritability of the heart. The 
 law discovered by Bowditch is : Minimal stimtili cause maxi- 
 mum pulsations. This law has been thus paraphrased : " all or 
 nothing " that is to say, that instead of a weak stimulus 
 evoking a weak contraction, and a strong stimulus a strong 
 contraction, any stimulus which will produce a contraction at 
 all will produce as powerful a pulsation as the most powerful 
 stimulus. 
 
 To this law Bowditch found two exceptions : 
 
 (1) Intermittent pulsation, with constant regular normal 
 stimulation. 
 
 (2) Feebler pulsations after longer rest. 
 
 This subject was more fully investigated by Kronecker, who 
 succeeded in obtaining a pulsation without fail on the applica-
 
 APPENDIX D 22J 
 
 tion of each minimal stimulus, if the stimuli were kept of 
 exactly equal strength by the use of a mercurial contact kept 
 perfectly clean by a constant stream of water. 
 
 He also showed that the first pulsations after rest were not 
 smaller than the later, if the contents of the heart were kept 
 fresh during rest. 
 
 Thus he proved that Bowditch's law holds good without 
 any exception. 
 
 Refractory Period. More important still was Kronecker's 
 discovery that the heart is not irritable during systole. Many 
 called this the refractory period. Even after the systole is 
 over, the heart only gradually regains its irritability. Tem- 
 perature modifies the irritability of the heart to a great extent. 
 He found that at a temperature of 30 C., a heart can be made 
 to beat sixty times a minute by induction currents of 15 units 
 (Kronecker) and the contracture augments. When cooled to 
 8 C., it can beat twelve times per minute; at 5 C., only six 
 times per minute, even when 12 stimuli of 30 units each are 
 applied. Every pulsation lasts about 5 seconds so that the new 
 systole begins after 5 seconds of diastole. 
 
 This curious reaction of the heart to frequent (intermitting) 
 stimuli explains why the heart cannot be tetanized. 
 
 The frog's heart, at a temperature of 30 C., and stimulated 
 forty to fifty times per minute, makes a pulsation every second. 
 At a medium temperature, 15 C., it pulsates about every 
 second second. At a low temperature, 10 C., it beats about 
 every fifth second, although the pulsation only lasts 2.5 sec- 
 onds. In the cold heart the duration of the pulse is 6 seconds, 
 but the heart only regains its irritability again after 15 sec- 
 onds. This behavior of the frog's heart supplies an explana- 
 tion of the fact that constant stimuli, such as chemical ones, 
 have an intermitting effect. Within the last few years, Kro- 
 necker and his pupils have found that the ventricle of the 
 frog's heart ceases to beat if its contents are deprived of all 
 stimulating properties. Thus, Algina found that a ventricle 
 would remain without beating for an hour and a half at a time 
 for as long as three days, when it was supplied with sheep's 
 serum which had been dialyzed, neutralized, and then brought 
 up to 0.6 per cent, of sodium chloride contents. 
 
 It would therefore seem that there is no true automatism 
 in the ventricle, but only intermittent action to a constant 
 stimulus.
 
 228 THERAPEUTICS OF THE CIRCULATION 
 
 Coordination of the Heart-Beats. Two opposite views 
 are held by physiologists in regard to this subject. 
 
 Those who hold the myogenic view consider that the 
 muscular cells which form the cardiac wall transmit a stimulus 
 from one to another. But Kronecker and Irachanitzky 1 made 
 the following observation, which seems to show that this is not 
 the case. Microscopic preparations of rabbits' hearts fixed in a 
 state of fibrillation show that the condition of irritation does 
 not pass the limits of the cell. Preparations of hearts, which 
 were fixed while the pulsations were normally coordinated, 
 exhibit equidistant stria. Coordination is effected by nu- 
 merous plexuses of non-medullated nerves. As soon as these 
 are paralyzed, the heart falls into an irregular kind of motion, 
 either fibrillary or peristaltic. 
 
 The nerve centers of the heart, like those of the brain, con- 
 sist of groups of ganglion cells and nerve plexuses. These are 
 quickly paralyzed by want of blood. 
 
 Fibrillation occurs in the heart 
 
 1. If the coronary arteries are ligatured. 
 
 2. If small branches of the coronary arteries are plugged 
 
 by embolism (reflex effect). 
 
 3. If the heart is tetanized. 
 
 4. If the mammalian heart is quickly cooled down to about 
 
 25 C. 
 
 5. If the ventricular septum is punctured about the junction 
 
 of the upper and middle third. 
 
 6. Sometimes by the rapid application of chloroform. 
 Rabbits' hearts in a state of fibrillation may spontaneously 
 
 commence to beat rhythmically. Dogs' hearts (except when 
 the animals are very young) continue to fibrillate, and die 
 unless they are saved artificially. Dogs' hearts may be saved 
 from a state of fibrillation 
 
 (1) By very strong electric shocks (240 volts), applied 
 directly to the heart (Batelli and Prevost). 
 
 (2) By heating to 43 C. or 45 C. 
 
 (3) By chloral-hydrate (Barbera). 
 
 If the roots of the coronary arteries have been ligatured, 
 they cannot be saved. 
 
 Kronecker succeeded in reestablishing pulsation, but only 
 
 1 Archiv. Internation. dc Physiol., vol. iv., p. i, July, 1906. This paper 
 contains a very complete resume of the literature on the subject of the 
 channels through which stimuli pass from one part of the heart to another.
 
 APPENDIX D 229 
 
 on the right ventricle of the dog's heart, in the following ex- 
 periment. He ligatured the anterior root of the coronary 
 artery; they produced fibrillation, and finally conducted a 
 strong current of 240 volts through the heart. From this he 
 concluded (i) that narrowing of the coronary arterial system 
 paralyzes, either -directly or reflexly, the coordinating nervous 
 system of the heart; (2) that the paralysis may be removed 
 by producing dilatation of the coronary arteries by heat, 
 chloral-hydrate, or electric currents of high intensity; (3) that 
 a center for the innervation of the coronary vessels lies in 
 ventricular septum. At the point in the ventricular septum 
 where puncture produces fibrillation, no ganglion cells are to 
 be found, but only nerve plexuses, which have a similar func- 
 tion as ganglia. 
 
 Conduction of Stimuli from Auricles to Ventricles. 
 When the heart is beating normally the two auricles are seen 
 to contract simultaneously, and the same is the case with the 
 ventricles. The coordination between the auricles and ven- 
 tricles is such that they begin their contraction in regular inter- 
 vals, so that the completion of systole in an auricle is followed 
 without any interval by the commencement of the systole of 
 the ventricle. 
 
 Such coordination is, like the act of swallowing, only pos- 
 sible through central nervous arrangements. 
 
 Those W 7 ho hold the myogenic theory say that the relaxa- 
 tion occurs on account of the specific structure of the muscle. 
 This is not to be found in the frog's heart. In the mammalian 
 heart the retarded conduction is ascribed to the bundles of 
 Stanley-Kent and His. 
 
 Kronecker and Imchanitzky have showed that this bundle 
 can be ligatured without disturbing the coordination between 
 auricles and ventricles. 
 
 Dr. Paukul of Dorpat, while working recently in Professor 
 Kronecker's laboratory, found that the Stanley-Kent and His 
 bundle of muscular fibers connecting the auricles and ventricle 
 is accompanied by nervous plexuses, injury of which disturbs 
 coordination, whilst ligature of the muscular part of the bun- 
 dle does not impair coordination. 
 
 Dr. Imchanitzky, also working under Kronecker's direction, 
 discovered in the hearts of lizards two nerves with immense 
 groups of ganglia uniting the auricle with the ventricle. When 
 these were ligatured, the coordination between the beats of 
 the auricle and ventricle was destroyed.
 
 230 THERAPEUTICS OF THE CIRCULATION 
 
 Dr. Lomakina several years ago observed disturbance of 
 coordination, after the application of ligatures to the hearts 
 of dogs and rabbits at points where the bundle could not be 
 injured e. g. to the pulmonary artery at its exit from the 
 right ventricle. 
 
 Kronecker often saw incoordination occur on the applica- 
 tion of a ligature to the right ventricle at the point where the 
 vense-cavae inosculate. How is it possible on the myogenic 
 theory to explain the occurrence of fibrillation in the tetanized 
 auricles while the ventricles are pulsating normally or vice 
 versa ? 
 
 Is His's bundle then in a state of fibrillation and yet effect- 
 ing pulsations? Kronecker also showed that the vagi when 
 stimulated can inhibit the ventricles whilst they do not affect 
 the fibrillating auricles. 
 
 How can this fact be explained otherwise than on the hy- 
 pothesis that the nerves conduct the inhibition through the 
 fibrillating muscular masses? 
 
 The cardiac vagi do not act on cavities of the heart which 
 are under the influence of local stimulation. A ventricle 
 through which normal saline solution is being circulated can- 
 not be stopped by stimulation of the vagus, but if the ventricle 
 is supplied w r ith Ringer's solution or blood stimulation of the 
 vagus, it produces its ordinary inhibitory effect. The same 
 minimal stimulus which will cause the ventricle in a state of 
 ordinary rest to pulsate, suffices to produce a pulsation in an 
 inhibited ventricle. The vagus is therefore not an anabolic 
 nerve. 
 
 Conduction of Stimuli in the Heart. In a paper on this 
 subject from Kronecker's laboratory, D. Maria Imchanitzky 
 (Archives Internationales de Physiologic, vol. iv., p. I, July, 
 1906) gives a very full abstract of all the literature on the 
 subject, and a resume of the results of original experiments 
 made under Kronecker's direction. These are : 
 
 I. From the histological researches it appears : 
 
 (a) That the muscular cells in the ventricles of the heart 
 in repose or in coordinated action present everywhere the 
 same histological appearance, the striation being identical 
 everywhere. 
 
 (&) When the heart is fixed in a state of fibrillation, the 
 cells, on the contrary, present different aspects. The state of 
 striation differs from one cell to another. The intercellular
 
 APPENDIX D 
 
 2 3 I 
 
 limits generally form sharply marked dividing- lines between 
 a cell with striae widely apart and another with them close 
 together, although sometimes these different appearances can 
 be found in one and the same cell. (See Fig. 240.) 
 
 (c) From the aspect of these structures one must conclude 
 that the contraction does not pass from one muscular cell to 
 another, but that the stimulation is transmitted by coordinating 
 nervous communications. 
 
 II. Experiments made by ligaturing the bundle of His 
 
 FIG. 240. Cells taken from a heart in fibrillation. The preparation shows that the 
 intercellular limits separate very sharply parts with striae widely apart from others with 
 striae close together, whilst in the interior of the cells numerous transitions may be 
 observed. The larger figure is magnified 750 diameters by an apochromatic objective, 
 No. 2 of Zeiss, and compensating eyepiece, No. 6. The small portion strongly magnified 
 was observed with Zeiss's No. 2 objective and a compensating eyepiece, No. 18, with an 
 intense illumination. 
 
 prove that hearts may exhibit coordinated pulsations of the 
 auricles and ventricles after the destruction of this bundle. 
 
 Importance of the Pulse for the Current of Blood in the 
 Arteries. In experiments made with his pupil, Dr. Gustav 
 Hamel, 1 in which nutrient fluid was perfused through the blood 
 
 1 Zcitschrift f. Biologic, Ed. xxv., X. F., vii., p. 4/4.
 
 232 THERAPEUTICS OF THE CIRCULATION 
 
 vessels of a frog, Kronecker found that when the flow was 
 interrupted rhythmically by a stopcock worked by an electric 
 pendulum, the vessels allowed much more fluid to flow through 
 them than when the flow was continuous. The advantage of 
 the rhythmical impulse appears to consist in this : that the 
 alternate movements maintain the elasticity of the arteries and 
 the pauses serve for recuperation of their muscular walls. The 
 intermitting rest is certainly of great value to the vascular 
 walls, for when they are subjected to continued pressure they 
 are injured and allow fluid to exude into the tissues and pro- 
 duce cedema. On the other hand, when the flow is rhyth- 
 mically interrupted, very little cedema appears (cf. p. 128). 
 The cardiac pulsation acts like an internal massage, and by 
 producing passive gymnastics maintains the cohesion, elas- 
 ticity, and contractility of the arteries. 
 
 Circulation in the Splanchnic System. In 1889 Kro- 
 necker showed at the Naturforscherversammlung, in Heidel- 
 berg, that normal saline solution flows readily into the portal 
 venous system of a rabbit under a pressure equivalent to 30 
 centimeters of water. When the portal vein is ligatured close 
 to the hilus of the liver, the saline solution only begins to 
 enter under a pressure of 60 centimeters. But if the abdominal 
 aorta is ligatured close to the diaphragm, and above the ab- 
 dominal arteries, the veins become paralyzed, and allow enorm- 
 ous quantities of saline solution to flow into them under a very 
 low pressure.
 
 INDEX. 
 
 NOTE. In this index the numbers of the figures referred to are not given, but only 
 the pages on which they may be found. 
 
 ABDOMEN, blow on, shock due to twofold 
 action Goltz's experiments on frog, 
 showing, 1 13 
 
 cold wet compress applied to beneficial 
 in sleeplessness why, 175 
 
 constriction of, by corsets or belts, risks 
 from, 141 
 
 extra pressure on, when thighs are 
 swollen, 133 
 
 - serous cavity of, effusion into Tap- 
 ping to remove, 204 
 
 Abdominal distension (see also stomach, 
 distention of), mechanical interfer- 
 ence by, with lungs and heart, 131, 
 138 
 
 massage, flatulence lessened by how, 
 138 
 
 - vessels, contraction of, due to severe 
 pain circulation maintained by, 113 
 
 viscera, duty of the diaphragm to, in 
 upright and in recumbent positions, 
 133 
 
 Abscess, cerebral bradycardia in connec- 
 tion with, 187 
 
 Absorbent cotton wool use of, in tap- 
 ping, 204 
 
 Absorption, drugs causing, useful in cases 
 of high blood-pressure due to gouty 
 kidney, 101 
 
 fluid supplied by, replacing that drawn 
 from blood by kidneys in oedematous 
 diseases of the heart, 150, 152 
 
 of oedema, ascites, or pleural effusion, 
 effected by rest and massage, 138 
 
 Accelerators, probable effect on, of atro- 
 pine, 107, note 
 
 stimulation of, deduced from pulse- 
 rate in exophthalmic goitre, 107 
 
 Accessory muscles of circulation, 7 
 
 Acidity of stomach, aggravation of drowsy 
 sleeplessness of cardiac disease how 
 relieved, 193 
 
 Acocanthera (Oubain), action of not 
 used in medicine, 146 
 
 Aconite typical cardiac depressant, char- 
 acteristic physiological action of, 171 
 
 effect of, on frog's heart, 171 
 
 in local inflammations, 172, 174 
 
 in nervous flutterings of heart, 172 
 
 in high tension in angina pectoris,. 174 
 
 on mammals, in large and in small 
 
 doses, 171 
 on very rapid pulse, 166 
 
 Acute anaemia, fatty degeneration of the 
 heart in, 100 
 
 Acute disease, sequelae of, dilatation of 
 the heart in, 126 
 
 rheumatism bradycardia with weak 
 heart in convalescence from, 186-7 
 
 Adami, see Roy & Adami 
 
 Adonis rernalis (pheasant's eye), uses of, 
 146 
 
 Adrenaline, action of, on heart and ves- 
 sels, 1 60 
 
 Adult (s) heart, action on, of Digitalin, 
 147 
 
 not injured by moderate smoking 
 
 double action of smoking in, 169 
 
 After-cure, subsequent in Nauheim treat- 
 ment, 20 1 
 
 Age, see elderly, old age, senile, and 
 senility 
 
 Agurin, nature and uses of, 162 
 
 Albumen in urine, disappearance of, due 
 to rest and massage, 139 
 
 effect on, of mercury, 208 
 
 in sleeplessness in cardiac disease 
 
 not centra-indication of use of 
 opium or morphine, 195 
 
 Albuminuria, a consequence of venous 
 engorgement, 129 
 
 use in, of mercury author's view, 208 
 
 Alcohol, bradycardia sometimes caused 
 by how, 109, 187 
 
 effect of, on medusae (contractile tis- 
 sue), 30-31 
 
 excessive use of, as cause of palpita- 
 tion to be cut off or docked, 179 
 
 ingestion of large quantities causing 
 speedy death analogy, 113 
 
 Alcoholic neuritis, paralysis of the vagi 
 due to rapidity of pulse after, 107 
 
 Alcoholism, chronic, fatty degeneration 
 of the heart in, 100 
 
 Alkalies, form of bradycardia in which 
 suitable, 188 
 
 Aloes, as aperient, in senile rise of pres- 
 sure how taken, 208 
 
 American modifications of Riva-Rocci's 
 instrument, 79, 80, 81 
 
 Amoeba, contraction in, of vesicle, 27 
 
 Ammonia liniment over cardiac region, 
 extremely stimulating action of, 178 
 
 Ammonium, bromide of, in Graves's dis- 
 ease effects of, 184 
 
 Hippurate (Oliver), in treatment of 
 high tension, 208 
 
 Amyl nitrite, efficacy of, as vascular dila- 
 tor, 165 
 
 in angina pectoris, 208 special ad- 
 vantages, 189, (figs.) 190 
 
 in cardiac asthma, less useful than 
 
 in angina why, 193 
 investigations on, of Guthrie, etc., 
 
 and of author, 163 
 -overdoses of, sole ill-effect from, 191 
 
 Anaemia, acute and chronic, fatty degen- 
 eration of the heart in, 100 
 
 bradycardia associated with, 186 
 
 dilatation of the heart in, 126 
 
 of the brain, sudden, probable cause of 
 syncope, 1 14 
 
 of the tissues with temporary contrac- 
 tion of arteries, in Raynaud's dis- 
 ease, 117 
 
 233
 
 234 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Anaesthesia, imperfect, fatal shock, how 
 caused by author's view, 113-4 
 
 Anaesthetics, tight-lacing dangerous dur- 
 ing administration of, 141 
 
 Ancients, the, views of, on circulation 
 and arteries, basis of, 2. 
 
 Aneroid manometer, Gaertner's portable 
 form of his tonometer, 76, (fig.) 76 
 
 sphygmomanometer, author's apparatus 
 for standardizing, 83 
 
 Aneurism, indicated by louder second 
 heart sound, 42 
 
 cerebral, bradycardia in conjuction 
 with, 187 
 
 Anger, angina pectoris due to historic 
 fatal case, 189 
 
 Angina pectoris, difficulty of making ob- 
 servations in author's recorded, 121, 
 and note 
 
 high tension in, aconite sometimes use- 
 ful in precaution advised, 174 
 
 claudication in, Brodie cited on, 116 
 
 in relation to contraction of coronary 
 arteries, 116, 189 
 
 liability in, to sudden death, 196 
 
 pain of causes, 116, 121, and note, 
 
 123, 189 
 
 location and extent, 189 
 severity of, 121 
 
 pain simulating, due to over-smoking, 
 170 
 
 sensations akin to, in paroxysmal tachy- 
 cardia, 108 
 
 sensations frequent in (see Pain) 
 (a) intense oppression, 121 
 (b) extreme pain, 121 nature of the 
 latter in author's view, 121-2, and 
 note 
 
 (c) anxiety, 122, note 
 
 treatment and relief of aims of, 189-90 
 during attacks, 191 
 during intervals, ib. 
 
 amyl nitrite in, 208 
 
 -author's successful use of, 164-5 
 
 bleeding, 175, 177, 208 
 cold bandages application of, effect 
 on radial artery, 175, 177, (fig.) 176 
 diet and regimen in, 191-2 
 Angio-neurotic oedema, conditions of, 153 
 no venous obstruction in, 153 
 pathology not made out author's 
 
 view, 1 1 8 
 Animal, an, " bled into its own veins," 
 
 Ludwig cited on, 16 
 Animals, blood-pressure in, 60 
 poisoned by digitalis, apex-beat in, in- 
 creased, I 12 
 slain for sacrifice, arteries empty in 
 
 reason, 2, 5 
 Antiaris to.ricaria. or upas, action of, not 
 
 used medicinally, 146 
 Antiseptics, in treatment of toxin-caused 
 
 bradycardia, 188 
 Anti-streptococcic serum universal cedema 
 
 brought on by injection of, 118 
 Anxiety, in angina pectoris, 121, note 
 effect of, on the circulation, 104 
 oppression of chest, caused by to what 
 
 due, 121 
 
 Aorta, blood-pressure in, in mitral in- 
 competence, 127 
 composition of, 44 
 contractile power of, 44 
 in elderly people, atheromatous and 
 rough with systolic murmur, but re- 
 gurgitation not necessarily resulting, 
 
 122 
 
 Aorta, investigation of, with Marey's 
 cardiograph results, 86-90, (figs.) 
 86, 88 
 
 relative resistance of, 44 
 Aortic bulb, frog's heart, 19 
 cartilage, aortic regurgitant murmur 
 
 usually well heard over, 195 
 disease, liquid allowed in, by Dr. 
 
 Schott, 20 1 
 incompetence causes consequences, 
 
 122-3 
 
 orifice narrowing of, due to inflam- 
 mation during foetal life, or to vege- 
 tal growths in later years, 122 
 pulse, tracings of, with Marey's car- 
 diograph, 89, (figs.) 88 
 regurgitation, patients with, arterial 
 pulsation observable in coincidence 
 of the three rhythms in, 47 
 
 as affecting snhygmograms, 9 
 
 full diet advised in, by Dr. Schott 
 
 why, 20 1 
 
 how recognized, 122-3, "95 
 left ventricle yielding before strain 
 consequences, 196 danger of, 
 and treatment, 196-7 
 
 liability in, to sudden death, 196 
 
 murmur of, 43, place where heard 
 caution on case illustrating, 195-6 
 
 process, causes and results of, 122 
 
 aspect of those affected by, 122-3 
 risk of syncope in, 196 
 uncomplicated, effects of digitalis in, 
 alone, and in combination risks 
 from, 196 
 
 use of digitalis, strychnine, and caf- 
 feine in, 196, 203 
 Aortic stenosis, how recognized, 122-3, 
 
 195 
 valves, aortic regurgitant murmur 
 
 usually well heard over, 195 
 closure of, cause of second sound 
 
 (Williams), 41 
 
 destruction of, bruit or murmur re- 
 sulting from, 43 
 
 stiffness of, with years consequence, 
 
 122 
 
 vegetal growths on consequence, 122 
 
 Aperients (see also Purgatives), in cases 
 
 of senile rise of pressure how taken, 
 
 208 
 Apex of heart, angina pain felt towards, 
 
 189 
 frog's, dilatation of, by pressure from 
 
 within, 28, 128 
 
 point of chest wall over, first sound 
 
 of heart best heard at, 42 
 Apex-beat, Burdon-Sanderson's cardio- 
 graph for, (fig.) 86 
 in palpitation of the heart, 112 
 Apocynum cannabinum (Canadian hemp), 
 
 uses of, 146 
 Appetite, improved, in absolute rest 
 
 treatment, by massage why, 138 
 lessened by disordered circulation 
 
 why, 131 
 
 Apoplexy (ia), brain-pressure due to, caus- 
 ing bradycardia how, 109 
 causes of, 14, 15 
 cerebral common in advanced life 
 
 cause, 205-6 possible means of 
 
 averting, 208-9 
 - risk of, in cases of arterio-capillary 
 
 fibrosis, due to kidney disease, 101-2 
 risk of causing, by Digitalis in cases 
 
 of fatty heart why, 162-3
 
 INDEX 
 
 235 
 
 Archangelsky, views of, on importance of 
 
 cardiac ganglia, 32, note 
 Arm(s), application to, of cold bandage 
 effect of, on radial artery, 175, 
 (fig.) 176 
 bend of, source of blood at, author's 
 
 deductions from, as to syncope, 115 
 bleeding from cases in which bene- 
 ficial, 175, 208 
 
 (specially left arm), affected by an- 
 gina pain, 189 
 
 volume of reduced, during hard think- 
 ing Mosso's demonstration, 114 
 Arrow-poisons, also used similarly to 
 
 digitalis, 146 
 Arsenic, fatty degeneration of the heart 
 
 found after administration of, 100 
 Arterial circulation, as assisting venous, 
 
 6, 99, 102 
 
 massage of the nerves, in health, 135 
 pulsation, coincident with respira- 
 tion, 46 
 
 runture, risk of, from rise of blood- 
 pressure in chronic interstitial ne- 
 phritis, 49, 50 
 
 Arterial tension (see also blood-pres- 
 sure), 10 
 
 instrument for estimating, suggested 
 
 combined use of, with sphygmo- 
 graph, 94 
 
 rnitroglycerine the stock remedy for 
 
 lowering how administered, 165-6 
 
 quickened pulse, and pain of angina 
 
 pectoris, relations between cases 
 illustrating, 121, and note 
 high, in advanced age diet, regi- 
 men, and medicines prescribed for, 
 208-9 risks of, with antheroma- 
 tous arteries, 206-7 
 in angina pectoris relation be- 
 tween and the pain, 121, and 
 note, 174, 189 
 
 in Bright's disease, 90, (fig.) 88 
 in attacks of paroxysmal tachy- 
 cardia, calling for vascular dila- 
 tors, 185 
 
 indicated by louder second heart 
 sound, 42 
 
 high ana low, as affecting first heart 
 
 sound, 43 
 
 regulation of, 13-15 
 
 Arterial walls, degeneration of, in the 
 aged, conditions and consequences, 
 89, 99, 100, 101, 116, 205, 206-7 
 Arterialized blood, first portion of, re- 
 ceived by coronary arteries, 94 
 Artery(ies), see also under Names 
 as affected by old age, 89, 99, (fig.) 98, 
 100, 101, 1 1 6, 206-7; timely atten- 
 tion to, a means of prolonging life, 
 205 
 of brain as affected by Raynaud's 
 
 disease, 117 
 
 in cases of aortic regurgitation, irri- 
 tability of, and tendency to rhythm- 
 ical contraction in, 46, 123 
 contractile force of, to what due, work 
 
 done by, 10-11 
 
 contraction of, due to digitalis, 148, 
 how effected, 149 due to local ap- 
 plication of cold, 175, (fig.) 176 
 in old age consequences, 116 
 temporary, in Raynaud's disease 
 
 consequences, 117 
 
 diastolic and systolic pressure in, how 
 estimated, 71, (fig.) 70 
 
 Arteries, elastic recoil of, 4 
 
 as affected by age, 89, 116, 205, 
 
 (fig.) 88 
 
 as affected by Bright's disease, 90 
 
 (fig.) 88 
 in relation to contractile force, 10 
 
 emptiness of, causes of, 2, 5, 90 
 
 of head and neck, peripheral contrac- 
 tion of, with central dilatation the 
 cause of migraine, in author's view, 
 119 
 
 with impaired elasticity, tracings yielded 
 by, 89, (fig.) 88 
 
 internal, as affected by Raynaud's dis- 
 ease, 117 
 
 large, alterations in, in relation to mi- 
 graine, 119-20 
 
 massage by, of nerves, 134 
 
 of moderate size, alterations in, in re- 
 lation to migraine, 1 19-20 
 
 motor and peristaltic action of, 5 
 
 ossification of (or obliteration), angina 
 pectoris and claudication due to 
 (Brodie), 116 
 
 periodical pulsation in, observable in 
 patients with aortic regurgitation 
 coincidence of the three rhythms in, 
 46-7 
 
 renal, effects on, of ligature of, and 
 similar effect of digitalis, etc., 155-6, 
 162 how overcome, 163 
 
 self-massage of, process and value of, 
 
 6, 99, 102 
 increased by digitalis, 149 
 
 by massage and exercises, 202 
 
 sensitiveness of, 119 how proven, 120 
 
 single, compression of, to measure hu- 
 man blood-pressure, instruments for 
 - 60 et seq., (figs.) 60-67 
 
 size of, Oliver's arteriometer for meas- 
 uring, 83 
 
 three functions of, 4 
 
 (i) storers of force, ib. 
 
 (2) regulators, ib. 
 
 (3) motors, ib. 
 Arteries and capillaries, 45 
 
 blood entering and leaving, need of 
 balance between: results of upset- 
 ting, 13-15 
 
 Arterio-capillary fibrosis (Gull & Sutton), 
 nature, causes, and results of, 101 
 
 Arterioles, contractibility of, probable 
 effect of, 10 
 
 contraction and dilatation of causes, 
 45-6, 118 
 
 due to nicotine how caused, 167 
 
 transverse, suggested as possible, 45, 
 
 (fig.) 46 
 
 effect on, of digitalis, 146 
 
 of high tension in chronic interstitial 
 
 nephritis, 49 
 
 frog's dilatation in, caused by local 
 irritation, observed by Gunning & 
 Cohnheim, 46 
 
 importance of, pointed out by author 
 in thesis of 1866, 157 
 
 increased peripheral resistance in, dan- 
 gers from, 101 
 
 irritation of, local author's observa- 
 tions on effect of, 46 
 
 lumen of, lessening of, risks of, and 
 some causes, 101 
 
 muscular layer in, 45 
 
 nervous fibrils in, 45 
 
 small, and capillaries, diseases in which 
 chiefly affected, 117-8
 
 236 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Arterioles of submaxillary gland effect on 
 of irritation of chorda tympani -par- 
 allel, 115 
 
 Arterioles and veins, nerves of observa- 
 tions on, of Brunton & Schweigger- 
 Seidel results, 45 
 
 Arteriometer, Oliver's, use of, 83 
 
 Arterio-sclerosis diffuse, or arterio-capil- 
 lary fibrosis (Gull & Sutton), nature, 
 causes, and results of, 100-1 
 
 nodular, how induced, 101 
 
 Artificial circulation Ludwig's invention 
 and methods, 143, (fig.) 142 
 
 Ascites, removed by rest and massage, 
 
 . 139 
 - in venous engorgement how induced, 
 
 129 
 with flatulence, effect of, on the heart, 
 
 131 
 
 without flatulence, rare, 139 
 
 Ashanti campaign, value of beef-tea, etc., 
 as stimulants, shown in, by Parkes, 
 145, and note 
 
 Ashes, and waste products of tissues 
 parallel, 145 
 
 Asphyxia, local, in Raynaud's disease a 
 parallel, 117 
 
 Assimilation, improved, due to lessened 
 venous congestion caused by digi- 
 talis, 153-4 
 
 Asthma, cardiac, causes symotoms 
 treatment, 192-3 
 
 spasmodic, permanent dilatation of 
 right side of heart due to, 130 
 
 Atheroma, aortic, indicated by louder 
 second heart sound, 42 
 
 blocking by, of arteries, results of, sim- 
 ilar to those caused by cerebral hem- 
 orrhage, 205 
 
 of arteries, consequences, 205 
 
 of coronary artery consequences, 96 
 
 of right pulmonary artery conse- 
 quences of, 130 
 
 Atheromatous button, formation of, how 
 induced, 101, (fig.) 98 
 
 Atheromatous arteries of old people, 89, 
 115, 205, (fig.) 98 
 
 danger of, with high blood-pressure, 
 
 205 
 
 Atheromatous ulcers, in arterial walls in 
 old people provoking causes, 101 
 
 Atonic condition of embryonic heart, in- 
 duced by drugs retarding oxidation, 
 148 
 
 Atrophy, brown, causes of, 100 
 
 Atropine, effects of digitalis on frog's 
 heart, not overcome by, 147 
 
 paralysis of vagi caused by pulse-rate 
 after, 107 -probable action of the 
 drug, 107, note 
 
 Auricular beats in frog's heart, as af- 
 fected by stimulation, 34, (fig.) 35 
 
 Auricle, hypertrophy of, caused by 
 
 mitral obstruction, 127-8 
 
 mitral regurgitation, 127 
 
 right, dilatation and hypertrophy of 
 venous engorgement due to, 129 
 
 Auricles in frog's heart, 19 
 
 electric stimulation of, effects of 
 (Brunton and Cash), 34, (fig.) 35 
 
 Auriculo-ventricular orifices, muscular 
 fibers round, aid given by, to valves, 
 40, (figs.) 39 
 
 symptoms consequent on non-closure 
 
 or, 124 
 
 BACK, lying on, in bed, characteristic 
 nightmare from what it indicates, 
 1 80 
 
 Badenweiler, graduated walk at, for 
 Oertel's treatment, 202_ 
 
 Band instruments for estimating blood- 
 pressure, 71 et seq. 
 
 Barclay, Captain, feat of walking 1,000 
 miles in 1,000 hours, 3, 4 
 
 Barnard, see Hill & Barnard 
 
 Bartel's tubes for drainage of legs or 
 scrotum, 204 
 
 Basch, Von, sphygmomanometers of, 
 (figs.) 63-5, 67 
 
 Brunton's modification of, 65 
 
 fallacies in applying, 68 
 
 practically founder of blood-pressure 
 measurements in man, 645 
 
 Basch, Von, and A. Frohlich, experi- 
 ments of, on action of cocaine on 
 the heart -reflex mechanism in heart 
 itself, part cause of cardiac pulsa- 
 tions deduced from, 171 
 
 experiments of, bearing out author's 
 
 view on causes of tachycardia, 112 
 
 Baths, as employed in Nauheim treat- 
 ment, 198-9, (figs.) 197, 199 
 
 exercises, general massage, as external 
 means for increasing amplitude of 
 pulse, object of, 102 
 
 Bayer, O., experiments of, on first sound 
 of heart, 42 
 
 Beats, see heart-beats and pulse-beats 
 
 Bed, getting into work involved in, 132 
 
 position in, in regard to difficulty of 
 
 breathing, 133-4 
 in regard to palpitation, 179-80 
 
 protection of, in tapping, 204 
 
 rest in, prolonged, and absolute 
 best treatment in Graves's disease, 
 184 
 
 severe cases of palpitation, 183 
 
 rules regarding, 132 
 
 Bed-time, water to be sipped at, by the 
 flatulent, 182 
 
 Beds, special, for patients with severe 
 valvular disease, not sufficiently made 
 use of, 134 
 
 Beef-tea, cardiac stimulant, not nutrient, 
 
 145 
 Begbie, Dr. Warburton, and the " Pulvis 
 
 Mirabilis " for functional irritation 
 
 of the heart, 181 
 Belladonna, paralysis of vagus, caused 
 
 by pulse- rate after, 107 
 Belladonna plaster, over heart, as cardiac 
 
 sedative, 178 
 
 Bezold, Von, see Traube & Von Bezold 
 Bicarbonate of soda, in sleeplessness in 
 
 cardiac disease, 193 
 Bidder's ganglia, frog's heart, (figs.) 
 
 19. 27 
 
 Bigeminal pulse- -nature instance, 189 
 Bile acids in jaundice, action of, in 
 
 causing bradycardia, 187 
 elimination of, in toxin caused 
 
 brachycardia, aim of treatment 
 
 methods employed, 188 
 - substances having poisonous action ex- 
 creted in, reabsorbed by liver risks 
 
 from, in angina, how eliminated, 
 
 191-2 
 Bismuth, in treatment of bradycardia due 
 
 to reflex inhibition from stomach, 188 
 use of, in certain forms of tachycardia, 
 
 185 
 Bitartrate of potassium, addition of, to 
 
 compound jalap powder advantage 
 
 of, 203 
 Bladder, see Urinary bladder and Gall 
 
 bladder
 
 INDEX 
 
 237 
 
 Blake, demonstration by, of action of 
 digitalis, 146 
 
 Bleeding general, from the arm cases 
 in which beneficial, 175, 208 
 
 to slow very rapid pulse, 166 
 
 local, by leeches and cupping cases in 
 which beneficial action not under- 
 stood, 177 
 
 Blocking of the coronary arteries, conse- 
 quences of, 96, 100, 105-6 
 
 Blood, bulls', drinking warm as punish- 
 ment, 141, and note 
 
 circulation (q. t'.) of, how kept up by 
 the heart, 96-8, and figs. 
 
 diluted, as used in Ludwig's artificial 
 circulation experiments, 143 
 
 driven back into auricle and pulmo- 
 nary veins in mitral incompetence, 
 127 
 
 flow of (see also Circulation), during 
 syncope Hunter's observation on, 
 
 US 
 quality of, effect of alteration in, 100 
 
 effect of, on nutrition of heart, 94 
 
 quantity of, in the body, Ludwig cited 
 on, 5 
 
 effect of, on nutrition of heart, 94 
 
 from stomach, passage of, through liver 
 before reaching general circulation 
 why to be remembered in relation 
 to palpitation, (fig.) 179 
 well aerated, best cardiac nutrient, 143 
 Blood and lymph, circulation of, as af- 
 fected by 
 
 self-massage of heart and arteries, 6, 
 
 7. 8, 97-9, 102 
 
 as affected by digitalis, 153 
 
 as affected by massage, 138, and ex- 
 ercises, 202 
 
 Blood-pressure, see also arterial tension 
 abnormally low, as precursor of phthi- 
 sis case in point, 105 
 in animals, 60 
 backward (see also Regurgitation), 
 
 causes consequences, 128-9 
 in brain, in relation to position, 114 
 in the capillaries, measurement of, 84, 
 
 (jtg.) 62 
 
 - Cause of, on what dependent, 13-14 
 in dog's heart, slow fall after high 
 rise how caused Brunton, Meyer 
 and Tunnicliffe's experiments, 158, 
 (figs.) 157-8.. . 
 effect on, of injection of adrenaline, 
 
 160 
 
 enormous, caused by nicotine a par- 
 allel the reason, 167 
 in gouty kidney disease, difficulty in 
 
 reducing, 101 
 high, in advanced age, treatment of, 
 
 208-9. 
 in auricle, pulmonary veins, and aorta, 
 
 in mitral incompetence, 127 
 in auricle and ventricle in mitral ob- 
 struction, 127-8 
 
 extra work of the heart in overcom- 
 ing causes bradycardia caused 
 by, 1 88 
 
 risks of, in combination with athero- 
 
 matous arteries, 206-7 
 increase of, as found in diffuse arterio- 
 sclerosis, dangers from, 101 
 influence on, of splanchnic area, 16 
 
 of vagus nerve, 15, (fig.) 13 
 
 of yaso-motor center, 15, (fig.) 13 
 
 lowering of, caused by amyl nitrite 
 Gamgee's & Brunton's experiments 
 in full, 163 
 
 Blood-pressure in man, 60 
 
 measurement of, author's experiments 
 
 with different by finger pressure, 
 60, instruments deductions, 79 
 
 instruments for (see Cardiographs, 
 
 Haemodynamometer, Kymographs, 
 Manometers, Plethysmographs, 
 Sphygmographs, and Sphygmo- 
 manometer), described, 10-12, 
 55, 60 et seq., 90 
 standardization of, author's 
 
 method, 82 
 
 two classes of, (a) for com- 
 pressing single artery, 62 et 
 seq.; (b) for compression of 
 digit or limb, ib. 
 
 maximum, coincidence with, of stop- 
 page of urine secretion, in cases of 
 poisoning with digitalis and stro- 
 phanthus, observed by Brunton and 
 Power and Brunton and Pye, 155, 156 
 measurement of, in relation to pro- 
 longation of life, 205, 209 
 rapid raising of (however caused), an- 
 gina pectoris brought on by, (figs.) 
 190, 189 
 
 diet in connection with, 191-2 
 - regulation of, 13 
 rise of, in chronic interstitial nephritis, 
 
 risks from, to life, 49-51 
 due to digitalis, as affecting the kid- 
 neys, 51 
 
 cause of, according to Traube and 
 
 Von Bezold, 157, views of Brun- 
 ton - experiments of Brunton 
 and Meyer, 157-8, and of Brun- 
 ton and Tunnicliffe confirming, 
 158 
 
 risks of, 163, how overcome, 163 
 
 sources of mischief in, 14 
 in the veins, measurement of, 83-4 
 Blood-supply, of arm at bend source 
 of author's deduction from, as to 
 syncope, 115 
 to brain, insufficiency of as causing 
 
 syncope, 15, (fig.) 12, 114 
 to heart, importance of quality and 
 quantity of, and why, 94-5, 98-9 
 
 function of the coronary arteries 
 
 in, 95-6 
 
 enlarged by aortic regurgitation, more 
 
 required consequences if not de- 
 livered, 123 
 - large, required by brain when active, 
 
 114 
 quantity of, in heart how increased 
 
 by digitalis, 149 
 
 Blood-vessels, see also Arteries and Veins 
 action on, of adrenaline, 160 
 alone chiefly acted on by Erythro- 
 
 phlceum, 160 
 alteration in, the primary cause of 
 
 senile decay, 207 
 as well a_s heart acted on by digitalis, 
 
 1 60 
 Cerebral diseases of, in relation to 
 
 senile decay, 206 
 
 contraction of, by application of cold 
 relieving inflammation, 175 
 
 caused by digitalis, etc., drawbacks 
 
 incidental to, 162, overcome by 
 combination on the vaso-dilators, 
 163 
 
 injection of adrenaline, 160 
 
 rhythmical, discovered by Wharton, 
 
 Jones and others, 46 cause, 
 according to Luchsinger and
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Schiff observations on, by au- 
 thor and Fayrer, 27 
 
 Blood-vessels, contraction of, reflex of, 
 not present in reflex stoppage of 
 heart in imperfect anaesthesia au- 
 thor's view, 113-4 
 
 dilatation of, to relieve the heart, in 
 attacks of angina pectoris methods 
 of, 189, 191, 192 
 
 diseases of, frequency of deaths from, 
 in old people, 206 
 
 effect on, of heat and cold, 51-4, 106 
 
 local, as affecting local inflamma- 
 tion, 174-5 
 
 x of shock, 113 
 
 enfeeblement of, fourth stage of action 
 of digitalis, 160 
 
 excessive tension in, effect of, on the 
 vagus center, 15, (fig.) 13 
 
 exudation of fluid from, cause of 
 oedema, how arrested by digitalis, 153 
 
 nutrition of, effect on, of feebleness 
 of the heart, 100 
 
 obliteration of, caused by embolism 
 and thrombosis gangrene ensuing, 
 115-6 
 
 opposing action of nerves in, 45 
 
 ossification of, consequences, 1 16-7 
 
 power of, to contract or dilate from 
 alteration in contractile apart from 
 nervous element, 47 
 
 rupture of, in brain how caused, 205; 
 results. 206 
 
 risk of, from arterio-capillary fibro- 
 
 sis, 101 
 
 stimulation of, from within, 49-51 
 from without, 47, 49, (figs.) 47. 48 
 
 tonic effect on, of digitalis "roved by 
 author, 146, and note 
 
 vessels of the heart, effect on, of heat 
 and cold, 106-7 
 
 vessels of Thebesius, circulation some- 
 times maintained by, in default of 
 coronary arteries, 96 
 
 Blow on abdomen, twofold action shock 
 induced by Goltz's experiment on 
 frog showing, 1 13 
 
 Blue pill, powdered digitalis and pow- 
 dered squill pill of value of, modi- 
 fications of, 203 
 
 Bokenham, Mr. T. J., see Brunton and 
 Bokenham 
 
 Bowditch's (Dr. H. P.) apparatus for 
 experiment on frog's heart, (fig. and 
 note) 22 
 
 Bowels, as affected by compassion, 104 
 
 attention needed by, in relief of palpi- 
 tation why, 181 
 
 to be kept freely open in angina pec- 
 toris how why, 191 
 
 treatment of, in senile rise of pres- 
 sure, 208 
 
 Brachycardia, see also Bradycardia 
 
 Bradycardia chief characteristic, slow 
 pulse, 108, 186 
 
 causes, 108-9, 186-7. 
 
 when most frequent, 186-8 
 
 treatment of aims in, 188 
 
 pulse in, rate altered, rhythm regular 
 varieties of intermission in, 109-12 
 
 Brain, see also Medulla 
 
 arteries of, as affected by Raynaud's 
 disease, 117 
 
 blood-pressure in, as affected by posi- 
 tion, 115 
 
 blood-supply to, defective causes and 
 consequences, 123 
 
 Brain, large supply of blood required by, 
 
 when active, 114 
 
 condition of, in shock (clear), 114 
 in syncope (unconscious), 114 
 
 due to inadequate blood-supply, 15, 
 
 (fig-) 12 
 nerve cells in, destroyed by macrophags 
 
 in old age, 207 reason, 207 
 pressure on, various forms of causing 
 
 bradycardia, 109 
 rupture of vessel in, in old people, 
 
 cause of, 205 results, 205 
 stimulation of, by tobacco-smoking, 169 
 sudden anaemia of, probable cause of 
 
 syncope, 114, and see 15 
 Braune, cited on walls of veins when 
 
 stretched, 6 
 Bread, made with sugar and no salt, in 
 
 diet for mitral disease aim of, 204 
 Bread and tea fatal meal of why so, 
 
 140-1 
 Breath, shortness of (see also cardiac 
 
 dyspnoea), in mitral incompetence 
 
 treatment, 197 
 Breathing, difficulty of, in recumbency, 
 
 133 probable twofold origin of, 133 
 Bright's disease, advanced, double risk 
 
 in, of use of digitalis, 163 
 arterial distention due to tracings of 
 
 aortic pulse consequent on, 89-90, 
 
 (fig.) 88 
 
 bradycardia caused by, 109 
 Brodie, Sir Benjamin, cited on claudica- 
 
 tion before senile gangrene, 116, and 
 
 on angina pectoris, it>. 
 Bromide (s) of potassium, in treatment 
 
 of bradycardia due to reflex inhibi- 
 tion from stomach, 188 
 sodium and ammonium, separately or 
 
 mixed, in treatment of sleeplessness 
 
 in cardiac disease doses, 193 
 use of, in certain forms of tachycar- 
 dia, 185 
 useful in Graves's disease why how, 
 
 184 
 Bronchitis, chronic, strain due to effect 
 
 of, on right side of heart, 130 
 suffocative, wet cupping over the back 
 
 for, 177 
 Bronchitis and emphysema, results of, to 
 
 the heart, 202 
 Brucke's analogy for the pericardium, and 
 
 view of suction-action of ventricular 
 
 systole, 97, (fig.) 96 
 Bruits or murmur cardiac, characteristic 
 
 sounds of, how caused, 43 
 Brunton, Lauder 
 
 - advice and rules of, on rest for pa- 
 tients, 132 
 
 arrangement of for evacuation for pa- 
 tients kept recumbent, 132-3 
 diagrams by, of hypothetical nervous 
 
 apparatus, frog's heart, (fig. and 
 
 note) 20 
 to illustrate the experiments of Stan- 
 
 nius, 20 
 discovery by, of action of amyl nitrite, 
 
 165 
 double 
 
 ile action of digitalis and its tonic 
 effect on heart and vessels proved 
 by, 146, and note 
 experiments of, on 
 
 action of digitalis, 162-3 
 
 regurgitant murmur observed in 
 
 healthy heart of dog poisoned 
 with, 126 
 thirst produced by, 150, 152
 
 INDEX 
 
 239 
 
 Brunton, experiments of, on action of 
 blood-pressure in man as ascertained 
 by different instruments deductions, 
 79 
 
 effects of heat and cold on frog's 
 
 lungs, 56, (fig.) 54 
 
 own pulse, 130, 163 
 
 importance of arterioles pointed out by, 
 
 . J 57 
 
 instruments or apparatus devised or 
 adapted by, for various purposes, 
 
 ascertaining competence of mitral or 
 
 tricuspid valves, etc., (fig.) 38 
 
 combination of Ludwig's and Pick's 
 
 kymographs, (fig.) 59 
 combination of Potain's sphygmo- 
 manometer with other instruments, 
 (fig.) 80 
 
 modification and application of Riva- 
 
 Rocci's sphygmomanometer, (figs.) 
 79, 80 
 
 modification of Von Basch's sphyg- 
 momanometer, 63, further modifi- 
 cation, (fig.) 80 
 
 showing action of heat, cold, and poi- 
 sons on frog's heart, (fig.) 21 
 showing effect of heat, cold, and poi- 
 sons on frog's lungs, 56, (fig.) 54 
 standardizing an aneroid sphygmo- 
 manometer, 82, (fig.) 83 
 observations of, on 
 
 action of nitrite of amyl in angina 
 pectoris tension reducing power 
 proved by, 163 
 
 angio-neurotic oedema, 118 
 
 arterial tension and quick pulse in 
 relation to pain of angina pectoris, 
 121, and note 
 
 case of cardiac strain from indoor 
 
 dancing, 126 
 
 dilatation of arterioles sometimes 
 due to local irritation, 46 
 
 distensibility of liver, 17 
 
 effect of ammonia liniment over car- 
 diac region, 178 
 
 nicotine in raising blood-pressure, 
 
 167 
 
 smoking " pig-tail " tobacco, 170 
 
 fingers in Raynaud's disease, 117 
 
 his own sensation of chest-oppression 
 
 due to grief deductions, 121 
 influence of oxygen in relief of car- 
 diac asthma, 193 
 
 irregularity of pulse from digitalis 
 
 poisoning, no-n, (figs.) in 
 
 local irritation as sometimes causing 
 
 dilatation, and not contraction of 
 arteriole, 46 
 migraine own case, 119-20 
 
 mitral regurgitation from digitalis 
 
 poisoning in a dog, 126 
 as affected by exercise and excite- 
 ment, 126 
 
 one-sided case of angio-neurotic 
 
 oedema, 118 
 
 only ill-effects of amyl nitrite, or 
 
 nitro-glycerine, 191 
 peristaltic action of arteries, 5 
 pattern of belladonna plaster advised 
 
 by, 178 
 - schema of the circulation by, 57-9, (fig.) 
 
 use by, of amyl nitrite for first time 
 in angina pectoris, 175, 177 
 
 of bleeding, 175, 177 
 
 of calcium chloride and suprarenal 
 
 extract, in Graves's disease, 183-4 
 
 Brunton, Lauder, views of, on 
 albumen in urine, not contra-indica- 
 tion of use of opium or morphine, 
 195 
 
 arterial contraction as largely the 
 
 cause of high tension, 50 
 
 cause (s) of emptiness of arteries 
 
 after death, 5 
 
 intermittent pulse, 109-12 
 
 senile decay, 207 
 
 effects of imperfect anaesthesia, 113-4 
 
 on palpitation and its causes, 112 
 
 transverse as k well as longitudinal 
 
 contraction in muscular cells of 
 arterioles effect of, 45 
 
 treatment of bradycardia, 188, and 
 
 note 
 
 work of, on action of drugs on blood- 
 pressure when begun, 1 1 
 
 Brunton and Bokenham, experiments of, 
 on action of hydroxylamine, 166 
 
 Brunton and Cash, experiments , of, on 
 the action of strychnine on the heart 
 deductions, 161, and note 
 
 on nervous and muscular conduction 
 
 in the heart, 33, (figs.) 35 de- 
 ductions, 34 et seq., 36 
 
 on oxidation of protoplasm acceler- 
 ated by digitalis and caffeine, 148 
 
 Brunton and Fayrer, rediscovery by, of 
 independent pulsation of veins, 18, 
 44, 127-8, note 
 
 Brunton and Gamgee, experiments of, on 
 the former in nitrite of amyl, 163-4 
 
 Brunton and Gresswell, experiments of, 
 on the action of other nitrites un- 
 published, 1 66 
 
 Brunton and Meyer, experiments by, 
 proving importance of arterioles, 
 157-8, and figs. 156, 157 
 
 Brunton and Power, observations of, on 
 coincident arrest of secretion of 
 urine, in digitalis poisoning, with 
 maximum blood-pressure, 155-6, and 
 on condition of urine subsequently, 
 156 
 
 Brunton and Pye, observations of, on 
 coincident arrest of secretion of 
 urine in strophanthus poisoning, with 
 maximum blood-pressure, and on sub- 
 sequent condition of urine, 155-6 
 
 Brunton and Tait, experiments of, on 
 nitroglycerine, 165 
 
 Brunton and Tunnicliffe, experiments of, 
 on effect of digitalis during irrita- 
 tion of vagus, 158 
 
 Buisson, instrument of, for estimating 
 blood-pressure in a limb, 71 
 
 Bull's blood, warm draughts of, as pun- 
 ishment effect of, 141, and note 
 
 Burdon-Sanderson, Sir John, see Sander- 
 son, Sir John Burdon- 
 
 CABBAGE, to be avoided in palpitation 
 
 why, 181 
 
 Caffeine or trimethylxanthine, 
 action and use of, as cardiac tonic, 98, 
 
 145, 161-2, 203 
 
 in large and small doses, 145 
 
 on the heart of embryo and adult 
 
 Pickering on, 148 
 Caffeine and strychnine, in combination 
 
 with digitalis, benefits of, in certain 
 
 cases of aortic regurgitation, with 
 
 care, 196-7 
 Calcium chloride, used by author in 
 
 Graves's disease, 184
 
 240 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Calcium and its salts, diminished transu- 
 
 datioii effected by deduction as to 
 
 diet, 204 
 Calomel, in treatment of cardiac diseases, 
 
 203 
 Canadian hemp (Apocynum cannabinum), 
 
 medicinal uses of, 146 
 Cancer, reflex irritation from bradycar- 
 
 dia due to, 109, 187 
 Capillary (ies), contractile cells and no 
 
 muscular layer in, 45 
 contractility of, established by Strieker 
 
 and others, 46 
 dilatation, as affecting sphygmograms, 
 
 90, (figs.) 88, 89 
 in frog's foot, dilatation of by nitrite 
 
 of amyl (Richardson), 163 
 measurement of, pressure in, 84, (fig.) 
 
 62 
 pulmonary, effect on, of heat and cold, 
 
 Si, (fig-) 54 
 
 giving way of, cause and conse- 
 quence, 129 
 
 rhythm, the, 47 
 
 Capillaries and arteries, 45 
 
 blood entering and leaving, need of 
 balance between results of upset- 
 ting, 13-15 
 
 Capillaries and small ' arterioles, diseases 
 in which chiefly affected, 117-8 
 
 Capillaries and veins, 5 
 
 Cardiac action, effect on, 
 
 of chloral, 193 
 
 of fatty degeneration, 105 
 
 of nicotine, described and explained, 
 
 167-8 
 
 Cardiac asthma, causes symptoms treat- 
 ment, 1 92-3 
 
 Cardiac beat (see also Heart-beat), origi- 
 nating frequently in independent pul- 
 sations of vena cava and pulmonary 
 veins, 18, 44 
 
 Cardiac depressants, see infra, drugs 
 used in cardiac diseases 
 
 Cardiac diseases (see tinder name of each 
 form) 
 
 commonest, connected with faulty 
 valves, 40 
 
 deaths from statistics of, in old peo- 
 ple, 206 
 
 diet advised in, by Schott, 201 
 
 drugs, etc., used in, classes of, i/ii, 143 
 
 (i) cardiac nutrients, 141, 143 
 
 blood, well aerated, the best, 143 
 
 glucose, 145 
 
 saline solutions, 141, 145, (figs.) 
 144 _ 
 
 (2) cardiac tonics, 141 
 
 - action of, on embryonic heart -re- 
 lation of, to oxidation, 147-8 
 digitalis (q. v.) proved to be so by 
 
 author, 146, and note 
 and its congeners, 145-7 draw- 
 backs to action of, 162-3 how 
 removable, 163 
 nutritive effects of, 98 
 
 other than digitalis, difference be- 
 tween them and it, 160 
 
 (3) cardiac stimulants, 141, 145 
 
 adrenaline, 160 
 
 beef-tea and meat-extracts, 145 
 
 caffeine, 145, 161-2, 203 
 
 purin bodies, 145, 161-2 
 
 (4) cardiac depressants, 141 
 
 aconite, 171 
 
 chloral, 193 
 
 digitalis formerly regarded as, 146 
 
 (5) vascular contractors, 1 141 
 
 Cardiac diseases, drugs used in, continued 
 (6) vascular dilators, 141, 163-6 
 
 (7) others with indirect action on 
 
 heart, 143 
 
 forms of, most liable to sudden death, 
 196 
 
 sleeplessness frequent along with 
 characteristics aggravations treat- 
 ment, 193 et seq. 
 
 surgical treatment of, possible benefit 
 in some cases, 205, and note 
 
 treatment of (and see under name of 
 each form), 178 et seq. 
 
 surgical, 205, and note 
 
 ultimate impotence, some cases, 205 
 
 unenumerated forms of, 129-30 
 
 use of drugs in, 141 et seq. 
 
 use in, of purgatives, 203 
 
 mercurial purgatives, value of 
 
 author's view, 208 
 
 vicious circle in, 131 
 
 Cardiac dyspnoea, associated with mitral 
 obstruction and regurgitation, 128-9 
 
 Cardiac failure, causes and symptoms of, 
 126 
 
 common cause of death in old age, pos- 
 sibility of averting, by treatment of 
 arterial conditions, 209 
 
 danger of, in condition of high blood- 
 pressure combined with atheroma of 
 arteries, 205 
 
 threatened by rise of blood-pressure in 
 chronic interstitial nephritis, 49 
 
 Cardiac ganglia (see also Ganglion-cells), 
 importance of, 32, and note 
 
 Cardiac movements, slowing of, when 
 requisite two modes of effecting, 15, 
 and note, (fig.) 13 
 
 views on, of Gaskell and of Engel- 
 mann, 18-19 
 
 Cardiac murmurs, see also Sounds of 
 heart 
 
 carotid pulse to be used to fix time 
 of, when and why, 92 
 
 characteristic sounds of, to what due, 
 
 43 
 Cardiac muscle, effect on, of digitalis, 
 
 147-8 
 
 fatty degeneration of, see that head 
 local action on (probable '. of aconite, 
 
 171 
 
 nerve-like action of (Gaskell), 25 
 want of relationship between its power 
 and the resistance to be overcome by 
 it the probable cause of angina pec- 
 toris, 189 
 - weakness of, indicated by lessened first 
 
 heart sound, 42 
 
 Cardiac nerves, abundance of functions, 
 32 et seq. 
 
 intrinsic, effect on, of digitalis, 147 
 
 opposing action of, 45 
 
 probable importance of, 32, and note 
 
 Cardiac nutrients, see under cardiac dis- 
 eases, drugs, etc., used in, supra 
 Cardiac nutrition, how benefited by digi- 
 talis, 149 et seq. 
 
 by Nauheim treatment, 201 
 
 how effected, importance of, 94, and of 
 
 its own activity, 98 
 self-massage in relation to, 96-98 
 tonics (cardiac), how they aid, 98 
 Cardiac pain (see also angina pectoris), 
 caused by over-smoking, 170 
 
 self-caused, 121 
 
 Cardiac plexus, vagus branches in, pos- 
 sible effects of irritation of, in caus- 
 ing bradycardia, 186
 
 INDEX 
 
 2 4 1 
 
 Cardiac pulsations, reflex mechanism con- 
 cerned with, how deduced, 171 
 Cardiac region, local applications over, 
 pressure, heat, and cold, benefits 
 from, 177-8 
 
 Cardiac rhythm, disturbance of, 
 by mitral obstruction, 128 
 by mitral regurgitation, 12? 
 
 consequence in both cases, 128, 129 
 nervous system's share in, author's 
 view on, as possible cause of tachy- 
 cardia, I 12 
 
 Cardiac sedatives, local and external, 178 
 Cardiac stimulants, see under cardiac dis- 
 eases, drugs, etc., used in, supra 
 Cardiac strain, dilatation due to, 126 
 induced by excessive exercise symp- 
 toms treatment, 184 
 
 Cardiac tonics, see under cardiac dis- 
 eases, drugs, etc., used in, supra 
 Cardiac uneasiness, causes, 123 
 frequently felt without pain, 120-1 
 Cardiac walls, disease or degeneration of, 
 causing 
 
 (a) paroxysmal tachycardia, 108 
 
 (b) bradycardia, 108 
 Cardiac weakness, 
 
 after diphtheria, double cause, 105 
 
 bradycardia due to, 108, 186-7 
 
 causes - 
 
 fatty degeneration, 100, 105 
 nervous depression, 103, 104 
 
 dilatation of the heart due to, 126 
 
 effect on, of digitalis, former, 
 
 and present (true) view of, 
 146, and note 
 
 effect of, on nutrition of blood- 
 vessels, 1 02 
 sphygmograms of, 90, (figs.) 88, 89 
 
 Cardiograph and sphygmograph (q. v.), 
 Burdon-Sanderson's, for apex-beat, 
 84, (figs.) 86 
 
 Marey's, 86, investigations with, 86-90, 
 (figs.) 88, 89 
 
 Carminatives, alone, or with rhubarb, in 
 treatment of sleeplessness in cardiac 
 disease, 193 
 
 benefit from, in attacks of angina pec- 
 toris, 189 
 
 for relief of palpitation, due to flatu- 
 lence two prescriptions, 180 
 
 Carotid artery, alterations observed in, in 
 migraine, 119-20 
 
 pressure on, relieving migraine, why 
 
 of little use, 120 
 
 Carotid pulse, to be used to fix time of 
 cardiac murmurs when and why, 92 
 
 Casca or sassy-bark (Erythrophlocitm 
 guinense), medicinal uses of, 146, 160 
 
 Cascara, as aperient, in cases of senile 
 high pressure, 208 
 
 Cash, Dr. (see also Brunton and Cash), 
 instrument devised by, for experi- 
 ments on frog's heart, 34, and note 
 
 Cash and Dunstan, research by, on var- 
 ious nitrites results, 166 
 
 Cerebral abscess, bradycardia in conjunc- 
 tion with, 187 
 
 apoplexy in advanced years, cause of, 
 205 possible means of averting, 209 
 
 vessels, diseases of, in relation to se- 
 nile decay, 206, 207 
 
 Cervical cord, disease of, or injuries to, 
 bradycardia due to, 109, 188 
 
 Cetti, Mr., modification of Von Basch's 
 sphygmomanometer made by, to au- 
 thor's plan, 65 
 
 '7 
 
 Chair for sitting patients with severe val- 
 vular disease, 133-4 
 
 Chelius's instrument for estimating blood- 
 pressure, 78 
 
 Chest, oppression of, caused by irritation 
 of, or pressure on, the vagus cases 
 illustrating, 120-1, and note 
 
 Chewing tobacco, nicotine absorption in, 
 168 
 
 Chilblains, causes of, 117 
 
 Child-birth, slowness of pulse after, 186 
 
 Chloral, in treatment of sleeplessness in 
 cardiac disease dose action of, 193 
 
 Chloride-free food, milk and, 204 
 
 Chlorides, effect of, on transudation from 
 vessels into tissues disadvantageous 
 in dropsy, 204 
 
 Chloroform, effect of, on medusae (con- 
 tractile tissue), 30 
 
 fatty degeneration of the heart, found 
 after administration of, ipo 
 
 few whiffs of, to assist action of nar- 
 cotic in sleeplessness in cardiac dis- 
 ease, 195 
 
 - reinforcing of morphine in relief of 
 neuralgic element in angina attacks 
 - how given, 191 
 
 Chlorosis, bradycardia associated with, 186 
 
 Chocolate, dietetic action of, 162 
 
 Cholera toxins, effect of, on stomach, 155 
 
 Christmas rose (Helleborus niger), uses 
 of, 146 
 
 Chronic alcoholism, fatty degeneration of 
 heart, in, 100 
 
 bronchitis, strain due to effect of, on 
 right side of heart, 130 
 
 contraction of arterioles causes con- 
 sequences, 50 
 
 dyspepsia, bradycardia caused by how, 
 109 
 
 inflammation of the brain, bradycardia 
 caused by how, 109 
 
 interstitial nephritis, bradycardia in- 
 duced by how, 1 88 
 
 myocarditis, diet in, according to 
 Schott, 20 1 
 
 pharyngitis, and its concomitants due 
 to excessive smoking, 170 
 
 Cigar-smoking, why less harmful than 
 cigarette-smoking, 169 
 
 Cigarette-smoking, chief dangers of, 169 
 
 Cinders, and modified products of tissues 
 parallel, 143, 145 
 
 Circulation of the blood, see also entero- 
 hepatic circulation and pulmonary 
 circulation 
 
 accessory muscles of, 6 
 
 aid to, from the fasciae, 6, 131 
 
 artificial, Ludwig's methods for secur- 
 ing, 143, (fig.) 142 
 
 branches of science involved in treat- 
 ment of, i 
 
 in coronary arteries, see that head 
 
 disordered action of, on other or- 
 gans, and their reaction worsening it 
 how, 131 
 
 disturbance in, from sleeping on the 
 back how deduced, 180 
 
 effects on, of digitalis first stage, 159 
 
 of heat and cold, 51, (figs.) 50, 52, 
 
 53 
 
 of mercury, in albuminuria, 208 
 
 of over-smoking, 170-1 
 
 in fevers rapidity of reason for, 107 
 general, abnormally high pressure in 
 cause bradycardia caused by, 188
 
 242 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Circulation of the blood, general, more 
 affected by nitrites than pulmonary 
 circulation, 193 
 
 how maintained, 96, and figs., 113 
 
 imperfect, waste products due to elim- 
 ination of, 20 1 
 
 local modification of in inflammation 
 methods of, explained, 174-5 
 
 mammalian, experiments on, of Traube 
 in relation to digitalis), 146 
 
 pathology of, i 
 
 effect of altered quality of blood, 100 
 
 blocking of coronary arteries 
 
 consequences, 96, 100, 105 
 feebleness of the heart on nutri- 
 tion of blood-vessels, 102 
 
 exophthalmic goitre, 107 
 
 fatty degeneration, 105-6 
 
 nervous depression, 102, 104 
 
 pulse-rate, 106-7 
 
 pharmacology of, i 
 
 - quieted in nervous fluttering of heart 
 by very small doses of aconite, 172 
 
 schema of (author's), 57, 59, (fig.) 55 
 
 semeiology of, 2 
 
 therapeutics of, 2 et passim. 
 
 venous, how benefited by digitalis, 149- 
 50 
 
 how maintained, subsidiary agencies, 
 
 5-6 
 
 of blood and lymph, 9, 10; as affected 
 by self-massage of heart, 96-8, (figs.) 
 97, and of arteries, 99, 101, (figs.) 
 6, 99, 134 
 
 Circulatory nerves and muscles, increased 
 action of all, first stage of action of 
 digitalis, 159 
 
 Clark, Sir Andrew (the late), failure of 
 to diagnose aortic regurgitation how 
 caused, 195-6 
 
 Claudication, Brodie's description cited, 
 116 
 
 Coagulation in using kymographs, how 
 prevented, 59 
 
 Cocaine, action of, on the heart, experi- 
 ments in, of Von Basch and A. 
 Frolich, deductions from, as to exist- 
 ence in the heart of sensory mech- 
 anism, part cause of cardiac pulsa- 
 tion, 70 
 
 Coeliac, hepatic and splenic plexuses, ac- 
 tion of the pneumogastric nerve 
 through, on intestines, liver, and 
 kidneys, 104, note 
 
 Coffee, to be avoided in angina pectoris 
 _ why, 191 
 
 dietetic action, 162; medicinal action of 
 derivatives, 162 
 
 excessive use of, as cause of palpita- 
 tion to be cut off, or docked, 179 
 
 poison in, bradycardia caused by, 109, 
 187 
 
 strong, to relieve paroxysmal tachy- 
 cardia, 184 
 
 Cohnheim, see Gunning and Cohnheim 
 
 Colchicum, to show very rapid pulse, 166 
 
 Cold, see heat and cold 
 
 bandage covered with oil-silk, effects 
 of, how evidenced, 175 
 
 external, locally applied, sedative effect 
 of, on heart, 178 
 
 external and internal, in paroxysmal 
 tachycardia, uses of, 184 
 
 local application of effect of, on an 
 artery, 175, (fig.) 176 
 
 modification by, of local circulation in 
 inflammation when of use why, 
 '74-5 
 
 Cold-water compress, uses of, 175 
 
 Colds, see febrile colds 
 Colic, pain of how caused that of mi- 
 graine similar to, 120 
 
 Colin, acquainted with the independent 
 pulsation of veins (1862), 18 
 
 Collapse after slowing of pulse and ex- 
 cessive vomiting, caused by toxic 
 doses of digitalis, 155 
 
 Collidine in smoking-tobacco in its var- 
 ious forms, 1 68 
 
 Compassion as affecting the bowels, 104 
 
 Compensation, see failing compensation 
 
 Compensatory hypertrophy of the ven- 
 tricle, when occurring, 123 
 
 Compound jalap powder, in treatment of 
 cardiac diseases use dose, 203, how 
 enhanced in effect, 203 
 
 Compression, a s affecting passage of 
 stimuli in medusae, 29, and frog's 
 heart, 31 
 
 Conduction of stimuli (see also Trans- 
 mission) in the heart, nervous and 
 muscular, experiments of Brunton 
 and Cash, 32, 33, and note, (figs.) 
 35; deductions, 34, 35 
 
 Congestion of liver, etc., lessened by mas- 
 sage, 138 
 
 Contractile effects of digitalis on frog's 
 heart not overcome by atropine, 148 
 
 force of arteries, to what due, work 
 done by, 10 
 
 muscular walls and accompanying 
 nerves of arterioles, effect on, of dig- 
 italis, 147 
 
 power of the aorta, 44 
 
 blood-vessels, apart from influence of 
 
 nervous system, 46 
 heart, dependent on due nutrition, 94 
 
 tissue of medusae, action on, of poi- 
 sons (Romanes), 29, 30, (figs.) 28, 
 30, 31 
 
 Contractility of arterioles, probable effect 
 of, ip 
 
 of capillaries, established by Strieker 
 and others, 46 
 
 in protoplasm, under stimuli, (a) un- 
 differentiated, 24, 25; (b) differen- 
 tiated, 25 
 
 Contraction of abdominal vessels, caused 
 by severe pain, circulation main- 
 tained by, 113 
 
 of arterial walls with degeneration in 
 the old senile gangrene due to, 116 
 
 arteries, caused by local application of 
 cold, 175, (fig.) 176 
 
 peripheral, with central dilatation 
 
 cause of migraine in author's view, 
 1 20 
 
 temporary, in Raynaud's disease 
 
 consequences, ordinary, and in se- 
 vere cases, 117 
 
 tendency to rhythmical, in cases of 
 
 aortic regurgitation, 123 
 
 of arterioles, caused by digitalis, 147 
 
 by nicotine, method of, 167 
 
 chronic, of arterioles causes, conse- 
 quences, 50 
 
 of the heart, mode of, instruments for 
 ascertaining, 84 et seq. 
 
 of isolated frog's heart, effected by dig- 
 italis, 147-8 
 
 muscular, as affecting flow of blood, 6, 
 and lypmh, 9, (figs.) 7, 8 
 
 of muscular fibers, in (i) heart, (2) 
 arteries, in mammals, caused by dig- 
 italis how effected consequences, 
 149 et seq.
 
 INDEX 
 
 243 
 
 Contraction of abdominal vessels, rapid- 
 ity of, cause of loud first heart 
 sound how it acts, 43 
 reflex, of vessels, not present in reflex 
 stoppage of the heart in imperfect 
 anaesthesia author's view, 113-4 
 rhythmical, of arteries, tendency to, in 
 
 aortic regurgitation, 123 
 of vessels, caused by application of 
 cold effect of, on inflammation, 174 
 
 caused by digitalis, etc., drawbacks 
 
 incidental to, 162 overcome by 
 
 combination with vaso-dilators, 163 
 
 caused by injection of adrenaline, 
 
 160-1 
 
 of vessels, veins, etc. causes, 46; 
 views on, of Luchsinger and Schiff, 
 and of Brunton and Fayrer, 128, 
 note 
 
 Contraction and dilatation, nerves gov- 
 erning, 
 
 jn heart, 45 
 
 in vessels of the heart, ib. 
 Contraction-wave in medusa, 29-30 
 Convallaria majalis (lily of the valley), 
 
 uses of, 146 
 
 Convulsions, caused by nicotine, 167 
 Coronilla, action of not used medici- 
 nally, 146 
 
 Coronary arteries, blocking of conse- 
 quences, 96, 100, 105-6 
 
 circulation in, connection of, with 
 
 angina pectoris, 189 
 consequences of interference with, 
 
 105-6 
 inadequacy of, in cases of enlarged 
 
 heart consequences, 123 
 ossification of, in relation to angina 
 pectoris, and to claudication, ob- 
 servations on, of Jenner and 
 Parry, cited by Brodie, 116, 189 
 quality of blood, received by, 94 
 how they supply the heart, 95-6 
 
 right interference with circulation 
 
 in, causing cardiac asthma how, 
 192 
 
 terminal branches of, communicating 
 
 consequences of closing either, 
 artificially or by disease, 96, 105-6 
 Corsets, dangers of, during administra- 
 tion of anaesthetics, 141 
 in fainting, 141 
 in flatulence, 141 
 in palpitation, 141 
 Cough, due to over-smoking, 170 
 Cougning, process of effect of, on pul- 
 monary circulation, 130 
 Cranium (sec also Brain), pressure within, 
 variously caused bradycardia in- 
 duced by, 187-8 
 Cupping, dry, possible reasons for benefit 
 
 from, 177 
 wet, possible reasons for benefit from, 
 
 177 
 Curare, effect of, 
 
 on medusas, contractile tissue, 30 
 
 on motor nerves, 30 
 Curate, jilting by, of fiancee, physiolog- 
 ical results, 105 
 
 Czermak, Professor, experience of, as to 
 compression of the vagus producing 
 feeling of oppression, 121, and note 
 
 DANCING-PARTY, effect of, on Girl's heart 
 not produced in same case by 
 lawn-tennis, 126 
 
 Death, common causes of, in old age, 209 
 
 Death, emptiness after, of arteries, 2, 5 
 
 sudden, forms of cardiac disease most 
 
 liable to, 196 
 
 from drinking large quantities of al- 
 cohol at one time analogy, 113 
 from rupture of vessel in brain, 206 
 
 Debility, association with, of palpitation, 
 112; treatment, 183 
 
 dilatation of the heart due to, 126 
 
 general, cardiac-weakness due to, caus- 
 ing bradycardia, 108, 186-7 
 
 Decay, see Senile Decay 
 
 Degeneration in arterial walls, in the old, 
 89, 99, 100-1, 115-6, 205-7, (fig.) 98 
 
 Depressor nerves, functions of, 17 
 
 Diabetes, bradycardia associated with, 186 
 
 Diaphragm, movement by, of viscera, in 
 upright and in recumbent position, 
 133 
 
 upward pressure of, in flatulence from 
 disordered circulation -consequences, 
 131 
 
 Diastole, defined, 3 
 
 coincidence with, of radial pulse 
 
 when found, 92 
 
 more complete how secured by dig- 
 italis, 148 
 
 in dog's heart, effect on, of digitalis 
 deductions as to arterioles, 158 
 
 in frog's heart, reduplication caused by 
 stimulus, 34, (fig.) 35 
 
 Diastolic murmur over aorta, significance 
 of, I9S 
 
 Diastolic and systolic pressure in arteries, 
 how estimated, 71, (fig.) 70 relation 
 between, at highest and lowest, 82 
 
 Dicrotic wave, the, what it means, and 
 how caused, 92, (fig.) 90 
 
 Diet and massage, 141 et seq. 
 
 in angina pectoris, 191-2 
 
 chloride-free, in mitral disease, 204 
 
 for gouty sufferers from paroxysmal 
 tachycardia, 184 
 
 milk, useful in sleeplessness in cardiac 
 disease, 193, and see 204 
 
 in Nauheim treatment, 201 
 
 nitrogenous, injurious in cases of ar- 
 terial high tension (Haig), 207-8 
 
 in palpitation of the heart, 181-3 
 
 Digestibility of food essential in angina 
 pectoris, 191 
 
 Digestion, adjustment of, essential to 
 permanent relief of palpitation ^pre- 
 scription, 181-3 
 
 - Improved, due to absolute rest, and 
 
 massage, 138 
 due to digitalis, 153-4 
 
 in stomach, how long after meal before 
 completed, 181-2 
 
 Digestive ferments, use of, in certain 
 forms of tachycardia, 185 
 
 period, slightest exertion during and 
 immediately after, causing angina 
 pain, 189; precautions requisite, 192 
 
 Digit or limb, compression of, for meas- 
 uring human blood-pressure, 60, 61, 
 68 et seq. 
 
 Digitalin, action of, on embryonic and 
 on adult heart Pickering on, 147-8 
 
 Digitalis, 
 
 action, uses, etc., of, 
 
 in aortic regurgitation (uncomplica- 
 ted) alone, and in combination, 
 196-7 
 
 on arterioles, 1 57-8 
 
 stages in, 158-60, (figs.) 156, 157, 
 
 158
 
 244 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Digitalis, action, uses, etc., of, Brunton's 
 experiments on case of regurgitant 
 murmur in heart of dog poisoned 
 with, due to irregular action of mus- 
 culi papillares, 126 
 in cardiac asthma, 193 
 . as cardiac tonic, 146 nutritive ac- 
 tion of, 98 strengthening effect 
 first proved by author, 146 
 frog's heart, in situ, 148 excised, 
 147-8, 160 
 
 on kidneys, 150, 152, 160 
 
 in mammals, 149-50 
 
 on the medulla, 149, 155 
 
 in mitral incompetence aggravated 
 cases, 197 
 
 in oedema, 152-4 
 
 resume of, 147-8 
 - changed view regarding, 146 
 - different effects of small and large 
 
 doses of, on nervous system, 149 
 good effects of, enhanced by addition 
 
 of mercury, 203 
 
 organs affected by, 147, 150, 160 
 - physiological action and uses of, ex- 
 periments on double action of, and 
 tonic effect first proved by author, 
 146, and note, 150-2 
 
 poisons having similar effects to used 
 and unused vegetable, and from 
 toad's skin, 146-7 
 toxic action of, 154-6 
 in animals effect on apex -beat, 112 
 in man effect on pulse in, 1 10-1, 
 
 (figs.) in, 160 
 uses of, 150-2 
 
 Digitalis in combination with powdered 
 squill and blue pill value of, as pill, 
 in cardiac disease, 203 
 
 with " pulvis mirabilis " for feeble 
 
 heart, 181 
 
 Digitalis and its congeners, amplitude of 
 pulse, how increased by, 102 
 
 differences between, 160 
 
 drawbacks to the action of, 162-3 
 
 how removable, 163, 203 
 importance of, 146 
 Dilatation, see also Distension, Vascular 
 
 Dilatation and Vaso-dilators 
 of arterioles, due to local irritation, ob- 
 versation on, of Brunton, Gunning 
 and Cohnheim, 46 
 
 rdue to migraine, no 
 
 of capillaries, as affecting sphygmo- 
 
 grams, 90, (figs.) 88, 89 
 power of nitrite of amyl to produce, 
 
 163 
 
 central, with peripheral contraction, of 
 arteries of head and neck cause of 
 migraine, in author's view, 119-20 
 of heart causes and consequences, 123 
 
 lessened by digitalis, 150 
 
 right side of a cause of venous 
 
 stasis, 202 
 
 permanent, caused by chronic 
 
 bronchitis or spasmodic asthma, 
 13 
 nerves causing explanation, general, 
 
 and Brunton's views, 45-6 
 of ventricle from regurgitation with 
 
 stenosis, 122-3 
 
 of vessels aim of treatment in attacks 
 of angina pectoris methods for, 189, 
 191 
 by heat, 174, 175 how affecting 
 
 local inflammations, 174 
 Dilating nerves, 45 
 
 Dilating power of blood-vessels, apart 
 from influence of nervous system, 47 
 
 Dilute hydrocyanic acid, use of, in cer- 
 tain forms of tachycardia, 185 
 
 Dimethylxanthine, or theobromine use 
 of, 145 
 
 Diphtheria, weakness of the heart after 
 double cause of, 105, 107 brady- 
 cardia induced by, 108 
 
 Diphtheria antitoxin urticarial rashes 
 common after injection of, 118 
 
 Discomfort experienced in cases of val- 
 vular disease under absolute rest 
 treatment causes, 132-3 relieved 
 by massage, 134-8 
 
 without pain, frequently felt by the 
 heart, and other hollow muscular 
 organs, 120-1, and see 126 
 
 Diseases (see also Cardiac Diseases), and 
 conditions in which fatty degenera- 
 tion of the heart is found, 96, 99, 
 100, 105-6 
 
 Disgust, as affecting the stomach, 104 
 
 Distension, 
 
 abdominal, effect of, on heart and 
 lungs, 131, 138 
 
 from within, of hollow muscular or- 
 gans intense pain produced by, 120 
 
 of stomach, angina pain increased by 
 
 why, 189 
 
 causes, consequences, and treatment, 
 120, 131, 138, 139, 140, 141. 180, 
 189. 193 
 
 Diuretic action of digitalis, causes thirst 
 induced by, 150, 152-3 
 
 action of purins, 161-2 
 
 effect of venous congestion overcome 
 by digitalis, 150-1 
 
 Diuretics, synthetic compounds as how 
 employable, 162 
 
 Diuretin, nature and uses of, 162 
 
 Dog, blood-pressure in, 6p 
 
 circulation in, maintained by vessels 
 of Thebesius on obstruction of coro- 
 nary arteries, 96 
 
 heart of, effect on, of injection into 
 veins, of digitalis (Brunton and 
 Meyer), 158, (figs.) 156, 157-9 
 
 regurgitant murmur in healthy, due 
 
 to digitalis poisoning (Brunton), 
 126 
 
 vena cava in Ranvier's experiment 
 on, as to dropsy, 153 
 
 Dogiel, experiments of, on first sound of 
 heart, 41-2 
 
 views of, on importance of cardiac 
 ganglia, 32, note 
 
 Double nature of the heart, 44 
 
 Down Bros., Von Basch's latest sphyg- 
 momanometer obtainable from, 68, 
 note 
 
 Drainage tubes, Southey's or Bartel's, 
 for leg's or scrotum, 204 
 
 Drinking large quantities of alcohol at 
 one time causing speedy death 
 analogy, 113 
 
 at meals, to be given up and why, 
 
 in indigestion, 181-2 
 
 in palpitation, ib. 
 
 instances of danger from, 140, 141 
 
 Dropsy (see also Ascites, and (Edema), 
 chlorides disadvantageous in why, 
 204 
 
 Ranvier's experiment on deductions, 
 153 
 
 Drugs (see also under Names), causing 
 absorption, best suited to cases of
 
 INDEX 
 
 245 
 
 high blood-pressure due to gouty 
 kidney disease, 101 
 
 Drugs, use of, in cardiac diseases clas- 
 sification, 141 et seq. 
 
 used in treating palpitation, 172, 179- 
 80, 183 
 
 Drowsy sleeplessness, occurring with car- 
 diac disease how aggravated how 
 relieved, 193 et seq. 
 
 Du Bois Reymond's observations on the 
 arteries of his own head in migraine, 
 119 
 
 Dudgeon's sphygmograph, 93, (fig.) 94 
 
 Dunstan, Prof., see Cash and Dunstan 
 
 Duodenum, poisonous substances from 
 liver via bile reabsorption of, by 
 liver risks of, in angina how 
 dealt with, 191 
 
 Dyspepsia, chronic bradycardia induced 
 by, 109, 187 
 
 great rule in all kinds of no liquid 
 during meals why, 181, 182 
 
 treatment of, in certain forms of tachy- 
 cardia, 185 
 
 Dyspnoea, cardiac, associated with mitral 
 obstruction and regurgitation, 128-9 
 
 EATING, slowness in, requisite in cases 
 of palpitation why, 181, 182 
 
 Effusion (see also Transudation)- of 
 lymph with vascular dilatation ail- 
 ments due to, 117 
 
 arrest of, by digitalis, 153 
 
 Eggs, as chloride-free food how pre- 
 pared, 204 
 
 Eichhorst, fatty degeneration in fowl's 
 heart found by, on section of vagi, 
 105 
 
 Elasticity of arteries, etc., 4 
 
 as affected by age, 89, 116, 205, 
 
 (fig.) 88 
 
 as affected by Bright's disease, 90, 
 
 (fig.) 88 
 
 in relation to contractile force, to 
 
 Elderly people (see also Age, Old Age 
 and Senile), aortic obstruction in 
 how caused, 122; regurgitation not 
 necessarily resulting, 122-3 
 
 circulation of, as affected by grief, 
 
 worry and anxiety case in point, 
 104 
 
 Electrical stimulation of frog's heart, 
 effects of (Brunton and Cash), 33, 
 34, (figs.) 35 deductions, 34, 35 
 
 Elimination of waste products in cardiac 
 disease by purgatives, 203 
 
 Eliminatory function of kidneys, inter- 
 fered with by disordered circulation 
 consequence, 131 
 
 Elongation of muscle(?), 45, (fig.) 46 
 
 Embolism in coronary artery result, 96 
 
 obliteration of blood-vessels caused by 
 - gangrene resulting from, 115 
 
 Embryonic heart, action on, of cardiac 
 tonics, Pickering's observations on, 
 147-8 
 
 aortic orifice sometimes inflamed in 
 consequence, 122 
 
 structure of, modifications in as affect- 
 ing pulsation (Gaskell), 23-6 
 
 Emetics, attacks of paroxysmal tachycar- 
 dia sometimes cut short by those 
 suitable, 184-5 
 
 Emotional causes, angina pectoris brought 
 on by historic (fatal) case, 189 
 
 -^-nervous depression from, effect of, in 
 disease of the circulation, 104 
 
 Emotionalness in Graves's disease drugs 
 
 beneficial against, 184 
 Emotions, association of, with vagus, 104, 
 
 121 
 Emphysema, bradycardia caused by, 109, 
 
 188 
 conditions present in, affecting first 
 
 heart sound, 43 
 - strain due to effect of, on right side 
 
 of heart, 130, 202 
 Enemata of tobacco, former uses of 
 
 dangerous, 168 
 Enfeeblement of vessels, fourth stage of 
 
 action of digitalis, 160 
 Engelmann, views of, on movements of 
 
 the heart, 18 
 Engorged conditions of right side of 
 
 heart, high value in, of blood-letting, 
 
 177 
 
 Enteric fever, see Typhoid 
 Entero-hepatic circulation absorption, 
 
 excretion, and reabsorption in, by 
 
 liver of substances with poisonous 
 
 action risks from, in angina how 
 
 eliminated, 191-2, (fig.) 192 
 Epicardium, as affected by cocaine (Von 
 
 Basch and Frolich), 171 
 Epilepsy, bradycardia occurring in, 188 
 Epileptic symptoms, Raynaud's disease as- 
 sociated with, 117 
 Ergograph, Mosso's, 137, (fig.) 136 
 Erlanger's modification of Riva-Rocci's 
 
 sphygmomanometer, 81 
 Erythrophlaeum guinense, medicinal use 
 
 of, 146; principal action of, on the 
 
 vessels, 160 
 Ether, effect of, on medusae (contractile 
 
 tissue), 30 
 Ethyl, iodide of, use of, in cardiac 
 
 asthma, 193 
 Evacuation, arrangements for, in cases 
 
 where recumbency or fixed position 
 
 must be maintained, 132-3 
 Excitement, simple, as affecting the kid- 
 neys, 104 
 
 soothing effect in, of smoking, 169 
 Exercise, aid given by, to circulation, 6, 
 
 131 
 excessive, persistent rapid action of 
 
 heart after probable cause treat- 
 ment, 184 
 plus late hours and emotion, effect of 
 
 on girl's heart not produced by 
 
 lawn-tennis, 126 
 
 Exercises, in and after, Nauheim treat- 
 ment, 200 et scq. 
 in treatment of cardiac asthma why 
 
 beneficial, 193 
 Exertion, angina pectoris brought on by 
 
 why when most easily, 189 
 inability for, in old persons causes of, 
 
 (Brodie), 116 
 
 of getting into bed, sometimes fatal, 132 
 of going upstairs illustration of, 131-2 
 Extremities, as affected by Raynaud's 
 
 disease, 117 
 Exophthalmic goitre (see also Graves's 
 
 disease), effect of, on the circulation, 
 
 107 
 Eyeballs, protrusion of, not a necessary 
 
 condition of Graves's disease, 183-4 
 
 FACE, flushing of, caused by nitrite of 
 
 amyl (Guthrie), 163 
 tint of, in persons suffering with aortic 
 
 regurgitation, 123
 
 246 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Fagge and Stevenson, experiments of, on 
 frog's heart (in relation to action of 
 digitalis), 146 
 
 Failing compensation in enlarged heart, 
 demanding more blood conse- 
 quences, 123 
 
 Fainting, corset-loosening in reason for, 
 141 
 
 tendency to (or actual), cause of, 123 
 - stooping position to avert, 115 
 
 Fainting persons, best position for re- 
 storing, 115 
 
 Faintness in warm rooms, how induced, 
 107 
 
 Faivre and Albert, experiments of, on 
 blood-pressure in man, 60, and note 
 
 False vocal cords, raised pressure due to 
 closure of expiration made against 
 in coughing, 130, and note 
 
 Fasciae, action of, in relation to circula- 
 tion, 6, 131 
 
 hard, inflammation under, why re- 
 lieved by cold, 174-5 
 
 Fasting condition, angina pain less easily 
 brought on by exertion in, than at 
 and after digestive period, 189 
 
 Fatal shock, see under Shock 
 
 Fatty or fibroid degeneration of cardiac 
 walls, 
 
 bradycardia apt to occur with, 
 
 108, 186-7 
 cardiac asthma caused by, 192 
 
 causes and consequences of, 96, 
 
 99, 100, 105-6, 130, 192, 207 
 diseases and conditions in which 
 found, ib. 
 
 in rabbits on section of vagi 
 
 (Wassilieff), 105, 108, 109, 
 184, 186-7 
 
 risk, double, in cases of, in use 
 of digitalis, 163 
 
 Fayrer, Sir J., and Lauder Brunton, re- 
 discovery by, of independent pulsa- 
 tion of veins, 18, 44, 127, 128, and 
 note 
 
 Febrile colds, aconite useful in, in small 
 doses, 171 
 
 Feet, immersion of, in hot water, increas- 
 ing pulsation in femoral artery, 175 
 
 and ankles, oedema of, first sign of 
 venous engorgement why how re- 
 lievable, 129 
 
 Femoral artery, pulsation of, increased, 
 by immersion of feet in hot water, 
 i7S 
 
 Fermentation in stomach arrest of, es- 
 sential to permanent relief of palpi- 
 tation, 180 
 how set up how prevented, 181 
 
 Fevers, 
 
 cardiac weakness from how indicated, 
 42 
 
 infective heart weakness from, caus- 
 ing bradycardia, 108 
 
 toxins of, degenerative effect of, on 
 
 the heart, 100 
 
 rapidity of circulation in, to what due, 
 107 
 
 Fibers, described by Purkinje, 35, note 
 
 Fibroid degeneration of cardiac walls, 
 see Fatty or Fibroid Degeneration _ 
 
 thickening as cause of high tension in 
 chronic interstitial nephritis, 49 
 
 Fibrils, nervous, in arterioles, 45 
 
 Fibrosis, arterio-capillary (Gull and Sut- 
 ton), nature, causes, and results of, 
 101-2 
 
 Fick's instrument for estimating blood- 
 pressure by limb compression, 71, 
 (fig.) 68 
 
 spring manometer (kymograph), 59, 
 (fits.) 58, 59 
 
 Finger-bending exercises in treatment of 
 venous stasis, described wide effect 
 of, 202 
 
 Fingers, aspect of, in Raynaud's disease, 
 117 
 
 Flatulence, aggravation of anginal pain, 
 189 
 
 aggravation by, of drowsy sleeplessness 
 of cardiac disease how relieved, 193 
 
 due to disordered circulation alone, or 
 with ascites, effect of, on the heart, 
 131. 139. 180 
 
 precautions against in diet and regi- 
 men, 181-3 
 
 prescriptions in relief of, 180-1 
 
 - lessened by abdominal massage, 138 
 
 jessened by action of digitalis, 154 
 
 - in stomach and intestine, in venous en- 
 gorgement, 129 
 
 Flatulence-causing foods to be avoided 
 in angina pectoris, 191; in palpita- 
 tion, 181-2 
 
 Flow of blood, see Blood and Circulation 
 
 lymph, see Lymph 
 
 Fluid (see also Drinking and Liquids), 
 allowance of, in various cardiac com- 
 plaints, by Dr. Schott, 201 
 
 Fluid, drain of, from blood by kidneys in 
 cardiac disease, how supplied and 
 how arrested by digitalis, 149, 150, 
 151, 152, 160 
 
 Fluid-pad instruments for measuring hu- 
 man blood-pressure, 62 et seq. 
 
 Fluttering, nervous, of the heart, quiet- 
 ing effect on, of very small doses of 
 aconite, 172 
 
 Fatal life (see also Embryonic heart), 
 aortic orifice sometimes inflamed 
 during consequence, 122 
 
 Fomentation, warm, over heart, stimulat- 
 ing effect of, 178 
 
 Food, see also Diet 
 
 - chloride-free, in dropsy, 204 
 
 flatulence-causing, to be avoided in an- 
 gina pectoris, 191; in palpitation, 
 181-2 
 
 proteids in, reduction of, advised, in 
 senile rise of pressure, 208 
 
 Force-storing function of arteries, 4 
 
 Fowls' hearts, fatty degeneration in, on 
 section of vagi (Eichhorst), 105 
 
 France, attention paid in, to transudation 
 as affected by chlorides, 204 
 
 Frangois's instrument for measuring 
 blood-pressure in a limb, 71 
 
 Frey, Von, see Ludwig and Von Frey 
 
 Frog, 
 
 arterioles of, dilatation in, caused by 
 local irritation, observed by Gunning 
 and Cohnheim, 46 
 
 foot of, capillaries in, dilatation of, 
 caused by amyl nitrite (Richard- 
 son), 163 
 
 heart of, 
 
 apex, dilatation of, by pressure from 
 within result, 28, 128 
 
 effect on, of aconite, 171 
 
 of compression, as to passage of 
 
 stimuli, 31 
 
 of digitalis, 146-7, 149-50 
 
 effect on, of heat, cold, 51, (figs.) 
 
 52-3, and poisons, author's instru-
 
 INDEX 
 
 247 
 
 ment for showing, (fig. and note) 
 
 21 
 
 Frog, heart of, effect on continued 
 
 of nicotine, 167-8 
 
 of shock Goltz's experiment show- 
 ing, 113 
 
 electrical stimulation of, experiments 
 
 of Brunton and Cash, 33-4, (figs.) 
 35 deductions, 34, 35 
 of auricle, 34, (fig.) 35 
 of venous sinus, 34, (fig. 
 
 5, 34, (fig-) 36 
 , .(figs.) 35 
 
 of ventricle, 34, 
 
 -excised, or isolated, 
 
 effect on, of digitalis, 146-7, 160 
 
 -Ludwig's mode of keeping alive and 
 in action, 143, (fig.) 142 
 
 -pulsatile pouches on, during contrac- 
 tion with digitalis, 148 
 
 -experiments on, and deductions, 
 
 author's, instrument used in, (fig.) 
 
 -Bowditch's, 
 (fig.) 22 
 
 instrument used in, 
 
 Gaskell's, 23, 25, 26, 31 
 
 Fagge and Stevenson's (as bearing 
 
 on digitalis), 146 
 Stannius's author's diagrams to 
 
 illustrate, 20 
 Williams' s, (fig.) 23 
 
 movements of, investigation of, 22 
 
 (i) nervous control theory (Stan- 
 
 nius), 21, (diags.) 20 
 
 . (2) muscular contraction theory 
 
 (Gaskell), 23-26 
 
 parts composing, and nerves hypo- 
 
 thetically controlling, 19, 21 (figs.) 
 19, 20 
 
 stoppage of, due to digitalis period 
 
 at which occurring, 147-8, 160 
 
 due to shock consequences, Goltz's 
 
 experiments, 113 
 
 vessels of, as affected by heat and 
 
 cold, 51, (figs.) 52-3 
 lymph hearts in, 9 
 
 Frog's lungs, capillaries of, effect on, of 
 heat and cold author's experiments 
 on deductions, 51, (fig.) 54 
 Frohlich, A., and Von Basch, experiments 
 of, on action of cocaine on the heart 
 deductions from, as to reflex mech- 
 anism in heart, 171 
 
 Functional irritation of the heart, " pul- 
 vis mirabilis " for prescription 
 comments, 181 
 
 mitral incompetence causes and conse- 
 quences, 124-5 
 
 GAERTNER'S aneroid manometer, portable 
 form of his tonometer, 76, (fig.) 75 
 
 tonometer, 73-6, (figs.) 74, 75, 76 
 
 Gall-bladder, discomfort without pain, fre- 
 quently felt by, 120 
 
 effect on, of (a) pressure from without, 
 120; (b) distension from within, ib. 
 
 Gall-duct, discomfort without pain, fre- 
 quently felt by, 1 20 
 
 effect on, of (a) pressure from without, 
 120; (b) distension from within, ib. 
 
 Gangee, Dr. A., discoverer of power of 
 nitrite of amyl to lower blood-pres- 
 sureexperiments of, on author's 
 pulse, 163 
 
 Ganglia, 
 
 in frog's heart, 19, 20, 28, 29, 32, note 
 
 in medusa, function of, 29; effect on, 
 of nicotine, 30-1 
 
 peripheral, dilatation connected with, 46 
 
 Ganglion cells (see also Cardiac Ganglia), 
 
 share of, in heart's action, 24, 25, 
 
 (fig-) 25 
 Gangrene, caused by severe cases of Ray- 
 
 naud s disease, 117 
 senile, cause of, and main preliminary 
 
 symptom (Brodie), 116 
 Gaskell, experiments of, on heart-beat, 
 
 22, III 
 
 views of, on heart of embryo devel- 
 opment of, 25 
 
 on heart movements in cold-blooded 
 
 vertebrates, 23 
 
 on heart movements in mammals, 18, 
 
 19 
 
 Gaskell's clamp, effect of applying to 
 frog's heart, 31, 37, note 
 
 Gastric irritation, early indication of 
 toxic action of digitalis, 153-4 
 
 mucous membrane, treatment to soothe 
 in bradycardia due to reflex inhibi- 
 tion from stomach, 188 
 
 ulcer, reflex irritation from bradycar- 
 dia due to, 109, 187 
 
 General debility, see Debility 
 
 General paralysis of the insane, brain- 
 pressure due to, causing bradycardia, 
 109 
 
 General paresis, bradycardia occurring in, 
 1 88 
 
 Getting into bed, exertion involved in 
 sometimes fatal in valvular disease, 
 132 
 
 Giddiness, causes of, 123, 170 
 
 Girl, death of, from being jilted physio- 
 logical causes, 105 
 
 heart of, affected by evening dancing, 
 not by open-air lawn-tennis, 126 
 
 Gland, see Submaxillary 
 
 Glendinning, see Williams, C. J. B., and 
 others 
 
 Glomeruli, rise of blood-pressure in, due 
 to digitalis ^-consequences, 1 5 1-2 
 
 Glucose as cardiac nutrient, Locke's ex- 
 periments, 145 
 
 Gluteus maximus muscle, function of, 7 
 Going upstairs work involved in dem- 
 onstration of, 131-2 
 
 Goitre, see Exophthalmic Goitre 
 Goltz's experiment on frog, showing two- 
 fold action of blow on abdomen, 113 
 Gouty kidney disease, drugs causing ab- 
 sorption, why useful in, 101 
 Gouty sufferers from paroxysmal tachy- 
 cardia, diet for, 185 
 
 Graves's disease (see also exophthalmic 
 
 Goitre), palpitation in, and other 
 
 symptoms best treatment for, 183-4 
 
 Gresswell, Dr. (the late), of Melbourne, 
 
 see Brunton and Gresswell 
 Grief, as causing sighing, 104 
 effect of, on the circulation, 104 
 Grief or anxiety (q. v.), sense of oppres- 
 sion of the chest from to what due 
 author's observation on himself, 
 
 121 
 
 Guarana, dietetic use of, 162 
 
 Gull and Sutton, originators of the term 
 
 " arterio-capillary fibrosis," 101 
 Gunning and Cohnheim, experiments of, 
 
 on dilation of arterioles (frog's) by 
 
 local irritation, 46 
 Guthrie, discoverer of face-flushing power 
 
 of nitrite of amyl, 163 
 
 ILEMODYNAMOMETER, Marey's how used, 
 (fig.) 55
 
 248 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Haemoglobinuria, Raynaud's disease fre- 
 quently associated with, 117 
 
 Haemoptysis, occurring most frequently in 
 mitral obstruction, 128 
 
 profuse, dicrotic wave in case of, 92, 
 
 (fig-) 9i 
 
 Haemorrhage, cerebral, bradycardia occur- 
 ring with, 187 
 
 Haig, Dr., cited, on injurious effects of 
 too nitrogenous a diet, 207-8 
 
 Hale, see Williams and others 
 
 Hales, Rev. Stephen, inventor of the 
 manometer, 10 
 
 Haller, acquainted with the independent 
 pulsation of veins (1757), 18 
 
 Hallion and Comte's plethysmograph, 
 
 (fig-) 73 
 
 Hand, effect on, of plunging into hot 
 water, 51 
 
 Hand-pressure over heart, as cardiac sed- 
 ative, 178 
 
 Harvey, and the case of Lord Mont- 
 gomery proof that external pressure 
 is not felt by the heart, 120 
 
 cited on the regulating power of the 
 arteries, 4 
 
 discovery by, of the circulation, 2 
 
 Haustus scoparii compositus of St. Bar- 
 tholomew's Hospital, as eliminatory 
 agent composition, 203 
 
 Hay, Dr. Matthew, action of sodium ni- 
 trite first described by, 166 
 
 Head, lowering between hands or knees, 
 to avert fainting why effectual, 115 
 
 Head and neck, arteries of, as affected 
 in migraine author's view, 119 
 
 Headache, induced by nitroglycerine, 165 
 
 severe, relieved by application of 
 leeches over mastoid process, 177 
 
 sole ill-effect from overdoses of nitro- 
 glycerine or amyl nitrite, 191 
 
 Healthy man, thirst produced in, by diu- 
 retic action of digitalis, 150, 153 
 
 people, character of sphygmograms of, 
 90, (figs.) 88 
 
 Heart, see also Apex, Cardiac Dilatation, 
 Dog's Heart, Embryonic, Fatty De- 
 generation, Frog's Heart, Hypertro- 
 phy, Palpitations, Valvular Disease, 
 etc. 
 
 action on, of aconite, 171, 172, 174 
 
 of adrenaline, 160 
 
 of caffeine, etc., 145. 161-2 
 
 of cocaine experiments of Von 
 
 Basch and Frohlich, and . deduc- 
 tions, 171 
 
 of digitalis, 145 et seq. 
 
 of nicotine, 167 
 
 of strophanthus, 160 
 
 of strychnine, 161 
 
 adult and embryonic, effect on, of digi- 
 talin, Pickering on, 148 
 
 auxiliary, place of, supplied by mas- 
 sage, in treatment of venous stasis, 
 202 
 
 base of, aortic regurgitant murmur at 
 times not heard at, 195 
 
 beating of, from emotion, stilling of, 
 by hand-pressure over, 178 
 
 benefits to, of gentle exercises, in car- 
 diac asthma how produced, 193 
 
 and blood-pressure (q. v.), 9 
 
 chief function of, 3 
 
 comparison between, and a medusa 
 experiments of Romanes. 26 et seq., 
 fig*- 
 
 Heart, contraction in, of muscular fibers, 
 caused by digitalis how effected 
 results as to pulse and beats, 149 
 
 contraction of, effect on, of massage 
 and exercises, 202, (fig.) 198 
 
 mode of, instruments for ascertain- 
 ing, 84 et seq. 
 
 of parts of sequence of source of 
 
 (Gaskell), 25 
 
 under normal conditions due solely 
 
 to muscular tissue? or no? 26 
 
 dependence of, on due pulmonary aera- 
 tion (Powell), 94 
 
 dilatation of, causes and consequence, 
 123 
 
 discomfort without pain frequently felt 
 by illustrations, 120 
 
 diseases of, see Cardiac Diseases 
 
 double nature of, 44 
 
 effect on, of flatulence, 139 
 
 of heat and cold, 51, (fig.) 52-3 
 
 of over-smoking, 167-8 
 
 emotions affecting, 104, 178 
 
 enlarged, inadequate supply of blood 
 to causes and consequences, 123 
 
 how relieved by treatment, in attacks 
 of angina pectoris, 189, 191 
 
 increased work of, in overcomine ab- 
 normally high pressure causes 
 bradycardia induced by, 188 
 
 inhibitory apparatus in, double effect 
 on, of nicotine effect on pulse-rate, 
 167 
 
 excessive action of, one probable 
 
 cause of slow pulse, 186, 187 how 
 excited, 186 
 
 insensitiveness of, to pressure from 
 without historic instance, 120 
 
 isolated, effect on, of cold, 107 
 
 mammalian, compared with that of 
 frog, 19 
 
 isolated, Locke's experiments on 
 
 deduction as to value of glucose, 
 
 145 
 muscular tissue of, as affected, 
 
 by blocking of coronary arteries, 
 
 96, 100, 105-^6 
 
 by toxins of diseases, too, 106 
 
 nervous action and muscular fiber of, 
 stages of action of digitalis as affect- 
 ing, 159-60 
 
 fluttering of, quieting effect on, of 
 
 very small doses of aconite, 172 
 nervous and muscular conduction in 
 experiments of Brunton and Cash, 
 33i 34. and note, (figs.) 35 deduc- 
 tions, 34, 36 
 
 power of, to originate intense pain, 120 
 rapid action of, characteristic of tachy- 
 cardia cause treatment, 184 
 refractory period of, 4 
 
 investigations on, of Sanderson and 
 
 Page, 33 
 
 pointed out by Marey, 33 
 
 rhythmical power of, effect on, of Kro- 
 necker and Schmey's experiment, 
 37-8 
 
 right side of conditions of, causing 
 cardiac asthma, 192-3 
 
 dilatation of, one cause of venous 
 
 stasis, 202 
 
 permanent, induced by chronic 
 
 bronchitis and spasmodic asthma 
 why, 130 
 
 engorged conditions of blood-letting 
 
 in benefits from, 177
 
 INDEX 
 
 249 
 
 Heart, right side of extra tension in, in 
 
 recumbency, effect of (Hill), 133 
 self-massage of, in relation to nutri- 
 tion, 96-8 
 
 possibly inducible by inhalation of 
 
 oxygen, 203 
 
 sensitiveness of, 120-1 
 sleep of, duration of, 3, 9 
 
 maintenance of circulation during, 4 
 
 - sounds of, 41 et seq. 
 stimuli in, transmission of, 32, and note 
 stoppage of, caused by, 
 blow on abdomen, 113 
 
 drinking large quantities of alcohol 
 
 at a draught, 113 
 
 imperfect anaesthesia, 1 13 
 
 severe pain, 1 13 
 
 reflex, in imperfect anaesthesia unac- 
 companied by reflex contraction of 
 vessels author's view, 1 13-4 
 
 risk of causing, by digitalis, in 
 
 Bright's disease, 163 
 
 strengthening of, aim of all treatment 
 for bradycardia drugs best adapted 
 for, 1 88 
 
 suction exerted by, during ventricular 
 constriction, assistance of, to circu- 
 lation, 5 
 
 tilting up of, by flatulence cause and 
 consequence, 131, 140 
 
 by stomach-distension anginal pain 
 
 increased by, 189 
 valves of (q. v.), 39-40 
 various helping agencies in work of, 
 
 5 et seq. 
 
 walls of, see Cardiac Walls 
 weak or feeble, see also Cardiac Weak- 
 ness 
 
 stimulation of, local, external, by 
 
 various applications of heat, or 
 heat-producers, 178 
 
 work of, increase of, by digitalis, etc., 
 in raising blood-pressure risks from, 
 i62-3 : how overcome, 163 
 Heart and vessels, both acted on by digi- 
 talis, 1 60 
 
 combined effect on, of rest and mas- 
 sage, 137-8 
 
 coordination between, how maintain- 
 ed, 13-15 
 
 Heart-beats, see also Pulse-beats 
 acceleration of proportionate exhaus- 
 tion, 3-4 
 in frog's heart, as affected by aconite, 
 
 . T 72 . 
 
 origination of, 17, 44 
 -quickened by caffeine why, 162 
 Heat, see also Hot Water 
 - modification by, of local circulation in 
 inflammation when of use why, 
 174-5 
 
 vascular dilatation caused by, 107 
 Heat and cold, effect of, 
 
 an circulation, 51, (figs.) 50, 52-3 
 n frog's lungs author's experi- 
 ments, 56, (fig.) 54 
 an muscular tissue, 50, (figs.) 
 on pulmonary capillaries, 51, (fig.) 
 54 
 
 on pulse-rate, 106-7 
 
 Heat, cold, and poisons, action of, on 
 frog's heart, author's instrument for 
 showing, (fig. and note) 21 
 Helleborus niger (Christmas rose), uses 
 
 of, 146 
 Hemiplegia, see also Paralysis 
 
 Hemiplegia, resulting from rupture of 
 blood-vessel in brain, 205 
 
 transient, Raynaud's disease associated 
 with, 117 
 
 Hepatic plexus, see Coeliac, Hepatic, and 
 Splenic Plexus 
 
 Hepatitis, relief in, alone or with peri- 
 hepatitis, from application of leeches 
 over liver, 177 
 
 Herisson's sphygmomanometer, (fig.) 62, 
 63, 68 
 
 High pressure, see Blood-pressure, high 
 
 High tension, see arterial tension, high 
 
 Hill, Leonard, cited on cause of intoler- 
 ance of recumbent position by suf- 
 ferers from severe valvular disease, 
 133 
 
 instrument of, for measuring blood- 
 pressure, 68-9 
 
 Hill and Barnard's modification of the 
 Riva-Rocci sphygmomanometer, 78 
 
 His, William, neuro-muscular bundle de- 
 scribed by, 35, note 
 
 Hoarseness due to over-smoking, 170 
 
 Hollow muscular organs discomfort with- 
 out pain, frequently felt by, 120 
 
 distension from within productive 
 
 of intense pain, 120 
 
 pressure on from without not pro- 
 ductive of pain in, 120 
 
 Hope as affecting the heart, 104 
 
 Horse, blood-pressure in, 60 
 
 Hot food, not sleep-producing why, 175 
 
 Hot water, immersion of feet in, causing 
 increased pulsation of femoral artery, 
 175 
 
 with lemon, how and when to be 
 
 drunk by the flatulent, 182 
 
 Hot-water bap, action of weak heart stim- 
 ulated by, 178 
 
 Huka, or narghileh, smoking^ with inha- 
 lation in, 169 
 
 Hunter, John, death of, from angina pec- 
 toris brought on by anger, 189 
 
 observation by, on flow of blood dur- 
 ing syncope, 115 
 
 Hurtle, manometer of, 60 
 
 Hyaline tissue, deposit of, in coats of ar- 
 terial walls, due to kidney disease 
 effects, 101 
 
 Hyderabad chloroform commission, find- 
 ing of, on risks of giving anaes- 
 thetics without removal of corsets, 
 141, and note 
 
 Hydrocyanic acid, dilute, use of, in cer- 
 tain forms of tachycardia, 185 
 
 Hydroxylamine, a yaso-dilator, 166 
 
 Hyoscyamus, addition of, to purgative 
 pill aim of, 203 
 
 Hypertrophy of auricle, caused by mitral 
 obstruction, 127-8, and by mitral re- 
 gurgitation, 127 
 
 of heart, inadequacy to, of normal cor- 
 . onary artery, 96 
 
 palpitation rare in why, 112 
 
 some causes, and their effects, 101-2 
 
 of ventricle, in aortic regurgitation, to 
 what due compensatory advantages 
 of, 122 
 
 Hypnotics, useful in treatment of sleep- 
 lessness in cardiac disease, 193 
 
 Hypoxanthine and other purin bodies 
 use of, 145 
 
 ICE-BAG over heart, sedative effect of, 178 
 Iced water, drinking of, in paroxysmal 
 tachycardia, benefit of, 184
 
 250 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Incisions for oedema of legs methods, 
 
 204 
 
 Incompetence, see Aortic, Mitral, Valvular 
 Indigestion, see Dyspepsia 
 India-rubber ice-bag over heart, sedative 
 
 effect of, 178 
 tube coiled to form flat plate, with cold 
 
 water passed continuously through 
 
 it, as local cardiac sedative, 178 
 Infective diseases, 
 
 cardiac weakness from bradycardia 
 
 occurring in, 186-7 
 
 fatty degeneration of the heart fre- 
 quent in, 100, 105 
 Inflammation of aortic orifice during 
 
 fatal life consequences, 122 
 chronic, of the brain, bradycardia due 
 
 to, 109 
 
 local, use of aconite in, 172, 174 
 of mitral valves, narrowing of orifice 
 
 from -consequences, 127 
 modification of local circulation in 
 
 methods explained, 174-5 
 Inhalation of oxygen in cardiac asthma 
 
 remarkable benefit of, 193 
 - in venous stasis, action possibly in 
 
 part mechanical, 203 
 
 in smoking, with huka and with cig- 
 arette objections to, 169 
 Inhibitory apparatus in the heart double 
 
 action on, of nicotine effect on 
 
 pulse-rate, 167 
 
 in medulla or in heart, excessive ac- 
 tion of, probably cause of extreme 
 slowness of pulse, 186, 187 how 
 excited in the latter, 186 
 center of vagus, as affected by digitalis, 
 
 149 
 
 neurons still susceptible to local stimu- 
 lation after large dose of nicotine, 
 
 though inhibitory ganglia of heart be 
 
 paralyzed by drug, 168 
 Injuries of cervical cord, bradycardia 
 
 occurring in, 188 
 of medulla, bradycardia occurring in, 
 
 1 88 
 Insensitiveness of the heart to pressure 
 
 from without historic instance, 120 
 Instruments for measuring blood-pressure 
 
 in man, two classes of, descriptions 
 
 and uses of, 60 et seq. 
 standardization of, 82 
 used in tapping, 204 
 Intercostal space, second, second heart 
 
 sound best heard at, 42 
 Intermittent fever, pulse in, tracing of, 
 
 (.fig.) 89 
 pulse (.see also Irregularity of Pulse), 
 
 varieties of, no 
 causes uncertain author's own view, 
 
 112 
 
 Intestines (.see also Stomach and Intes- 
 tines), congestion of diminished by 
 rest and massage, 138 
 
 discomfort without pain frequently felt 
 by, 1 20 
 
 effect on, of (a) pressure from without, 
 120; (b) distension from within, ib. 
 
 flatulence in, in venous engorgement, 
 129 
 
 reflex stimulation of medullary vagus 
 center from bradycardia caused by, 
 187 
 
 Involuntary muscular fiber, in relation to 
 endurance of strain, 128 
 
 Iodide of ethyl, use of, in cardiac asthma, 
 193 
 
 Iodide of potassium, useful in cardiac 
 asthma, 193 
 
 Iodides, suitability of, in cases of high 
 blood-pressure due to gouty kidney 
 disease, 102 
 in senile high tension, 208 
 
 Iron, strychnine with, in treatment of 
 bradycardia, 188 
 
 Irregular action of musculi papillares, 
 regurgitation due to author's obser- 
 vations on, and others', 126 
 
 Irregularity of the heart (or pulse), com- 
 mon in over-smoking, 170 
 
 forms of causes persistence treat- 
 ment instances, 1 88-9 
 
 more frequent in mitral than in any 
 
 other form of cardiac disease 
 why, 126, 128 
 
 Irregularity and quickening of pulse 
 caused by large doses of aconite 
 why, 171 
 
 Irritability, see also Nervous Irritability 
 
 of arteries in cases of aortic regurgita- 
 tion, 123 
 
 of patients in absolute rest treatment 
 - causes, 134 relieved by massage, 
 137 
 
 of throat, due to over-smoking, 170 
 
 Irritants, inside stomach or intestine 
 effect of, similar to that of blow on 
 stomach, 113 
 
 Irritation, see also Stimulation 
 
 of arterioles local effects, as observed 
 by author, 46 
 
 of chorda tympani, effect of, on arte- 
 rioles of submaxillary gland and on 
 condition of gland a parallel, 115 
 
 of heart functional an excellent rem- 
 edy for prescription comments, 180 
 
 of nerves, severe pain from effects of, 
 on heart, 113 
 
 reflex, from stomach, as cause of par- 
 oxysmal tachycardia treatment, 185 
 
 from various organs and sources, 
 
 bradycardia due to, 109 
 
 of stomach, local, induced by toxic ac- 
 tion of digitalis parallels, 155 
 
 of tongue, due to over-smoking, 170 
 
 of the vagus (mechanical ,>, or pressure 
 on, feeling of oppression of chest 
 caused by- author's observations on 
 himself Czermak's personal expe- 
 rience, 121, and note 
 prolonged systole (dog's heart), se- 
 cured by, 1 58 
 
 of vagus center in medulla bradycar- 
 dia caused by how, 109 
 
 caused by excessive tension re- 
 sults, 15 
 
 caused by toxic action of digitalis, 
 
 iSS 
 
 of vagus roots, reaction of, on speed 
 of heart, 15, {fig.) 14 
 
 of vagus trunks, branches, or ends, in 
 cardiac plexus effect of, on speed 
 of heart, 15, 186, (fig.) 14 
 
 JACQUET'S sphygmograph, 93 
 
 Jalap powder, compound, 203 addition 
 to, of bitartrate of potassium advan- 
 tage of, 203 
 
 Janeway's and others' modifications of 
 the Riva-Rocci sphygmomanometer, 
 81 
 
 Jaundice, bradycardia in how caused, 
 109, 187
 
 INDEX 
 
 251 
 
 Jenner, Dr., observations of, cited by 
 Brodie on cause of angina pectoris, 
 116 
 
 Jones, Wharton, rhythmical contractions 
 in veins observed by, 46, 123 cause 
 of, according to Luchsinger and 
 Schiff observations of Brunton and 
 Fayrer referred to, 128, note 
 
 Joy, as affecting the heart, 104 
 
 KENT, STANLEY, and His, neuro-muscular 
 bundle described by, 35, note 
 
 Kidney action, aided by compound jalap 
 powder, 203 
 
 Kidney disease, deposit in, of hyaline tis- 
 sue in coats of arterial walls effects, 
 101 
 
 gouty, tension due to the above de- 
 posit, drugs best suited to relieve, 
 
 IOI-2 
 
 Kidneys (see also Renal Vessels), action 
 
 on, of macrophags, in old age 
 
 (Metchnikoff), 206-7 
 arteries of, as affected by Raynaud's 
 
 disease, 117 
 effect on, of disordered circulation, 131 
 
 of massage during rest, 138 
 
 of mere excitement, 104 
 
 of venous congestion overcome by 
 
 digitalis, 150-1 
 
 of venous engorgement, 129 
 
 secreting cells in, action of caffeine, 
 
 etc., 150, 161-2 
 
 of digitalis, 150, 152-3, 160 
 
 of purin bodies, 161-2 
 Kocher, opinion of, as to drugs used in 
 
 Gravea's disease, 184, and note 
 Kola, dietetic use of, 162 
 Kronecker and Marey, discovery by, of 
 
 refractory period of the heart, 33 
 Kronecker and Schmey, experiment of, 
 
 on puncturing point in septum of 
 
 ventricles effect of deduction from, 
 
 37 
 
 Kymographs, see also manometers, etc. 
 Brunton's combination of Ludwig's and 
 
 Pick's, (fig.) 59 
 how used, 60 
 Ludwig's, ID, (figs.) ii, 56 
 oscillations in, of mercury, 57, (fig.) 
 
 57, how avoided, 59 
 
 LACTOSE in milk, apparent diuretic action 
 of, 204 
 
 Lads, growing, harmfulness to, of to- 
 bacco-smoking, 169 
 
 Laulanie's sphygmograph, digital, 94, 
 (fig.) 95 
 
 Lead-poisoning, bradycardia caused by, 
 109, 187 
 
 Leech, Prof, (the late), lectures of, on 
 drugs of the nitrous group, referred 
 to, 166 
 
 Leeches, application of cases in which 
 beneficial, 177 
 
 Left side, lying on, causing palpitation, 
 1 1 2-3, 179 
 
 Legs, muscles of, accessory to circula- 
 tion, 6, 7, 131 
 
 tapping of, for oedema method, 204 
 
 raising of, effect on tension in vena 
 cava, 129, 133 
 
 Life, prolongation of, by attention to ar- 
 terial conditions, 205, 208-9 
 
 Ligaturing coronary arteries results, 96 
 
 Lily of the Valley (Convallaria mafalis), 
 uses of, 146 
 
 Limbs, circulation in, feeble in absolute 
 rest treatment consequences, 134 
 relieved by massage, 135-8 
 
 Limbs, reduction in size in, when brain 
 is active Mosso's demonstration, 114 
 
 Lime in saline solution, benefit of, in 
 artificial circulation Ringer's discov- 
 ery, 143 
 
 Liquid with meals to be avoided by the 
 flatulent why, 180, 181 
 
 Liver, attention needed by, in relief of 
 palpitation why, 181 
 
 application over, of leeches, in relief of 
 hepatitis, 177 
 
 congestion of, diminished by rest and 
 massage, 138 
 
 distension or swelling of, due to in- 
 creased blood-pressure, 17 
 
 due to venous congestion overcome 
 
 by digitalis, 154 
 
 excised, secretion by, of bile experi- 
 ments on, of Ludwig and Schmule- 
 witsch, 1 6 
 
 functions of, interfered with by disor- 
 dered circulation injurious reaction 
 on the heart, 131 
 
 poisonous substances absorbed by, ex- 
 cretion of, and reabsorption risks 
 from, in angina pectoris how elimi- 
 nated, 191 
 
 reflex irritation from, bradycardia due 
 to, 109 
 
 Liver and portal system, as affected by 
 venous engorgement, 129 
 
 Llangammarch, graduated walks at, for 
 Oertel's treatment, 202 
 
 Local action of nicotine on arterioles, 167 
 
 applications over cardiac region, of 
 pressure, heat, and cold, benefits 
 from, 177-8 
 
 of cold, effect of, on an artery, 175, 
 
 (fig.) 176 
 
 asphyxia, occurring in Raynaud's dis- 
 ease, 117 
 
 bleeding by leeches, and cupping cases 
 in which beneficial action not un- 
 derstood, 177 
 
 inflammations with general febrile dis- 
 turbance, use of aconite in, 172, 174 
 
 modification of the circulation, in in- 
 flammation, various methods of, ex- 
 plained, 174-5 
 
 paralysis resulting from rupture of 
 blood-vessel in brain, 206 
 
 Locke's experiments on glucose as cardiac 
 nutrient, 145 
 
 Luchsinger and Schiff, observations of, 
 on cause of rhythmical contraction in 
 veins, 128, note 
 
 Ludwig, Prof., demonstration by, on 
 cause of mitral incompetence, 125 
 
 experiments of, on cause of first sound 
 of heart, 42 
 
 invention of, for keeping isolated or- 
 gans alive by artificial circulation 
 methods and means, 143, (fig.) 142 
 
 kymograph of, 10, (fig.) 11; 56, 59 
 
 Ludwig's manometer, self-registering, 10, 
 (fig.) ii 
 
 method due to, of measuring pressure 
 in capillaries, 84 
 
 cited on possibilities of bleeding an 
 
 animal into its own veins, 16 
 vaso-motor system and its functions, 
 4, 5 
 
 Ludwig and Von Prey's modification of 
 Marey's sphygmograph, 92
 
 252 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Ludwig and Schmulewitsch, experiment 
 of, on secretion of bile by excised 
 liver, 1 6 
 
 Lumen of arterioles lessening of, causes 
 of, and risks from, 101 
 
 lessened, not necessarily indicated by 
 loud systolic murmurs, 122 
 
 Lungs of frog, effect on, of heat and 
 cold author's experiments, 51, (fig.) 
 54 
 
 Lungs, functions of, interfered with, by 
 disordered circulation -injurious re- 
 action on the heart, 131 
 
 mechanical interference with, of ab- 
 dominal distension, 131, 138 
 
 pressure in point at which stoppage 
 of pulse occurs Valsalva's experi- 
 ment author's tests on himself, 130 
 
 Lymphatics, the, course of, 96, 99 
 
 Lymph, circulation of, or flow of, 7, 8, 
 in and round heart, 96-8, (figs.) 97, 
 101, 102 
 
 effusion of, with local vascular dilata- 
 tion ailments due to, 117 
 arrest of, by digitalis, 153 
 
 Lymph hearts, in frogs, 9 
 
 MACLAGAN, PROF. DOUGLAS, experiments 
 of author in his laboratory under 
 Gamgee, 163 
 
 Macrophags, normal and destructive ac- 
 tion of, in body, explained in rela- 
 tion to senile decay, 206-7 
 
 Magendie's view on cause of first sound 
 of heart, 41 
 
 Malarial affection, possible slowing of 
 pulse due to, 186 
 
 Malnutrition, due to grief case illustrat- 
 ing, 105 
 
 Mammalian circulation, experiments of 
 Traube (in relation to digitalis), 146 
 
 heart, see Heart, Mammalian 
 
 Mammals, action in, of digitalis, 146, 147, 
 149 
 
 double action on, of nicotine, 167 
 
 effects on, of aconite, (a) small doses, 
 171; (b) large doses, 171 
 
 and frogs, effects on, of nicotine, 167-8 
 
 " Man (or men) as old as his arteries," 
 truth of saying, 99, 205 
 
 - blood-pressure in, 60 
 
 normal pulse-rate in, 107 
 
 Mania, bradycardia due to, 109, 188 
 
 Manometers, see also kymographs, sphyg- 
 momanometers, etc. 
 
 standardization of, 82 
 
 aneroid, of Gaertner, portable form of 
 his tonometer, 76, (fig.) 75 
 
 Burdon-Sanderson's, recording the first 
 in England, n 
 
 Pick's spring pattern, 60 how used, 
 (figs.) 58, 59 
 
 Hales's the first, 10 
 
 Hurtle's, 60 
 
 Ludwig's registering, 10, (fig.) u 
 
 Marey's metallic, 81; how used, (figs.) 
 57, 70; improved, (fig.) 81 
 
 combination of, with Mosso's plethys- 
 
 mograph, (fig.) 70 
 
 mercurial see Hales's, Ludwig's, and 
 Poiseuille's 
 
 Poiseuille's, 10 
 
 Roy's, 60 
 
 Marey and Kronecker, discovery by, of 
 refractory period of the heart, 33 
 
 Marey's apparatus for measuring blood- 
 pressure in digit, 71, (fig.) 71 
 
 Marey's cardiograph, 86, and fig. 
 
 investigations with, 86-90, (figs.) 87, 
 
 88 
 
 haemodynamometer, how used, (fig.) 55 
 
 metallic manometer, 81; how used, 
 (figs.) 57, 70: improved, (fig.) 8:; 
 combination of, with Mosso's plethys- 
 mograph, (fig.) 70 
 
 sphygmographs, 13 original, modified 
 by Ludwig and Von Prey transmit- 
 ting, 92, (figs.) 92-3 
 
 tambours, 64, (figs.) 58, 86, 93 
 
 Martin's modification of the Riva-Rocci 
 sphygmomanometer, 78-9 
 
 Massage, see also Arterial Massage and 
 Self-massage 
 
 effects of, on the pulse, 102, 202 
 
 high value of, in treatment of venous 
 stasis by complete rest, 202 
 
 use of, in cases of severe valvular dis- 
 ease during absolute rest treatment 
 high value of, 134 et seq. method 
 and results, 137-9 
 
 Massage and diet, 141 et seq. 
 
 Massage and rest, 134 et seq. 
 
 Mastication, thorough, and slow, neces- 
 sary in cases of palpitation, 181, 182 
 
 Mastoid process, application over, of 
 leeches to relieve headache, 177 
 
 Meals, precautions as to nature of, es- 
 sential in angina pectoris, 191 
 
 precautions essential after, in the same, 
 192 
 
 small and frequent, in treatment of 
 palpitation, 181-2 
 
 Meat, boiled, saltless, but otherwise fla- 
 vored, in diet for mitral disease 
 aim of, 204 
 
 butcher's, given sparingly in chronic 
 myocarditis (Schott), 201 
 
 Meat-extracts, cardiac stimulants, not nu- 
 trients, 145 
 
 of the purin type to be avoided in 
 angina pectoris why, 191 
 
 Medicine, poisons used in, in heart com- 
 plaints, 146-7 
 
 Medulla oblongata (see also vagus center 
 in), action on, of digitalis, 149, 155 
 
 (chief center of nervous system), in 
 
 relation to the blood-pressure, 15 
 
 disease of, or injuries to, bradycardia 
 
 due to, 109, 1 88 
 
 inhibitory apparatus in, or in heart, 
 
 excessive action of, probable cause 
 of slow pulse, 186, 187 
 
 Medusae, comparison between, and the 
 heart experiments of Romanes, 26 
 et seq. 
 
 compression as affecting passage of 
 stimuli in, 30 
 
 contractile tissue, (fig.) 28 action on, 
 of poisons, 30-1 
 
 described, 26-7 
 
 effect on, of constant and successive 
 stimuli, 29 
 
 of poisons (Romanes), 29-31 
 
 rhythmic movements of, dependent on 
 ganglia as affected by nicotine, 30 
 
 Megrim, see Migraine 
 
 Meibomius, acquainted with the indepen- 
 dent pulsation of veins (1668), 18, 
 note 
 
 Melancholia, bradycardia due to, 109, 188 
 
 Meningitis, relief in, by application of 
 
 leeches over mastoid process, 177 
 simple or tubercular, bradycardia oc- 
 curring in, 187-8
 
 INDEX 253 
 
 Mental activity, effect on, of tobacco- Mitral regurgitation, organic causes and 
 
 smoking, 169 consequences, 127 
 
 - effect produced by, on volume of - slight, frequency of treatment, 197 
 
 arm, 114 - with venous stasis, etc., 202 treat- 
 
 deterioration, a result of cerebral hem- ment, 197 
 
 orrhage, 206-7 - systolic murmur indicative of con- 
 
 Mercurial manometers, see Hales' s, Lud- ditions presenting, 126 
 
 wig's, and Poiseuille's Mitral stenosis, a cause of venous stasis, 
 
 purgatives, occasional use of, beneficial 202 
 
 in cases of senile rise of pressure, surgical treatment of its possibili- 
 
 208 ties, 205, and note 
 
 in treatment of angina pectoris Mitral valves, incompetence of, see Mitral 
 
 how reinforced reason for, 192 Incompetence, supra 
 
 in treatment of toxin-caused brady- less liable to incompetency than the 
 
 cardia, 188 tricuspid, 44 
 
 Mercurials, action of, not properly under- Montgomery, Lord, case of proof that 
 
 stood effects of, valuable, 203 external pressure is not felt by the 
 
 Mercury, danger of, in albuminuria, ex- heart, 120 
 
 aggerated action of, on circulation, Morphine, remedy par excellence for 
 
 208 sleeplessness in cardiac disease how 
 
 in kymographs, oscillations of, 57, (fig.) given, 194 doses danger in with- 
 
 57; how avoided, 59 holding, 195 
 
 Metchnikoff, cited on senile decay as due sometimes necessary to relieve neural- 
 
 . to destructive action of macrophags, gic element in severe anginal at- 
 
 206-7 tacks how given, 191 
 
 Methylxanthine and other purin bodies Mosso's ergograph, (fig.) 136 
 
 use of, 145 experiment on size of arm, as condi- 
 
 Meyer, A. B., see Brunton and Meyer tioned by hard thinking, 114 
 
 Microphags, function of, 206-7 plethysmograph, 69; combination of, 
 
 Micturition, risk of fatal syncope during, with Marey's metallic manometer, 
 
 in cases of overuse of digitalis why, (fig-) 70 
 
 163 sphygmomanometer, 71, 72 
 
 Mid-sternum, pain of angina felt at, 189 Motor function of arteries, 4 
 
 Migraine, megrim, or sick headache, Mouth, administration of opium by, why 
 
 pain in, causes of modes of relief, 119 less advantageous than by rectum, 
 
 - nature of similar to that of colic, I94~5 
 
 119-20 Movements of the heart, views on, of 
 
 pathology of, views of Du Bois Rey- Gaskell, and of Engelmann, 18 
 
 mond, and others author's personal Miiller, Johannes, acquainted with the 
 
 observations and conclusions, 119-20 independent pulsation of veins 
 
 Milk components in, why valuable in (1835), 18, note 
 
 mitral disease, 204 Murder (constructive) by a curate jilt- 
 
 - given freely in chronic myocarditis ing followed by grief, consequent 
 
 (Schott), 201 malnutrition, phthisis and death, 105 
 
 Milk diet and chloride-free food cases Murrell, Dr., anticipation by, of author 
 
 for which adapted, 204 in use of nitroglycerine why, 165 
 
 - useful in sleeplessness in cardiac dis- Muscle, elongation of(?), 45, (fig.) 46 
 
 ease, 193 in differentiated protoplasm, as affected 
 
 Milk and potatoes fatal meal of why by stimuli, 25 
 
 so, 140 Muscle(s), see also Cardiac Muscles, 
 
 Mitral disease, allowance of fluid in, in Fasciae, and tinder Names 
 
 Nauheim treatment, 201 accessory, of circulation, 7, 131 
 
 - milk diet and chloride-free food in, circulation in, effect on, of absolute 
 
 with rest, massage, and digitalis rest treatment, 135 influence on, of 
 
 and blue pill improvement often rest and massage, 138 
 
 rapid, 204 Muscular area, influence of, on blood- 
 
 - treatment of mitral incompetence pressure, 1 5 
 
 from aortic regurgitation as for, contraction as affecting flow of blood, 
 
 196-7 6, and of lymph, 9, (figs.) 8, 9 
 
 Mitral incompetence, engorged condition induced by small doses of caffeine, 
 
 of right side of heart due to, re- 145 
 
 lieved by blood-letting, 177 Muscular fiber (s) of arteries and heart, 
 
 - how induced by regurgitation con- contraction of, caused by digitalis- 
 
 sequences treatment, 196-7 how effected, 149-50 
 
 when 
 
 
 
 (functional) causes and conse- - o f heart, action of purin bodies prob- 
 
 quences, 126 a b] v more especially on, and on 
 
 shortness of breath in treatment, secreting cells in kidneys, 161-2 
 
 ,.... . J 97 - as affected by stages of action of 
 
 Mitral obstruction causes and conse- digitalis, 157, 159 
 
 quences, 127-8 - slight action on, of strychnine, 161 
 
 with regurgitation cardiac dyspnoea involuntary, less capable of, with- 
 
 associated with, 128-9 standing constant than intermit- 
 
 Mitral regurgitation causes and conse- tent strain proof seen in mitral 
 
 quences, 126, 201 obstruction, 128
 
 254 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Muscular fibers round auriculo-ventricu- 
 lar orifice, action of. in normal con- 
 traction of the ventricle (Ludwig), 
 125 aid given by, to the valves, 40, 
 (figs.) 39 
 
 Muscular inadequacy in walking, see 
 Claudication 
 
 Movements acting as subsidiary heart, 9 
 
 poisoning, caused by large doses of 
 caffeine, 145 
 
 spasm, high blood-pressure partly due 
 to, in cases of gouty kidney disease, 
 101 
 
 Muscular tissue (generally), effect on, of 
 heat and 'cold, 50, (figs.) 
 
 (structure) of the heart, as affected 
 
 by the toxins of diseases, 100, 105 
 effect on, of digitalis, 147 
 
 effect on, of gradual blocking of 
 
 coronary arteries. 100 
 fatty or fibrous degeneration of 
 (q. r.), 100 effects of, on car- 
 diac action, 105 
 
 Muscular walls (contractile) of arterioles, 
 effect on, of digitalis, 147 
 
 Muscular and nervous conduction in the 
 heart experiments of Brunton and 
 Cash, 33 et seq., 112, (figs.) 35 
 
 Musculi papillares, irregular action of, 
 causing mitral regurgitation, 126 
 
 Mustard poultice, redness from, imme- 
 diate and after probable causes, 47, 
 (fig.) 48 
 
 Mustard-and-water emetic to cut short 
 attack of paroxysmal tachycardia, 
 184-5 
 
 Myocarditis, chronic, diet in, according 
 to Dr. Schott, 201 
 
 Myxoedema, effects of protracted treat- 
 ment of, with thyroid gland extract 
 (by mouth), 107 
 
 NAPOLEON the Great, slow pulse of, 108, 
 186 
 
 Narcotics, to relieve neuralgic element in 
 angina attacks, 191 
 
 to relieve sleeplessness in cardiac dis- 
 ease, 193-5 
 
 Nauheim treatment cases to which ap- 
 plicable methods, 199 et seq., (figs.) 
 199 
 
 Nausea, early symptom of toxic action of 
 digitalis, 155 
 
 Neck and head, arteries of, as affected in 
 migraine author's view, 119 
 
 Nephritis, acute, wet cupping over kid- 
 neys for, 177 
 
 chronic interstitial, bradycardia in- 
 duced by how, 1 88 
 
 rise of blood-pressure in, risks 
 
 from, 49-51 
 
 Nerium oleander, action of not used 
 medicinally, 146 
 
 Nerve centers, reflex excitability of, in- 
 creased by strychnine, 161 
 
 Nerve-fiber in differentiated protoplasm, 
 as affected by stimuli, 25 
 
 Nerves, see also under Names 
 
 arterial massage of, in health, 134 
 
 irritation of severe pain from effect 
 of, on heart, 113 
 
 soothed by tobacco-smoking, 169 
 
 Nerves of arterioje-muscular walls, effect 
 on, of digitalis, 147 
 
 of arterioles and veins, observations on, 
 of Brunton and Schweigger-Seidel, 45 
 
 Nerves of opposing action in heart, and 
 in vessels, 45 
 
 Nerves and muscles of circulation, in- 
 creased action of all, first stage of 
 action of digitalis, 159 
 
 Nervi erigentes, dilatation by, how in- 
 duced, 46 
 
 Nervous centers, effects on, of digitalis 
 poisoning, 149, 154 
 
 depression, causes and consequences, 
 102, 104 
 
 fibrils, found by author on surface of 
 muscular layer of arterioles, 45 
 
 - fluttering of the heart, quieting effect 
 on, of very small doses of aconite, 
 172 
 
 irritability in bradycardia due to reflex 
 inhibition from stomach treatment 
 to soothe. 1 88, and note 
 
 in Graves's disease drugs quieting, 
 
 183-4 
 
 people, pulse-rate in, 107 
 
 stimulants, derived from dietetic uses 
 of plants producing caffeine, etc., 
 161-2 
 
 supply, altered, a cause of fatty degen- 
 eration of the heart, 105 
 
 Nervous system, as affected by digitalis, 
 149. 154 
 
 control of, over the heart and blood- 
 pressure, how exerted, 15; extent 
 of, 45 how affected by digitalis, 
 159 
 
 share of, in angio-neurotic oedema 
 
 how evidenced, 117-8 
 
 share of, in. cardiac rhythm author's 
 
 view on, 32, 33, and note, (figs.) 
 35 possible cause of tachycardia, 
 
 I I 1-2 
 
 Nervous wave in medusa, 29 
 
 Nervous and muscular conduction in the 
 heart experiments of Brunton and 
 Cash, 32, 33, and note, (figs.) 35, 112 
 
 Neuralgic element in severe anginal at- 
 tacks how best relieved, 191 
 
 Neuritis, alcoholic, paralysis of vagi due 
 to consequent rapidity of pulse, 107 
 
 of the vagus, effects of, in convales- 
 cence from diphtheria, 186 
 
 Neuro-muscular bundle described by Kent 
 and His, nature and apparent func- 
 tions, 35, note 
 
 Nicotine, action of, on circulation, 160 
 double nature of, 167 
 
 on frog's heart, 167-8 
 
 on ganglionic structures medusse, 30 
 
 Nightmare, characteristic, caused by sleep- 
 ing on the back what it indicates, 180 
 
 Nitrate of potash, with nitrite of so- 
 dium, beneficial in high tension 
 dose, 208 how supplemented, 208-9 
 
 Nitrites, see Amyl Nitrite and Sodium 
 Nitrite; see also Vaso-dilators 
 
 amplitude of pulse, how increased by, 
 1 02 
 
 effect of, on angina pectoris, 189, 191 
 
 on circulation, pulmonary and gen- 
 eral, 193 
 
 reduction by, of blood-pressure in 
 gouty kidney cases, 101 
 
 Nitrobutyl, etc., action of, in relief of 
 angina pectoris, 189 
 
 Nitro-erythrol, beneficial in cases of high 
 tension dose, 208 
 
 preventive action of, in persons other- 
 wise liable to angina pectoris how 
 employed, 192
 
 INDEX 
 
 255 
 
 Nitroglycerine, 165; action of, in angina 
 pectoris how administered special 
 advantage of tablet form to be nib- 
 bled quantity safe sole bad effect, 
 191 
 
 beneficial in cases of high tension 
 dose, 208 
 
 overdoses of, headache the sole ill- 
 effect from, 191 
 
 Nitro-mannitol, uses of, 166 
 
 Nitrogenous diet, ill-effects of, in age 
 Haig cited on, 207-8 
 
 Nodular form of interference with ar- 
 terial blood supply consequences, 
 101 
 
 Numbness and tingling caused by small 
 quantities of aconite applied to 
 tongue, 171 
 
 Nutrients, cardiac, see Blood and Cardiac 
 Tonics 
 
 Nutrition of blood-vessels, effect on, of 
 feebleness of the heart, 101 
 
 failing, from disease fatty degenera- 
 tion of the heart found in, 99 
 
 of heart, 94-6 how benefited by digi- 
 talis, 150 et seq. 
 
 general how improved by action of 
 digitalis, 154 
 
 Nutritive action of cardiac tonics, 98, 
 144, 145, 150, 154 
 
 Nux yomica beneficial in cases of pal- 
 pitation associated with debility, 183 
 
 in treatment of bradycardia, 188 
 
 OBLITERATION of blood-vessels causes 
 and consequences, 115-6 
 
 Obstruction, aortic, to be distinguished 
 from stenosis why, 122 
 
 CEdema, action on, of digitalis, 152-4 
 
 of rest and massage, 138 
 
 angio-neurotic, characteristics of 
 pathology not made out author's 
 view, 1 1 7-8 
 
 of feet and ankles, first indication of 
 venous engorgement why how re- 
 lievable, 129 
 
 of legs or scrotum tapping for meth- 
 od, 204 
 
 universal, induced by injection of anti- 
 streptococcic serum, 118 
 
 in relation to venous obstruction and 
 to vaso-motor nerves Ranvier's ex- 
 periment, 1 53 
 
 Oertel's treatment principles and meth- 
 ods, 20 1-2 cases to which applicable, 
 193, 201 
 
 Old people, see also Elderly and Senile 
 
 arterial changes in, 89, 99, 100-1, 116, 
 205, (figs.) 88, 98 
 
 aortic valves and aorta in, 122 
 
 brown atrophy in, causes of, 100 
 
 causes of death most frequent in, 207 
 
 destructive action in, of macrophags 
 (Metchnikoff), 206-7 
 
 effect on circulation of. of grief, 104 
 
 fatty degeneration of the heart found 
 in, 99 
 
 rise of blood-pressure in risks of, in 
 combination with atheromatous ar- 
 teries, 205 
 
 Oliver, ammonium hippurate recom- 
 mended by, in cases of high tension, 
 208 
 
 arteriometer of, 83 
 
 sphygmomanometer of, 68, (fig.) 67 
 
 Operations, formerly performed in a state 
 of syncope, 115 
 
 Opium, remedy par excellence for sleep- 
 lessness in cardiac disease how 
 given doses, 193-4; danger in with- 
 holding, 195 
 
 use and abuse of parallel in massage, 
 135 
 
 Oppression, intense sensation of, fre- 
 quent in angina pectoris probable 
 cause author's deduction from sim- 
 ilar sensation due to grief in own 
 case, 121 
 
 Organs, functions of, disturbed by disor- 
 dered circulation, rendering that dis- 
 order worse how, 131 
 
 to which the vagus nerve gives branches, 
 104 
 
 Oscillations in kymographs, how avoided, 
 60 
 
 Ossification of arteries consequences, 116 
 
 of coronary arteries, angina pectoris 
 due to observations on, of Jenner 
 and Parry, cited by Brodie, 1 16 
 
 Oubain (Acocanthera), action of- -not 
 used in medicine, 146 
 
 Overdoses of nitroglycerine or amyl ni- 
 trite, headache sole ill-effect from, 
 191 
 
 Oxidation, effect on, of digitalin and 
 caffeine, Pickering on, 147-8 
 
 effect on, of other drugs, condition of 
 embryonic heart induced by, 148 
 
 relation to, of cardiac tonics, 148 
 
 of waste products, effected by com- 
 bined rest and massage, 138 
 
 Oxygen, inhalation of, in cardiac asthma, 
 remarkably good effect of, 193 
 
 in treatment of venous stasis, benefit 
 
 of possibly in part mechanical, 203 
 
 PAGE, MR., see Sanderson, Sir J. Burdon-, 
 
 and Page 
 
 Pain of angina pectoris causes, 116, 126 
 author's view, 122, and note, 189 
 location of, 189 
 
 relief of, by general bleeding, 175, 
 
 177 
 
 relation between, and tension, 122, 
 
 and note 
 
 severity of, 121 
 
 intense, power of the heart to origi- 
 nate, 121 
 - of migraine causes mode of relief, 
 
 1 20 nature of, 120 
 
 severe effects of, contraction of abdom- 
 inal vessels and maintenance of cir- 
 culation, 113 
 
 heart-stoppages sometimes due to, 113 
 Palpitation of the heart absent (gener- 
 ally) in hypertrophied heart, 112 
 associated with debility, 112; treat- 
 ment, 1 83 
 causation of, obscure author's view, 
 
 112 
 
 disturbance in pelvic organs cau- 
 tion, 183 
 
 excitement, 177 
 
 failing compensation, 124-5 
 
 faulty diet, 179 
 
 Graves's disease, see that head 
 
 lying on back or left side, in bed 
 
 112, i So 
 
 over-smoking, 170 
 
 stomach-distension from flatulence, 
 i go 
 
 weakness of the heart itself, 183 
 
 characteristics of, 112 et seq. 
 effect on, of position, 112-3, 180
 
 256 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Palpitation of heart, induced by ammonia 
 
 liniment applied over heart, 178 
 mechanism of author's view, 112 
 position in sleen as affecting, 112-3, l % 
 quieting of, by local external means, 
 
 179. 
 sometimes subjective sensation only, 
 
 I 12 
 
 tendency to, increased by pressure of 
 
 corsets or belts, 141 
 treatment of 
 diet. 178-81 
 
 drugs, 1 80- 1, 183 
 
 exercise, open-air, 183 
 
 massage, ib. 
 
 regimen, 181-2 
 
 \\ eir-Mitchell methods in severe cases, 
 
 183 
 
 Paraldehyde, in treatment of sleepless- 
 ness in cardiac disease niose, 193 
 Paralysis, see also Hemiplegia and Paresis 
 after convulsions caused by nicotine, 
 
 167-8 
 after diphtheria causes consequences, 
 
 187 
 general, of the insane, bradvcardia in, 
 
 109 
 
 - of inhibitory apparatus in the heart,, by 
 nicotine effect on pulse- rate, 167-8 
 local, resulting from rupture of blood- 
 vessel in brain, 206 
 
 secondary to disease of cerebral ves- 
 sels, 206 how preventable, by treat- 
 ment of senile conditions of vessels, 
 208 
 
 of vagus and other nerve, caused by 
 diphtheria toxin, 105, 107, 187; and 
 after alcoholic neuritis, 107 -pulse- 
 rate in, 107 
 
 Paresis, general, bradycardia in, 187 
 Parkes, value of beef-tea, etc., as stimu- 
 lants shown by, in Ashanti campaign, 
 145, and note 
 Paroxysmal tachycardia, see Tachycardia, 
 
 Paroxysmal 
 
 Parry. Dr., observations of, cited by 
 Brodie on" cause of angina pectoris, 
 116 
 
 Pastry, to be avoided in palpitation, 181 
 Pathology of angio-neurotic oedema, not 
 
 understood author's view, 118 
 Pathology of the circulation, 
 
 effect of altered quality of blood, 99 
 
 of blocking (however caused) of 
 coronary arteries, 96, 100, 116, 
 192 
 
 of feebleness of the heart on nutri- 
 tion of blood-vessels, 102 
 
 causes of, 
 
 fatty degeneration (q. v.), 104 
 nervous depression, 104 
 exophthalmic goitre, 107 
 pulse-rate factors conditioning, 105 
 normal rate in men, 107 rate 
 in fevers, 107 
 Pathology of syncope, not thoroughly 
 
 made out, 114 
 Pelvic organs, disturbances in, palpitation 
 
 often associated with caution, 183 
 Peppermint water, useful in palpitation 
 
 from flatulence, 180 
 Pepsin, etc., use of, in certain forms of 
 
 tachycardia, 185 
 
 Pericardium, Briicke's simile for, 97 
 Pericarditis, relief in, from application 
 of leeches over cardiac area, 177 
 
 Perihepatitis, with hepatitis, relief in, 
 
 from application of leeches over 
 
 liver, 177 
 
 Peripheral contraction, with central dila- 
 tation of arteries of head and neck 
 
 -^-cause of migraine, in author's 
 
 view, 1 1 9-20 
 
 ganglia dilatation connected with, 45 
 resistance, increase of, in arterioles, 
 
 dangers from, 101 
 Peristaltic action and normal beats of 
 
 frog's heart alternating, as effect of 
 
 aconite, 171 
 
 and motor action of the arteries, 5 
 Peritoneal fluid, effect on, of movements 
 
 of respiration, 9 
 Permanent pressure, local, in relief of 
 
 palpitation, 178 
 
 relief of palpitation essentials, 178-9 
 Phagocytes two classes of functions of, 
 
 206-7 
 Pharmacology (.see also Treatment) of 
 
 the circulation, i 
 Pharyngitis, benefit in, from cold-water 
 
 compress how produced, 175 
 chronic, induced by over-smoking, 170 
 Pharynx, nerves going to, paralysis of, 
 
 due to diphtheria toxin, 105 
 Pheasant's eye (.Adonis vernalis), uses 
 
 of, 146 
 Phosphorus, fatty degeneration of the 
 
 heart found after administration of, 
 
 100 
 Phosphates, use of, in Graves's disease 
 
 (Kocher), 183-4, and note 
 Phrynin, source and action of story of, 
 
 146-7 
 Phthisis, abnormally low blood-pressure 
 
 as precursor of case in point, 105 
 induced by malnutrition due to grief 
 
 case of, 105 
 
 Physiology of the circulation, i 
 accessory muscles of circulation, 7 
 arterial tension, or blood-pressure (g. 
 
 v.), 10 
 
 arteries and, 15 
 
 regulation of, 13-4 
 
 depressor nerves, 17-8 
 
 - influence of muscular area, 15-6 
 
 influence of splanchnic area, 16-7 
 arteries, 4 
 
 motor and peristaltic action of, 5 
 capillaries and veins, 5 
 fasciae, action of, 6, 131 
 heart, chief function of, 3 
 
 movements of views of Gaskell, 18 
 
 refractory period of, 4, 33 
 
 sleep of, 3 
 
 valves of, 39-40 
 heart of the frog, 19 
 movements of investigation of, 22 
 
 comparison between and a me- 
 dusa experiments of Romanes, 
 26-7 
 transmission of stimuli in, 31-2 
 
 nervous and muscular conduction 
 in, 32 experiments of Brunton 
 and Cash, 33 et seq. 
 independent pulsation of veins, 18 
 - lymph, flow of, 9 
 Pickering's (J. W.), observations on the 
 
 action of cardiac tonics on the em- 
 bryonic heart, 148 
 Picoline bases in smoking-tobacco in its 
 
 various forms, 168 
 
 Piegu's instrument for estimating blood- 
 pressure, 71
 
 INDEX 
 
 257 
 
 Pig-tail tobacco, demerits of heart-beat 
 with, 170 
 
 Pill of digitalis powdered, powdered 
 squill, and blue pill one grain of 
 each how modified at St. Bartholo- 
 mew's Hospital and elsewhere, 203 
 
 Pipe-smoking, and cigar-smoking, better, 
 or less bad than cigarette-smoking, 
 169 
 
 Plant-poisons, similar in action to digi- 
 talisnames, 146 
 
 Plants containing caffeine, etc., dietetic 
 uses of, medicinal action (probable) 
 of, 161-2 
 
 Plasmon, in diet for mitral disease, 204 
 
 recommended by Schott in chronic 
 myocarditis, 201 
 
 Plasters over heart, quieting effect of, on 
 palpitation best kind, 178 
 
 Plethysmograph of Hallion and Comte, 
 (fig.) 73 
 
 Mosso's, (Jig.) 69 
 
 combination of, with Marey's metallic 
 
 manometer, (fig.) 70 
 
 demonstration by, of reduced size of 
 limbs, during brain activity, 114 
 
 Pleural effusion, insidious and serious 
 character of serious in valvular dis- 
 ease, 139 
 
 removed by rest and massage, 139 
 
 tapping for, 204 
 
 fluid effect on, of movements of respi- 
 ration, 9 
 
 Pleurisy, severe, immense relief afforded 
 in, by leeches to side, 177 
 
 Pliny, aware why drinking bull's blood 
 caused death, 141, note 
 
 Pneumogastric nerve, method of action 
 of, on intestines, etc., 104, note 
 
 Pneumonia, heart-weakness due to, caus- 
 ing bradycardia, 108, 186 
 
 Points at which first and second sounds 
 of heart are best heard, 42 
 
 Poiseuille's manometer, 10, (fig.) ll 
 
 Poisoning by bile acids in jaundice bra- 
 dycardia due to how induced, io'9 
 
 by digitalis effects of, on 
 apex-beat in animals, 112 
 nervous centers, 149, 155 
 
 pulse causing irregularity, in man, 
 
 no 
 
 Poisons causing bradycardia, 108-9, 187 
 
 effect of, on medusae, Romanes' experi- 
 ments, 29-30 
 
 giving rise to fatty degeneration of the 
 heart, 100 
 
 vegetable, similar in action to digitalis 
 names, 146 
 
 Position, see also Upright, Recumbent, 
 Sitting, Stooping Position 
 
 in bed, in relation to palpitation, 112, 
 179-80 
 
 best for averting faintness, 115 
 
 for restoring fainting persons, 115 
 
 change of, from recumbent to erect, in 
 rising to micturate effect of, on 
 blood-pressure fatal syncope due to, 
 163 
 
 in relation to blood-pressure in the 
 brain, i i 5 
 
 for severe cases of valvular disease, 
 132-3 
 
 recumbent best, 132 beds for, 133 
 
 sitting, reasons for adopting pre- 
 cautions, 133-4 
 
 Potain-Gaertner combined apparatus for 
 measuring blood-pressure, (fig.) 76 
 
 18 
 
 Potain's sphygmomanometer, 67, 79, (fig.) 
 66 fallacies in applying, 68 
 
 author's use of, (fig.) 80 
 
 Potash, nitrate of, with nitrite of sodium, 
 beneficial in high tension, 208 how 
 supplemented, 208 
 
 Potassium, bitartrate of addition of, to 
 compound jalap powder advantage 
 of, 203 
 
 bromide of, in treatment of bradycar- 
 dia due to reflex inhibition from 
 stomach, 188 
 
 in Graves's disease effects of, 184 
 
 Potatoes and milk fatal meal of why 
 so, 140 
 
 Poultice, mustard, redness after prob- 
 able causes, 47, (fig.) 48 
 
 warm, over heart, stimulating effect' of, 
 178 
 
 Power, Mr., see Brunton and Power 
 
 Powell, Sir Douglas, cited on heart's 
 great dependence on due pulmonary 
 aeration, 94 
 
 Pressure, see Blood-pressure, Diastolic, 
 and Systolic Pressure 
 
 on, or hi brain, bradycardia caused by 
 how, 109, 187-8 
 
 hand, or permanent, quieting effect of, 
 on palpitation, 178 
 
 from without, on hollow muscular or- 
 gans not pain-producing, 120 
 
 not felt by the heart historic in- 
 stance, 1 20 
 
 on vagus, discomfort due to Czermak's 
 personal experience, 121, and note 
 
 Prolongation of life, suggestions for, by 
 attention to arterial conditions, 205, 
 209 
 
 Proteids in food, benefit of reducing, in 
 cases of senile rise of pressure, 208 
 
 Protoplasm, living, in relation to con- 
 tractility under stimulus, (a) undif- 
 ferentiated, 24-5; (b) differentiated, 25 
 
 Pulmonary aeration, great importance of 
 proper, to the heart (Powell), 94 
 
 affections, engorged condition of right 
 side of heart due to, relieved by 
 blood-letting, 177 
 
 artery, relative resistance of, 44 
 
 right weakness of, from atheroma 
 
 consequences, 130 
 
 capillaries, effect on, of heat and cold, 
 
 Si. (fig-) 54 
 
 giving way of, in mitral obstruction 
 
 cause and consequence, 128 
 
 Pulmonary circulation, hieh pressure, ab- 
 normal in, causing bradycardia how, 
 
 T QQ 
 loo 
 
 impeded, the danger in mitral incom- 
 petence from aortic regurgitation 
 treatment, 196-7 
 
 less affected by nitrites than general 
 
 circulation, 193 
 
 engorgement, cause of, 126 
 
 Pulmonary veins, absence of valves in, 
 127 
 
 blood-pressure in, in mitral regurgi- 
 tation, 127 
 
 contractile power of, and independent 
 
 pulsation in, rediscovered by Fayrer 
 and Brunton, 18, 44, 127, 128, note 
 
 pressure on, in mitral obstruction 
 
 possible stimuli excited by, and 
 further interference with heart- 
 rhythm, 128, note 
 
 Pulsation, arterial, coincident with respi- 
 ration, 46-7
 
 2 S 8 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Pulsation, arterial, observable in persons 
 with aortic regurgitation coinci- 
 dence of the three rhythms in, 47 
 
 cardiac possible part cause of, 171 
 
 of embryonic heart, 25 
 
 of femoral artery, increased by immer- 
 sion of feet in hot water, 175 
 
 of frog's heart, rate and character of, 
 as affected by digitalis, 147 
 
 independent, of veins, 18, and notes, 
 44, 128 
 
 Pulse, see also Bradycardia and Tachy- 
 cardia 
 
 - aortic, tracings of, with Marey's car- 
 diograph, 90, (figs.) 88 
 
 arterial pulsation coincident with, 46-7 
 
 author's own, his own observations on, 
 163 
 
 bigeminal nature instance, 189 
 
 carotid, when to be used to fix time 
 of cardiac murmurs, 92 
 
 condition of, in bradycardia, 108, 109, 
 iii 
 
 in paroxysmal tachycardia, 108, 109 
 
 effect on, of aconite in large doses, 171 
 
 of digitalis-poisoning three stages, 
 
 1 88 
 
 of massage and exercises described, 
 
 202, (fig.) 197 
 
 feebleness of, effect of, on nerves, 
 I34-S 
 
 intermittent, varieties of, 109-11 
 
 causes uncertain author's own view, 
 
 ii i-i2 
 
 irregularity or intermittence of forms 
 of causes, 109-12 persistence 
 treatment instances, 188-9 
 
 greater frequency of, in mitral, than 
 
 any other form of cardiac disease 
 why, 126, 128 
 
 (man's), feeling of, methods and aim 
 in, 60 
 
 of Napoleon I., slowness of, 108, 186 
 
 opposite effects on, of sequelae of diph- 
 theria, 187 
 
 quickened, arterial tension, and pain of 
 angina pectoris relation between 
 cases illustrating, 121, and note 
 
 -radial, when not to be used to fix time 
 of cardiac murmurs, 92 
 
 rapid, characteristic of tachycardia 
 treatment, 184-5 
 
 drugs to reduce, and bleeding, 166 
 
 or quickened in attacks of angina 
 
 pectoris, 121, and note 
 
 rapidity of, extreme, indicating paral- 
 ysis of vagus, 105, 106-7 
 
 recurrent, how obstructed in measur- 
 ing human blood-pressure, 62, 67, 
 (fig.) 66 
 
 senile, analogy of, to ventricular beat, 
 (fig.) 88 
 
 slow, in bradycardia, characteristics of, 
 1 08, 1 86 
 
 naturally so, instances of, 108, 186 
 
 slowing of, by digitalis, how effected, 
 149 
 
 by general bleeding, 166 
 
 slowness of, abnormal, after toxic doses 
 of digitalis, 155 
 
 stoppage of, when pressure within 
 lungs reaches certain point Val- 
 salva's experiment author's tests of, 
 130 
 
 Pulse-beats (see also Heart-beats), alter- 
 nately weak and strong in brady- 
 cardia, 108 
 
 Pulse-rate, as affected by 
 exophthalmic goitre process, 107 
 
 nicotine acting on vagus center in 
 medulla, 167 
 
 in bradycardia and tachycardia, dis- 
 turbed rhythm unaltered, 109-10 
 
 -factors on which dependent, heat, cold, 
 106-7; poisons, 107 
 
 in fevers, 107 
 
 in mammals and frogs, action on, of 
 nicotine, 167 
 
 in nervous people, 107 
 
 normal, in men, 107 
 
 rapid, consequences of, and treatment, 
 
 3~4 
 
 when vagi are paralyzed, 105-7, J 87 
 
 Pulse-rhythm in bradycardia and tachy- 
 cardia remaining regular rate dis- 
 turbed, 109-10 
 
 Pulse-wave, amplitude of, external and 
 internal means for securing proc- 
 esses involved, 102 
 
 nature of, instruments for ascertaining, 
 84 et seq. 
 
 retardation of, 92, (fig.) 91 
 
 smallness or feebleness of, effect of, 
 however caused, 102 
 
 fatty degeneration (q. r.) as cause 
 
 of, 104 
 nervous depression as cause of, 104 
 
 " Pulris nrirabilis," for functional irrita- 
 tion of the heart prescription 
 notes on, 181, 183 
 
 Puncture (see also Tapping), for oedema 
 of legs methods, 204 
 
 Purgation, free, in treatment of toxin- 
 caused bradycardia- class of purga- 
 tives preferable, 188 
 
 Purgatives, see also Aperients, Mercurial 
 Purgatives, and Saline Purgatives 
 
 - best adapted for treatment of toxin- 
 caused bradycardia, 188 
 
 in treatment of cardiac diseases why 
 essential, 203 
 
 Purin bodies, enumeration of, and uses, 
 145, 161-2 
 
 Purin-type of meat-extracts to be avoided 
 in angina pectoris why, 191 
 
 Purkinje, fibers described, 35, note 
 
 Pye, Mr., see Brunton and Pye 
 
 Pyridine bases in tobacco, in its various 
 smoking forms, 168 
 
 QUALITY of blood, altered, effect of, 100 
 Quickening, sudden, of pulse, with sud- 
 den return to the normal, see Par- 
 oxysmal tachycardia 
 
 RABBITS' hearts, fatty degeneration found 
 in, on section of vagi (Wassilieff), 
 
 i5 
 
 Radial artery, decreased pulsation in, 
 caused by cold bandage to middle of 
 arm, 175 
 
 effect on, of massage and exercises, 
 
 (fig-) 197. 201 
 
 tension in effect on, of inhalation of 
 
 oxygen in cardiac asthma, 193 
 
 pulse, coincidence of, with cardiac dias- 
 tole when found, 92 
 
 Ranvier, M., figures of parts of frog's 
 heart due to, 24, 25, 37 
 
 Rapid action of heart, persistent, after 
 excessive exercise treatment, 184 
 symptom in paroxysmal tachycardia, 
 184
 
 INDEX 
 
 259 
 
 Rapidity of contraction, causes of loud 
 
 first heart sound how acting, 43 
 Rapidity of pulse, see under Pulse 
 Raynaud's disease, described, 117 
 Recurrent pulse, see under Pulse 
 Rectum, injections by, of opium conve- 
 nient mode advantages of, 194 
 Recumbent position, 
 best for restoring fainting persons, 
 
 blood-pressure in brain greater dur- 
 ing, 115 
 
 impossibility of assuming or main- 
 taining, in severe cases of valvular 
 disease causes explained, 132-3 
 inability to evacuate in author's ar- 
 rangement to meet this difficulty, 
 132 
 
 work of diaphragm in moving abdom- 
 inal viscera in, 133 
 Recuperation intervals how secured for 
 
 the heart by digitalis, 149 
 Reflex contraction of vessels, not present 
 in reflex stoppage of heart in imper- 
 fect anaesthesia author's view, 113-4 
 irritation from stomach, paroxysmal 
 tachycardia sometimes due to 
 treatment, 185 
 of various organs, and skin, causing 
 
 bradycardia, 109 
 
 stimulation of medullary center of 
 vagus, from stomach, skin, or sexual 
 organs bradycardia caused by, 187 
 treatment for, aims and methods, 
 188 
 
 stoppage of heart, caused by stomach 
 distension, 140-1 
 
 in imperfect anaesthesia unaccom- 
 panied by reflex contraction of 
 vessels author's view, 113-4 
 Refractory period of the heart, 4, 33 
 investigations on, as to time, and 
 electrical changes, of Sanderson 
 and Page, 33 
 
 pointed out by Marey, 33 by Kro- 
 
 necker, 33 
 
 stimulation (electric) non-effective 
 during (Brunton and Cash), 34, 
 (.fig-) 35 
 
 Regimen, see Diet and Regimen 
 Regulating function of arteries, 4 
 Regurgitation (see Aortic and Mitral Re- 
 gurgitation), prevention of, by valves 
 of heart, 40 beneficial action in aid, 
 of digitalis, 150 
 
 Remak's ganglion frog's heart, 19 
 Renal arteries effect of digitalis on, sim- 
 ilar to that of ligature of, 156, 162 
 how overcome, 163 
 
 vessels (see also Kidneys) spasm of, 
 occurring (with arrest of urinary 
 secretion) in second stage of action 
 of digitalis danger of, to man, 160 
 Resistance in finger exercises in treat- 
 ment of venous stasis graduation 
 of, 202 
 
 increased, to ventricular action dis- 
 eases causing bradycardia induced 
 by, 109 
 Respiration, arterial pulsation coincident 
 
 with, 46-7 
 as coadjutor to heart in carrying on 
 
 circulation, 5 
 imperfect, waste products due to 
 
 elimination of, 203 
 movements of, effects of, 
 on circulation (venous), 5 
 
 Respiration, movements of, effects of, on 
 flow of pleural and peritoneal fluids, 9 
 
 Respiratory center, as affected by poison- 
 ous doses of digitalis, 149 
 
 Rest, absolute, in treatment of valvular 
 disease of the heart, 13: author's 
 definition of, and insistence on, 132 
 discomforts experienced during, how 
 caused, 132-4 relieved by mas- 
 sage, 134 combined effects on 
 heart, etc., 137 
 
 position during, difficulty connected 
 
 with, 133 
 
 rules regarding, 132-3 
 
 after baths in Nauheim treatment, 200 
 
 after meals, essential to those suffer- 
 ing from, or menaced by, angina pec- 
 toris why, 192 
 
 in bed prolonged, the best treatment 
 for Graves's disease case illustrat- 
 ing, 183-4 
 
 prolonged, in severe cases of palpi- 
 tation, 183 
 
 complete, in advanced mitral disease, 
 197 
 
 preferably in bed with massage, in 
 
 venous stasis, 202 
 
 Rest and massage, combined effects of, 
 in treatment of valvular disease, 138 
 et pravi. 
 
 Restlessness in Graves's disease treat- 
 ment, 184 
 
 in patients in absolute rest treatment 
 causes, 134 relieved by massage, 135 
 
 Resume of the action of digitalis, 147-8 
 
 Retardation of pulse-wave, 92, (fig.) 91 
 
 Rheumatism, acute, bradycardia often 
 met with when heart is weak, during 
 convalescence from, 186 
 
 Rhubarb as aperient, in cases of senile 
 rise of pressure how taken, 208 
 
 with carminatives, in treatment of sleep- 
 lessness in cardiac disease, 193 
 
 Rhythm, capillary, 47 
 
 cardiac, see Cardiac Rhythm 
 
 and coordination of auricles and ven- 
 tricles, characteristics of the muscle 
 itself, 18-9 
 
 Rhythmical contraction in vessels ob- 
 served by Wharton Jones and others, 
 46- cause according to Luchsinger 
 and Schiff rediscovered by Brunton 
 and Fayrer, 18, 44, 127, 128, note 
 order, coincidence and number of, 
 46-7 
 
 Richardson, Dr. B. W., observations of, 
 on dilation of capillaries by nitrite 
 of amyl, 163 
 
 Right side, lying on, why resorted to by 
 sufferers from palpitation, 179-80 
 
 Rigidity (loss of elasticity) of arterial 
 walls of old people, 89, 99, 101, 116, 
 205 
 
 Ringer's discovery as to why tap-water is 
 better than distilled, in artificial cir- 
 culation, 143 
 
 Riva-Rocci's sphygmomanometer, 77-9 
 modifications of, 78-81 
 
 Romanes, Prof., experiments of, on me- 
 dusae (in comparison with the heart), 
 26-8 
 
 Rooms, warm, why causing faintness and 
 syncope, 107 
 
 Root of tooth, inflammation at, why re- 
 lieved by cold, 174-5 
 
 Rotator muscles of leg as accessories to 
 circulation, 6, 7, 131
 
 260 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Roy, manometer of, 59 
 
 Roy and Adami, cited on regurgitation 
 
 from irregular action of musculi pa- 
 
 pillares, 126 
 Rupture of blood-vessels, risks of, in 
 
 cases of arterio-capillary fibrosis due 
 
 to kidney disease, 101 
 
 in cases of atheromatous arteries 
 
 and high blood-pressure, 205 
 
 SACRIFICES, animals slain for, arteries of, 
 empty reason, 2, 5 
 
 St. Bartholomew's Hospital, purgatives 
 employed at, in cardiac complaints, 
 203 
 
 Saline purgatives in treatment of angina 
 pectoris when given aim of, 192 
 
 in treatment of senile rise of pres- 
 sure, 208 
 
 in treatment of toxin-caused brady- 
 
 cardia, 188 
 
 Saline solutions, as used in Ludwig's ex- 
 periments in artificial circulation, 
 143, (fig.) 142 
 
 Ringer's discovery concerning, 143 
 
 Salt, common, solution of, used in artifi- 
 cial circulation, by Ludwig, 143 
 
 use of, in Graves's disease, 184, note 
 
 Sanderson, Sir John Burdon-, cardio- 
 graph of, for apex-beat, (fig.) 86 
 
 manometer made by, n, (fig.) 12 
 
 investigations of, with Mr. Page, on 
 refractory period of the heart, .13 
 
 Sassy-bark, or casca (Erythrophlceum 
 guinense), medicinal uses of, 146, 
 1 60 
 
 Scanty urine, feature of venous engorge- 
 ment, 129 
 
 Schema of the circulation, author's, 57, 
 59, (fig-) 55 
 
 Schiff, observations by, on rhythmical 
 contraction of vessels, 46, 128 
 
 Schmey, see Kronecker and Schmey 
 
 Schott, the brothers, and the Nauheim 
 treatment, 199 et seq. 
 
 Schweigger-Seidel, see Brunton and 
 Schweigger-Seidel 
 
 S cilia maritima (squill), uses of, 146 
 
 Scrotum, oedema of, tapping for meth- 
 ods, 204 
 
 Second intercostal space, second sound of 
 heart best heard at, 42 
 
 Sedative effect of smoking, causes (prob- 
 able) of, 169-70 
 
 Sedatives, cardiac, local and external, 178 
 
 Self-massage of, 
 
 arteries, lymphatics and veins, 6, 9, 97, 
 99, 102 
 
 increased by digitalis, 149 
 
 by massage, 137; and exercises, 
 202 
 
 in relation to the pulse-wave and to 
 
 arterial nutrition, 102 
 
 heart, process and advantage of, 96 
 
 aided by digitalis, 149-50 
 
 increased by massage and exercises, 
 
 202 
 
 by massage and rest, 137 
 
 probably produced by inhalation of 
 
 oxygen, 203 
 
 Semeiology of the circulation, 2 
 
 Senac, acquainted with the independent 
 pulsation of veins (1783), 18 
 
 Senile conditions (see also Age, Elderly 
 persons, Old Age) of arteries, etc., 
 89, (fig-) 88, 99, 100-1, 116, 205, 207, 
 208 treatment, 208-9 
 
 Senile conditions of the vessels treat- 
 ment of, 208-9 
 
 Senile decay, 207 
 causes of, actual and primary, 207 
 
 Metchnikoff's views on, 206-7 
 
 preventable by attention to arterial 
 conditions, 209 
 
 gangrene, causes of, and main prelimi- 
 nary symptom (Brodie), 116 
 
 pulse, analogy of, to ventricular beat, 
 (fig.) 88 
 
 rise of pressure, 205; conditions of, 
 attended with special risk, 205 
 
 Sensitiveness of arteries, 119; how proven, 
 i i 9-20 
 
 of heart, 120-2 
 
 Sensory affections, resulting from rupture 
 of blood-vessel in brain, 205 
 
 mechanism in the heart, partly cause of 
 cardiac pulsations how deduced, 
 171-2 
 
 Serous cavity of pleura, effusion into 
 tapping for, 204 
 
 Sexual organs, reflex irritation from, bra- 
 dycardia due to, 109, 184 
 
 Sharpey, Professor, on Czermak's expe- 
 rience with mechanical irritation of 
 the vagus, 121, note 
 
 on functions of rotators of leg, 7-8 
 
 Sheep, blood-pressure in, 60 
 
 Shock, difference between, and syncope, 
 114 
 
 effect of, on heart and vessels, 113 
 
 Short-lived families, one reason for, 205 
 suggestions for prolongation of 
 life, 208 
 
 Shortness of breath, in mitral incompe- 
 tence treatment, 197 
 
 in mitral obstruction and regurgita- 
 tion a prominent symptom, 128 
 
 Shoulders, radiation towards, of anginal 
 pain, 189 
 
 Sick headache, see Migraine 
 
 Sighing, caused by grief, 104 
 
 Sight, bad effect on, of over-smoking, 170 
 
 Sitting position, when advisable for suf- 
 ferers from severe valvular disease 
 precautions, 133 
 
 Skin, changes of color in, due to cold 
 weather, what is indicated by, 117 
 
 - reflex irritation from, bradycardia due 
 to, 109, 187 
 
 of toads, phrynin from action of, on 
 heart, 146-7 
 
 Sleep of the heart, 3, 4, 9 
 
 positions in, in relation to palpitation 
 and nightmare, 179-80 
 
 Sleeplessness, in connection with cardiac 
 disease characteristics aggravations 
 of methods of relieving, 193 et seq. 
 
 effects in, of external cold, 175 
 
 - of internal warmth, ib. 
 
 in Graves's disease treatment, i83-4_ 
 
 Slow eating, necessary in cases of palpi- 
 tation, 1 8 1, 182 
 
 Slow walking after meals essential in 
 angina patients and those menaced 
 by angina, 192 
 
 Slowing of the heart by, 
 aconite cause effects, 171 
 
 nicotine cause effects, 167 
 
 of rapid pulse, general bleeding for, 166 
 
 Slowness of pulse, extreme, see Brady- 
 cardia 
 
 Skwness and strength of pulsation in 
 isolated frog's heart, under digitalis, 
 U7
 
 INDEX 
 
 26l 
 
 Smoke-rings, watching of, sedative effect 
 of, 170 
 
 Smoking, see Tobacco-smoking 
 
 Snuff-taking, nicotine absorption in, 168 
 
 Sodium bicarbonate, uses of, in certain 
 forms of tachycardia, 185 
 
 in palpitation from flatulence, 180 
 
 bromide of, in Graves's disease effects 
 of, 184 
 
 hydrate, in saline solution, as used by 
 Ludwig in experiments on isolated 
 frog's heart, 143, (fig.) 142 
 
 nitrite, action discovered but not an- 
 nounced by author first described 
 by Hay, 165-6 
 
 beneficial in cases of high tension, 
 
 208 
 
 Solids and fluids, manner of taking, im- 
 portant in diet for palpitation, 181-2 
 
 Somerville, Dr., case of bradycardia 
 treated by, referred to, 188, note 
 
 Sounds of the heart, 41 et seq. 
 
 cardiac murmurs, 43-4 
 
 first causes of, 41-2 
 
 changes in, 42-3 
 
 causes of, ib. 
 
 clinical importance of, ib. 
 
 -nature of, 41-2 
 -where best heard, 42 
 
 -second causes of, 41 
 changes in, great clinical impor- 
 tance of, 42 
 
 causes of, 42 
 
 -where best heard, 42 
 
 J a 
 
 La 
 
 Southey's tubes, for drainage of legs or 
 
 scrotum, 204 
 Spasmodic asthma, permanent dilatation 
 
 of right side of heart induced by 
 
 why, 130 
 Sphygmograms character of, in healthy 
 
 people, 90, (figs.) 88 
 
 in cases of feeble heart, 90, (figs.) 
 
 88, 89 
 
 crochet or hook in, 92, (fig.) 90 
 dicrotic wave in, what it means, and 
 
 how caused, 92, (fig.) 90 
 Sphygmograph, the, 84 principle of, 86 
 various forms of, devised by 
 -Dudgeon, 93, (fig.) 94 
 
 Jacquet, 93 
 
 Laulanie, 94, (fig.) 95 
 
 -Ludwig and Von Frey, 92 
 Marey (several forms and modifica- 
 tions of), 13, 86, 92 
 
 wider use of possibilities and condi- 
 tions of, 94 
 Sphygmomanometers author's apparatus 
 
 for standardizing, 82 
 various forms of, devised by 
 
 author, 65, 79, (fig.) 80 
 
 Herisson, 62-64, 68 
 
 Hill, 68 
 
 Hill & Barnard, 78 
 
 Martin, 78 
 
 Mosso, 71-3 
 
 Oliver, 67, (fig.) 67 
 
 Potain, 67, 79, (figs.) 66 
 
 fallacies in applying, 68 
 
 Riva-Rocci's, 77-9 
 
 modifications of, by 
 
 Americans, 79-82 
 
 author (and method of using), 
 
 79 
 
 others, 78-9, 81 
 
 Von Basch earlier designs, 63, 64-5 
 
 later designs, 66-7, (figs.) 64-7 
 author's cheap modification of, 63 
 
 Sphygmomanometers, various forms of, 
 
 fallacies in using, 68-9 
 Waller's, 62 
 
 Sphygmoscope, or Erlanger's sphygmo- 
 manometer, 81 
 
 Splanchnic area influence of, 16 
 in regulation of blood-pressure, 16 
 
 in relation to vascular dilatation and 
 
 faintness, 107 
 
 Splenic plexus, see Coeliac, Hepatic and 
 Splenic Plexus 
 
 Squill (S cilia maritima), medicinal uses 
 of, 146 
 
 digitalis and blue pill pill of, in car- 
 diac diseases, 204 
 
 useful in cardiac asthma, 193 
 
 Stages in the action of digitalis, 158, 159, 
 
 1 60, (figs.) 156, 157, 159 
 essential part of division of, 159 
 four stages enumerated, 159 
 
 conditions rendering second stage 
 
 dangerous to man, 160 
 not correspondent in different au- 
 thors, 159 
 
 Stairs, work involved in going up, 131-2 
 
 Standardization of instruments for meas- 
 uring blood-pressure, author's appa- 
 ratus for, 82, (fig.) 83 
 
 Stannius, experiments of, on movements 
 of frog's heart, 21, (figs.) 20, and 
 see 1 6 1, and note 
 
 Stanton's modification of Riva-Rocci's 
 sphygmomanometer, 80 
 
 Start, waking with, characteristic of sleep- 
 lessness with cardiac disease, 193 
 
 Stenosis, see also Aortic and Mitral 
 Stenosis 
 
 to be distinguished from mere obstruc- 
 tion why, 122 
 
 pure, slight degrees of, barely affecting 
 circulation, 122 
 
 Sternum, lower end of, to the left 
 aortic regurgitant murmur sometimes 
 only audible at case illustrating, 
 195-6 
 
 Stiffness of aortic valves in later life 
 consequences, 122 
 
 Stimulants (see also Cardiac Stimulants), 
 powerful (e. g., strong coffee) in 
 attacks of paroxysmal tachycardia, 
 benefit of, 184 
 
 Stimulation, see also Irritation and Re- 
 flex Irritation 
 
 electrical, of frog's heart, experiments 
 of Brunton and Cash, 33, (figs.) 35 
 deductions, 34-5 
 
 of feeble heart, various methods of, 178 
 
 of inhibitory apparatus in the heart, by 
 nicotine effects on arterioles, 168 
 
 of secreting structures in kidneys, by 
 digitalis (probable"* 151-2 
 
 - of vagus center, in medulla, 
 by aconite, 171 
 by nicotine, 167 
 causing bradycardia, 109, 188 
 
 of vessels from within, 49-51, from 
 without, 47, (figs.) 47, 48 
 
 Stimulus(i), conduction of, by 
 muscle, 23-4; nerve, ib. 
 
 constant, effect of, 
 
 on bell of medusa nerves removed, 
 
 nerves detached at one end only 
 waves induced by irritation how 
 hindered, 27-8, (figs.) 28 
 
 on embryonic heart, 25
 
 262 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Stimulus, generation in, and transmission 
 from, venous sinus and auricles, un- 
 der heat, 1 1 id 
 
 in the heart, transmission of, 31-3, and 
 note, 32 
 
 in the pulmonary veins possible mode 
 of excitation of, 128, note 
 
 to ventricle, from internal pressure, 
 causing dilatation of apex frog's 
 heart results, 27-8, 128 
 
 Stokes- Adams' syndrome characteristics, 
 1 86 
 
 Stomach (see also Abdomen), as affected 
 by disgust, 104 
 
 congestion of diminished by rest and 
 massage, 138 
 
 discomfort without pain, frequently felt 
 by, 120-1 
 
 - distension of, anginal pain increased 
 
 by, 189 
 
 danger in, from corsets, 141 
 flatulent, effect on heart, 138, 139-41 
 an aggravation of drowsy sleepless- 
 ness of cardiac disease how re- 
 lieved, 193 
 prescriptions to alleviate, 180-1 
 
 effect on, of (a) pressure from with- 
 out, 120 
 
 (b) distension from within, ib. 
 
 of toxic doses of digitalis parallels, 
 
 155 
 
 expulsion of gas from, by massage dur- 
 ing rest advantages of, 138 
 
 fermentation in arrest of, essential to 
 permanent relief of palpitation, 180 
 
 how caused how prevented, 182-3 
 
 - flatulence in (see also under Stomach 
 Distension, supra), in venous en- 
 gorgement, 129 
 
 - irritants inside effect of, similar to 
 that of blow on, 113 
 
 - reflex irritation from, causing brady- 
 cardia, 109, 184 treatment, 188 
 sometimes causing tachycardia 
 treatment, 185 
 
 stimulating effect on, of food, how in- 
 creased by aperients, 208 
 
 Stomach and intestines, benefit to, of 
 reduction in size of liver, effected by 
 diminished venous congestion, due to 
 digitalis, 154 
 
 Stooping position, helpful in averting 
 fainting why, 115 
 
 Stoppage 
 
 of heart, by 
 
 drinking large quantities of alcohol 
 
 at a draught, 113 
 
 imperfect anaesthesia author's view, 
 H3-4 
 
 shock, 113 
 
 of pulse Valsalva's experiment au- 
 thor's tests on himself, 130 
 
 Strain, see also Cardiac Strain 
 
 - avoidance of, by persons with slight 
 mitral leakage, 197 
 
 from being chased, sensation from, the 
 same as that felt in nightmare de- 
 duction, 1 80 
 
 constant, less well withstood than in- 
 termittent, by involuntary muscular 
 fiber proof seen in mitral obstruc- 
 tion, 128 
 
 in relation to stimulation of vessels 
 from within, 49-5 1 
 
 sudden, and sudden death, relation be- 
 tween, in aortic regurgitation, 196 
 
 Strengthening the heart, the aim of all 
 treatment for bradycardia most use- 
 ful remedies for this, 188 
 
 Strieker and others, contractility of cap- 
 illaries established by, 46 
 
 Strontium, bromide of, in Graves's dis- 
 ease, effects of, 184 
 
 Stroplianthus hispidus medicinal uses of, 
 146 
 
 action of, chiefly on heart itself, 160 
 
 added to " pulvis mirabilis " for fee- 
 ble heart, 181 
 
 as cardiac tonic nutritive action of, 
 98 
 
 poisoning by, effects of, as observed 
 
 by Brunton and Pye, 155-6 
 
 small doses of, between attacks of 
 
 paroxysmal tachycardia, benefit of, 
 185 
 useful, in aggravated cases of mitral 
 
 incompetence, 197 
 in cardiac asthma, 193 
 
 why good effects of, and of other 
 
 drugs, persist after discontinuance 
 of, 98-9 
 
 Strychnine, 
 
 action of, complex, affecting whole ner- 
 vous system, 183 
 on the heart, described, 160 
 in cardiac asthma, 193 
 
 as cardiac tonic nutrient action, 
 
 98 
 in palpitation with debility, 183 
 
 effect of, on medusae (contractile tis- 
 sue), 30 
 
 Strychnine and caffeine, in combination 
 with digitalis, benefits of, in certain 
 . cases of aortic regurgitation, with 
 care, 196-7 
 
 Strychnine with iron, in treatment of 
 bradycardia, 188 
 
 Submaxillary gland, condition seen in, on 
 dilation of its arterioles from irrita- 
 tion of chorda tympani, 115 
 
 dilatation in, how induced, 46 
 
 Substances having poisonous action ab- 
 sorbed by liver, excreted in bile, re- 
 absorbed from duodenum, and again 
 excreted risks from, in angina pec- 
 toris how eliminated, 191 
 
 Suction-power of the heart how increased 
 by digitalis, 150 
 
 Sudden anaemia of the brain, the (appar- 
 ent) cause of syncope, 1 14, and see 
 15 
 
 strain and sudden death relation be- 
 tween, in aortic regurgitation, 196 
 
 Sugar (s), to be avoided in palpitation 
 why, 181 
 
 instead of salt in foods for mitral dis- 
 ease cases, 204 
 
 - other than glucose, less good as car- 
 diac nutrients, 145 
 
 Sulphate of zinc (20 grains), emetic to 
 cut short attack of paroxysmal tachy- 
 cardia, 184-5 
 
 Sulphonal, in treatment of sleeolessness 
 in cardiac disease dose, 193 
 
 Sunstroke, bradycardia occurring in, 188 
 
 Suprarenal extract, enormous rise of 
 blood-pressure due to a parallel, 167 
 
 given by author in Graves's disease, 
 
 184 
 
 Surgical treatment of cardiac diseases, 
 205 
 
 of mitral stenosis possibilities of, 
 
 205, and note
 
 INDEX 
 
 263 
 
 Syncope, 
 
 association of, with bradycardia, 186 
 causes of, 15, (fig.) 14, 107 
 apparent probable, 114 
 
 heat of room, 107 
 
 strain on ossified coronary arteries 
 
 (Brodie), 116 
 
 difference of, from shock, 114 
 - fatal, from excessive use of digitalis 
 
 cases in which most frequent, 162-3 
 flow of blood during Hunter's obser- 
 vation on, 115 
 operations formerly performed in state 
 
 of method of, 115 
 pathology of, not thoroughly made out, 
 
 114 
 
 risk of, in aortic regurgitation, 196 
 Syndrome, Stokes-Adams characteristics, 
 
 1 86 
 
 Systole, denned, 3 
 in dog's heart, prolonged by irritation 
 
 of vagus, 158 
 in frog's heart electric stimulation of 
 
 ventricle during effects at different 
 
 stages, 34, (fig.) 35 
 reduplication of, due to stimulation, 34, 
 
 (fig-) 35 
 Systolic murmur over aorta, significance 
 
 of, 195. 
 
 indicative of mitral regurgitation 
 
 when found interesting case of, 
 126 
 
 loud, not necessarily indicating les- 
 sened lumen of vessel, 122 
 Systolic and diastolic blood-pressure, 
 
 how estimated, -71-2, (fig.) 70 
 
 highest relations between, 82 
 
 TABLETS of nitroglycerine in angina pec- 
 toris best nibbled safe dose sole 
 ill-effect, 191 
 
 Tachycardia, due to strain, 184 
 paroxysmal, characteristics, causes and 
 
 associated conditions, 108-12, 184-5 
 treatment during and between at- 
 tacks, 184-5 
 
 pulse in rate altered, rhythm regu- 
 lar varieties of intermission in, 
 109-12 
 
 Tait, see Brunton and Tait 
 " Taking it to heart," pathological eluci- 
 dation of, 104 
 
 Tambour, Marey's, for recording move- 
 ments, 64, (figs.) 58, 84, 93 
 Tapping, when advisable methods of, 204 
 Tap-water, why different in effect from 
 distilled water in artificial circulation 
 Ringer's discovery, 143 
 Tartar emetic, effect of, on stomach, 155 
 Tea, to be avoided in angina pectpris, 191 
 dietetic action of, 162 -medicinal ac- 
 tion of derivatives, 162 
 excessive use of, cause of palpitation 
 
 to be cut off or lessened, 179 
 use of, by flatulent precautions, 182 
 Tea and bread, fatal meal of why so, 
 
 140-1 
 Temporal artery, alterations in, observed 
 
 during migraine, 119-20 
 Tensor vaginae femoris muscle, true func- 
 
 . tion of, 7-8 
 
 Thebesius, vessels of, function of, 96 
 Theobromine, or dimethylxanthine 
 action of, differing from that of caf- 
 
 eine, 162 
 
 use of, in small quantities, 145 
 Theocine, nature and uses of, 162 
 
 Theophyllin, nature and uses of, 162 
 
 Thtvttta grandiflora, action of not used 
 in medicine, 146 
 
 Thighs, swollen, effect of, on abdomen, 
 133 
 
 Thinking, hard, effect produced by, on 
 volume of arm, 114 
 
 Thirst, intolerable, induced in healthy 
 man by diuretic action of digitalis, 
 150, 152 
 
 Throat, irritability of, due to over-smok- 
 ing, 170 
 
 Thrombosis, obliteration of blood-vessels 
 due to, causing gangrene, 115-6 
 
 Thyroid gland extract, effect of, on heart, 
 vessels and pulse in exophthalmic 
 goitre, 107 
 
 effects of too long treatment with 
 (by mouth), in myxcedema, 107 
 
 Tigerstedt, cited on blood-pressure in 
 man, 60 
 
 referred to, on dilating nerves, 45, and 
 note 
 
 Tissue (s), see also Muscular Tissues 
 
 anaemia of, in Raynaud's disease, 117 
 
 how supplied with blood, 5 
 
 hard or unyielding, in relation to self- 
 massage of arteries and general cir- 
 culation, 6 
 
 in relation to means for modifying local 
 circulation in inflammation, 174-5 
 
 hyaline, deposit of, in coats of arterial 
 walls, due to kidney disease, 101 
 
 Toads' skin, poison from (phrynin), effect 
 of, on heart story on, 146-7 
 
 Tobacco chewing and snuffinsr in relation 
 to nicotine absorption, 168 
 
 enemata, former uses of dangerous, 
 :68 
 
 smoking, attractions and results of, 
 169-70 
 
 bradycardia caused by how, 109, 187 
 
 characteristic irregularities in, in 
 
 double action of, in adults, 169 
 
 excessive, as cause of palpitation, to 
 be given up wholly or partly, 170, 
 i.79 
 
 various methods of, and their results, 
 168-9 
 
 Tongue, effect on, of small quantities of 
 aconite, 171 
 
 irritation of, due to over-smoking, 170 
 
 Tonic contraction drugs specially pro- 
 ducing, oxidation of protoplasm accel- 
 erated by (Brunton and Cash), 148 
 
 Tonics, see Cardiac Tonics 
 
 Tonometer, Gaertner's, 73-75, 76, (figs.) 
 74, 75, 76 
 
 Tonsillitis, benefit in, from aconite in 
 small doses, 172 
 
 - benefit in, from cold-water compress- 
 how produced, 175 
 
 Toxic action of digitalis symptoms, 155 
 
 Toxin of diphtheria, effect of, on cardiac 
 muscles and on vagus and other 
 nerves, 105 
 
 in typhoid fever, stimulation by, of in- 
 hibitory mechanism, effect of, on 
 pulse, 186 
 
 Toxins causing bradycardia treatment, 
 187 
 
 of various diseases causing fatty degen- 
 eration of the heart, or degeneration 
 of its muscular tissue, too 
 
 Train and telegram, comparison of, with 
 transmission of stimuli by cardiac 
 muscle and nerves, 32
 
 264 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Transudation from vessels into tissues, 
 
 effect of chlorides in promoting con- 
 sequent disadvantage of, in dropsy, 
 
 204 
 Transmission of stimuli in the heart, 31, 
 
 and note, 32 
 Traube, experiments of, on mammalian 
 
 circulation (in relation to digitalis 
 
 action), 146 
 and Von Bezold, views of, cited on 
 
 cause of rise of blood-pressure due 
 
 to digitalis, 157 
 Treatment of cardiac diseases, see also 
 
 Surgical Treatment 
 
 angina pectoris, 189, 191-2 
 
 cardiac asthma, 192-3 
 
 palpitation, 178, et seq. 
 
 senile conditions of the vessels, 207-9 
 
 sleeplessness in cardiac disease, 193-5 
 
 valvular disease, 131 et seq. 
 
 ultimate impotence of, in some cases, 
 
 205 
 
 Tremor, nervous, due to smoking, 170 
 Tricuspid valves, incompetence of, how 
 
 induced advantage of tendency to, 
 
 44 
 Trimethylxanthine (see Caffeine) use, 
 
 145 
 Trional, in treatment of sleeplessness in 
 
 cardiac disease dose, 193 
 Tuberculosis, predisposition to, produced 
 
 by grief case in point, 105 
 Tubes, for drainage of legs or scrotum, 
 
 204 
 Tumor on the brain, bradycardia caused 
 
 by, 109, 187 
 
 Tunnicliffe, Dr., see Brunton and Tunni- 
 cliffe 
 Turpentine stupe over heart, stimulating 
 
 effect of, 178 
 Typhoid fever 
 bradycardia often associated with weak 
 
 heart in convalescence from, 186 
 
 seen in, even while temperature is 
 
 high probable cause, 187 
 fatty degeneration of the heart in, 105 
 heart-weakness causing bradycardia, due 
 
 to, 1 08 
 prognosis grave when first heart sound 
 
 inaudible, 42-3 
 
 ULCERS, atheromatous in senile arterial 
 walls, how induced, 101 
 
 gastric, bradycardia, induced by, 109, 
 187 
 
 Umbilicus, swollen liver reaching below, 
 due to venous pressure, 154 
 
 Unconsciousness (and falling), from over- 
 use of pig-tail tobacco, 170 
 
 in syncope ^probable cause, 114 
 
 Upas (Antiaris toricaria), action of, not 
 used medicinally, 146 
 
 Upright position, blood-pressure in brain 
 less during, 115 
 
 work of diaphragm in moving abdom- 
 inal viscera in, 133 
 
 Uraemia, poison of, bradycardia caused 
 by, 187 
 
 Ureter, discomfort without pain fre- 
 quently felt by, 120 
 
 effect on, of (a) pressure from without, 
 
 1 20 
 (b) distension from within, ib. 
 
 Urinary bladder, discomfort without pain 
 frequently felt by, 120 
 
 effect on, of (a) pressure from without, 
 1 20 
 
 Urinary bladder, effect on, of (b) dis- 
 tension from within, ib. 
 
 Urine, albumen in, action on, of mer- 
 cury, 208 
 
 due to reaction from toxic doses of 
 
 digitalis, 156 
 
 due to venous engorgement, 129 
 
 in sleeplessness of cardiac disease not 
 
 centra-indication of use of opium 
 or morphine, 195 
 
 scanty, in venous engorgement, 129 
 
 secretion of, as affected by caffeine, 
 150, 161-2 
 
 as affected by digitalis, increase in, 
 
 150-1; often enormous, 152; second 
 stage, symptoms and danger in, 
 160; toxic stage, stoppage in o.b- 
 servations on, of Brunton and 
 Power, and Brunton and Pye, and 
 on subsequent condition of urine, 
 155-6 
 
 Uropherin, nature and uses of, 162 
 
 Urticaria, causes and symptoms of, 117 
 
 VAGUS(J), branches and ends in the 
 
 heart, 
 
 irritation of, in relation to bradycar- 
 dia, 1 86 
 
 paralysis of, from aconite, 171 
 
 from nicotine, 168 
 
 Vagus center (roots) in medulla, effects 
 on, of aconite results, 171 
 
 of digitalis, 146 
 
 ; of nicotine, 167-8 
 
 in relation to the emotions, 104, 121, 
 
 (/*) 100, 101, 103 
 - inhibitory and vaso-motor centers of, 
 
 as affected by digitalis, 149, 155 
 irritation of, causing bradycardia,causes 
 of, 109, 1 88 
 
 how induced how affecting heart's 
 
 rate, etc., 15, (fig.) 13 
 
 of (dog's heart), prolonged systole 
 
 secured by, 158 
 
 (mechanical) of, or pressure on 
 
 feeling of oppression of chest 
 caused by author's personal ob- 
 servation Czermak's personal ex- 
 perience, 121, and note 
 neuritis of, in convalescence from diph- 
 theria effects of, on the pulse, 187 
 Vagus nerve, organs to which it gives 
 
 branches, 104 
 origin of name, 104 
 paralysis of, 
 
 from alcoholic neuritis, 107 
 
 from atropine or belladonna in ex- 
 cessive doses, 107 
 
 from toxin of diphtheria, 105, 107 
 
 pulse-rate in men after, 107 
 
 roots, normal, and severed, action on, 
 
 of increased blood-pressure, 105 
 Valsalva's experiment nature of, 130 
 Valves of the heart (see also under 
 
 _ Names), 39-40 
 
 aid given to, by muscular fibers round 
 auriculo-ventricular orifice, 40, (figs.) 
 39 
 
 non-existent in pulmonary veins con- 
 sequence, 127 
 
 non-existent in venae cavse conse- 
 quence, 129 
 
 numerous, of lymphatics and veins, 6 
 uses of, 39-40; action of, how assisted, 
 
 40, (figs.) 38, 39 
 
 Valvular action of the heart how 
 strengthened by digitalis, 150
 
 INDEX 
 
 265 
 
 Valvular diseases of the heart, 122 et 
 
 seq. 
 
 causes and symptoms, 
 aortic obstruction, 122 
 
 aortic regurgitation, 122 
 
 cardiac strain, 126 
 
 failing compensation, 123 
 
 mitral incompetence, 124 
 
 treatment of aims uses methods 
 
 hopefulness of, 131 et seq. 
 rest, absolute, author's definition 
 
 of, and insistence on, 130 
 position in difficulties concern- 
 ing, 134 
 
 rules regarding 11 , 132; arrange- 
 ments for evacuation when re- 
 cumbency or fixed position is 
 essential, 132, 13^ 
 Valvular incompetency lessened and 
 
 often overcome by digitalis, 150 
 Vasa-vasorum, functions and importance 
 
 of, 99 
 
 Vascular dilatation, caused by heat, 106 
 local, with effusion of lymph, a cause 
 
 of urticaria, etc., 118 
 
 Vascular dilators, in relation to high 
 blood-pressure of gouty kidney dis- 
 ease, 101 
 
 requisite in cases of paroxysmal 
 
 tachycardia with high tension, 185 
 Vascular districts in the body, the four 
 
 largest, (fig.) 16 
 Vaso-dilators, 141, 163 
 amyl nitrite, 163-4 
 hydroxylamine, 166 
 ispbutyl nitrite, (fig.) 164 
 nitrites, 163-6 
 nitro-erythrol, 166 
 nitroglycerine, 165 
 - nitro-mannitol, 166 
 sodium, and other nitrites, 166 
 - combination of, with digitalis, etc. re- 
 sult, 163 
 Vaso-motor nerves, center(s) of, 
 
 location of chief and subsidiary, 
 
 1 6-7, 45 
 in medulla, 
 
 effect on, of caffeine, how differ- 
 ing in result from that of dig- 
 italis, 162 
 
 effect on, of digitalis, 149, 155 
 action in reducing oedema, 152 
 stimulation of, by nicotine, effects 
 of, on arterioles, 167 
 
 influence of, on blood-pressure, 
 
 13-15. (fig.) . i.3 
 
 in relation to migraine, 120 
 
 in relation to oedema, action on, of 
 
 digitalis, in reducing the disease 
 Ranvier's experiment, 153 
 Vaso-motor system as arterial turncock, 
 
 Ludwig cited on, 5 
 Vegetal growths, 
 
 on aortic valves often calcareous, 122 
 on mitral valves consequences, 127 
 Vegetarian diet, suitable in angina pec- 
 
 toris points to heed in, 191 
 Veins, see also under Names, and see 
 
 Capillaries 
 
 circulation in, how kept going, 5-6, 
 99, 101-2 
 
 function of valves in, ib. 
 
 intermittent external pressure in, ib. 
 
 independent pulsation of, 18, and notes, 
 
 44 
 
 measurement of pressure in, 83-4, 
 (figs.) 61, 66, 67 
 
 Veins, rhythmical contraction of, ob- 
 servers of, and views on, 128, note 
 stretching of, effect of, on walls of, 
 
 Braune cited, 6 
 valves in, uses of, 5 
 Venae cayae, absence of valves in, as 
 affecting venous engorgement, 129 
 
 as affected by raising of legs, 133 
 
 of dog, Ranvier's experiment on, as 
 
 to dropsy, 153 
 
 - independent pulsation in, 18, 44 
 Vense cavae and pulmonary veins, rhyth- 
 mical pulsations of, observations on, 
 of Brunton and Fayrer, and of 
 others, 128, note 
 
 Venous blood from stomach and intes- 
 tines passage of, through liver 
 how facilitated by action of digitalis, 
 154 
 
 circulation, how benefited by digitalis, 
 150 
 
 how maintained subsidiary agencies, 
 
 5-6, 99, 102 
 
 congestion, effect of, on digestive and 
 assimilative organs lessened by dig- 
 italis, 150-2 
 
 effect of, on kidneys diminished by 
 
 digitalis, 151-2 
 
 engorgement, cause first indication 
 how relieved -sequence of, and con- 
 sequences, 129 
 
 - obstruction in relation to, but not 
 always concomitant with, oedema 
 Ranvier's experiment, 153 
 Venous sinus and auricles, action of, 
 under heat, 106 
 
 in frog's heart, 19 
 
 as affected by stimulation, 35, (fig.) 
 
 36 
 
 Venous stasis, 
 Treatment of, 
 
 complete rest with massage, 202 
 
 gentle exercises, 202 
 
 inhalation of oxygen, 202 
 
 with drugs, in mitral incompetence, 
 
 197 
 
 Ventricle (s), action of, in mitral incom- 
 petence, 127 
 
 dilatation of, from regurgitation with 
 
 stenosis, 122 
 
 in treatment of angina attacks 
 methods for, very beneficial, 189, 
 191 
 
 hypertrophy of, in aortic regurgita- 
 tion cause compensatory effects, 
 122 
 
 investigation of, with Marey's cardio- 
 graph results, 86-7, (/>) 87 
 
 walls of, action of, in high arterial 
 
 tension and when hypertrophied, 
 as affecting first heart sound, 43 
 - left, relative work and strength of, 44 
 
 yielding of, before strain of aortic 
 
 regurgitation consequences, 196 
 right, hypertrophy of, how caused by 
 mitral obstruction consequent regur- 
 gitation, 129 
 
 relative work and strength of, 44 
 
 weakness of, absolute or relative 
 
 symptoms produced by, similar to 
 those of venous engorgement, 129 
 Ventricle(s), frog's heart, 19 
 
 frog's heart, construction of, 27-8 
 
 irritation (electrical) of, results at 
 different periods (Brunton and 
 Cash), 34, (figs.) 35
 
 266 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Ventricular action, increased resistance 
 to diseases causing bradycardia in- 
 duced by, 1 08 
 
 beats frog's heart inhibited by redu- 
 plicated auricular beat, due to stim- 
 ulation, 34, (fig.) 35 
 
 cycle, pressure-changes during, ascer- 
 tained by Marey's cardiograph, 84-7, 
 (.fig.) 87 
 
 pulse, analogy of, to senile pulse, 89, 
 (fig.) 88 
 
 systole, suction action of, Briicke's 
 view, 97, (fig.) 96 
 
 tracing of, with Marey's cardiograph, 
 
 (fig.) 87 
 
 Vessels, see Blood-vessels 
 Vocal cords false, in relation to cough- 
 ing, 130, and note 
 Vomiting center, as affected bv digitalis 
 
 in poisonous doses, 149, 155 
 as affected by disgust, 104 
 Vulpian, observations by, on rhythmical 
 contraction of vessels, 46 
 
 WALKING-POWERS, limited, of old persons 
 with degenerated arterial walls 
 (Brodie), 116 
 
 slowly after meals, essential to angina 
 patients and those menaced by an- 
 gina why, 192 
 
 steady, no risk from, in aortic regurgi- 
 tation, 196 
 
 uphill, in Oertel's treatment, 201, 202 
 
 Waller, Prof., observations of, on stimu- 
 lation of the vagus center prevent- 
 ing heart's beating, 16 
 
 simple s^ lygmomanometer of, 62 
 
 Warm-blooded animals (see also Mam- 
 mals), effect on, of heat and cold, 51 
 
 food, beneficial in sleeplessness why, 
 175 
 
 - poultice of heart, stimulating effect of, 
 178 
 
 Wassilieff, fatty degeneration of the 
 heart of rabbit found by, on section 
 of the vagi, 105 
 
 Waste products, accumulation of, in ab- 
 solute rest treatment cause, 134 
 relieved by massage, 135, 137, 138 
 accumulation of, dangers from, 143 
 in isolated frotr's heart how re- 
 moved Ludwig's experiment, 143, 
 (fig.) 142 
 
 elimination of, in cardiac disease 
 
 purgatives for, 203 
 stimulation by, of vessels, 49 
 
 tissues, " ashes " of, sec Waste Prod- 
 ucts. 
 
 Water, best way and time for taking, by 
 the flatulent, 182 
 
 withdrawal of, from body, use in, of 
 compound jalap powder dose, 203 
 how effect may be enhanced, 203 
 
 Weakness of cardiac muscle, indicated by 
 lessened first heart sound, 42-3 
 
 of the heart, see Cardiac Weakness 
 
 of right ventricle symptoms of venous 
 engorgement produced by^causes and 
 classes of, 130 
 
 of vision, due to smoking, 170 
 
 Weariness, weight and discomfort felt in 
 limbs of persons in absolute rest 
 treatment causes relieved by mas- 
 sage, 134 et seq. 
 
 Weir-Mitchell treatment in severe cases 
 of palpitation, 183 
 
 Williams, C. J. B., apparatus of, for in- 
 vestigating action of drugs on frog's 
 heart, (fig. and note) 23 
 
 and others, cause of second sound of 
 heart ascertained by, 41 
 
 discovery by, as to intensification of 
 first sound, 42 
 
 Work, see Exertion 
 
 Worry, effect of, on the circulation, 104 
 
 XANTHINE, and other purin bodies use 
 of, 145 
 
 ZINC, sulphate of, 20-gr. emetics to cut 
 short attack of parqxysmal tachy- 
 cardia, 184-5
 
 INDEX TO APPENDIX 
 
 ALCOHOL, effect of, on the sensitive plant 
 author's experiments, 211 
 
 Algina's experiments on ventricle-beat in 
 frog's heart, 227 
 
 Amoeba, undifferentiated functioning in, 
 212 
 
 Amphibian hearts self-massage in process 
 of Kronecker on, 226 
 
 Angina pectoris, exercise in, why bene- 
 ficial, 223-4 
 
 Animal protoplasm higher and lower 
 functions of, 212 et seq. 
 
 Animals, effect on, of chloroform, 211 
 
 Arteries, current of blood in impor- 
 tance of (rhythmic) pulse for, Kro- 
 necker and Hamel's experiments 
 proving, 231-2 
 
 Asphyxial blood, why poisonous, 226 
 
 Atrio-ventricular bundle of Stanley Kent 
 and His, 215 
 
 in relation to coordination of heart- 
 beats experiments of Kronecker and 
 others, 229 
 
 Auricles and ventricles, normal contrac- 
 tion of, simultaneous, 229 
 
 Auricles to ventricles, means of conduc- 
 tion of stimuli from, present view, 
 215 myogenic view, 228; not en- 
 dorsed by Kronecker's and others' 
 experiments, 229 
 
 Auricular and ventricular pulsations, coor- 
 dination of, function in regard to, of 
 Purkinje's cells, 215 
 
 BALFOUR, PROF. J. H. (the late), and 
 other observers of the functions of 
 vegetable protoplasm, 211 
 
 Beating of the heart materials enabling, 
 225-6 
 
 Blastoderm of vertebrate embryo, layers 
 in corresponding layers in fresh- 
 water hydra, 213 
 
 Blood, asphyxial, why poisonous, 226 
 
 as cardiac nutrient, not better than 
 serum why, 226; when injurious, ib. 
 
 laky (dissolved erythrocytes), why poi- 
 sonous to the heart, 226 
 
 Blood-pressure how lessened by exertion 
 of going uphill, 224 
 
 in man instruments for measuring, 
 
 choice of, 220 
 
 Gibson's clinical polygraph, 221 
 Janeway's, 216 
 
 Martin's new modification of Riva- 
 Rocci's, 217, 222; description, 
 directions for use, etc., 218-9 
 
 choice of Mummery's (Lockhart), 
 
 modification of Riva-Rocci's, 220 
 
 Oliver's new sphygmomanometer, 
 
 220 
 
 Blood-vessels, effects on, of muscular 
 compression of, 223, 224 
 
 Boulitte, M., maker of sphygmomanome- 
 ters, 221, 223 
 
 Bowditch's law (on stimuli in relation to 
 resultant heart-beats), 226; excep- 
 
 tions, ib. disproved by Kronecker, 
 226-7 
 
 Bowditch's " Treppe " (ascending stair- 
 case), Kronecker's explanation, 226 
 
 Briicke, experiments of, on the functions 
 of vegetable protoplasm, 211 
 
 observations on the suction-action of 
 cardiac systole, 225 
 
 Brunton, Lauder, experiments by, on 
 contractility and conduction* of stim- 
 uli by vegetable protoplasm, 211 
 extracts from unpublished essay on, 
 
 2 1 1-2 
 
 extract from Harveian oration by, on 
 exercise in angina pectoris, why ben- 
 eficial, 223-4 
 
 Bundle, see Atrio-ventricular Bundle 
 
 CARBOHYDRATES inadequate to replace al- 
 bumen as heart-food, 225 
 
 Cardiac energy, how maintained, 225 
 lessened restored, 226 
 
 systole, suction-action of, indicated by 
 Briicke, 225 
 
 Chloroform, effect of, on animals, 211 
 on the sensitive plant Marcet's ob- 
 servations, ib. 
 
 Circulation through muscles two antago- 
 nistic factors in, 223 
 
 in splanchnic system, Kronecker's ex- 
 periment, 231-2 
 
 Cold, as affecting the irritability of the 
 heart, Kronecker's experiments, 227 
 
 effect of, on pulsations of frog's heart, 
 Kronecker's experiments, 227 
 
 Coldstream, experiments of, on the func- 
 tions of vegetable protoplasm, 211 
 
 Conduction of stimuli, see Stimuli 
 
 - of stimuli in the heart, 230-1 
 
 Contractility of fresh-water hydra, 214 
 
 in vegetable protoplasm author's ex- 
 periments, 211 
 
 Contraction, normal, of auricles and ven- 
 tricles simultaneous, 229 
 
 Coordination of heart-beats, 
 
 how effected, 228 
 
 how disorganized, 228, 229 
 
 Coronary arterial system, effects of nar- 
 rowing on coordination of heart- 
 beats, Kronecker on, 229 
 
 Doc's bladder slight striation in invol- 
 untary muscle of (Schwalbe), 214 
 
 hearts, fibrillation in, only overcome 
 artificially, Kronecker's experiment, 
 228-9 
 
 Down Bros., makers of Von Basch's 
 sphygmomanometer, 222 
 
 Dutrochet, experiments of, on the func- 
 tions of vegetable protoplasm, 211 
 
 ECTODERM in fresh-water hydra, function 
 
 connected with Ranvier on, 213 
 cells of, functions of, 213 
 Embryonic muscle, striation in, 214 
 
 267
 
 268 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Embryo (s) of higher animals, incomplete 
 differentiation in, 212 
 
 vertebrate blastoderm of- layers in, 
 corresponding layers in the body-wall 
 of fresh-water hydra, 213 
 
 Endoderm in fresh-water hydra Ranvier 
 on, 212 
 
 Erythrocytes, dissolved, why poisonous to 
 the heart, how made harmless, 226 
 
 Exercise in angina pectoris why bene- 
 ficial, 223-4 
 
 FIBRILLARY action of the heart when 
 occurring how overcome Kroneck- 
 er's experiments, 228-9 
 
 Frog's heart, pulsations of, with varying 
 temperatures and stimuli, Kroneck- 
 er's experiments and deductions, 227 
 
 GANGLIA in lizards' hearts, discovered by 
 Imchanitzky function of, 229 
 
 Gibson's (Dr. A. G.), clinical polygraph, 
 221 
 
 Glycogen no adequate substitute for al- 
 bumen as heart-food, 225 
 
 HAMEL, DR. G., see Kronecker and Hamel 
 Harveian oration, by author extract 
 from, on exercise in angina pectoris, 
 why beneficial, 223-4 
 Heart, 
 
 conduction of stimuli in, 230-1 
 irritability of, as affected by heat and 
 
 cold, Kronecker's experiments, 227 
 non-existent during systole, Kroneck- 
 er's discovery, 227 
 
 refractory period of, Kronecker's dis- 
 covery concerning, 227 
 self-massage of, Kronecker on, 225, 226 
 tetanizing of, 228; why impossible, 227 
 work of, how performed, 225 
 Heart-beats, Bowditch's law on, proved 
 (without exceptions) by Kronecker, 
 226^7 
 
 coordination of the two views -Kro- 
 necker's and Imchanitzky's experi- 
 ments, 228-9 
 
 Heart-block, causation and treatment of, 
 conduction of stimuli in regard to 
 problem of, 225 
 Heat as affecting the irritability of the 
 
 heart, Kronecker's experiments, 227 
 effect of, on pulsations of frog's heart, 
 
 Kronecker's experiments. 227 
 His, see Kent, Stanley and His 
 Hydra, fresh-water, contractility of, 214 
 elongatory power of possible explana- 
 tion of, 214 
 
 incomplete differentiation in, 212 
 neuro-muscular cells in, 212 Ranvier's 
 description, 212 et seq. observa- 
 tions on, by him and by Kleinen- 
 berg, ib. 
 
 IMCHANITZKY, see Kronecker and Imcha- 
 nitzky 
 
 Incoordination of heart-beats how pro- 
 duced how readjusted Kronecker's 
 (and others) experiments, 228-30 
 
 Inorganic solutions incompetent to supply 
 energy to the heart, 225 
 
 Intermittent effect of constant stimuli (.e. 
 g., chemical), Kronecker's experi- 
 ments concerning, 227 
 
 Irritability of the heart, as affected by 
 heat and cold, Kronecker's experi- 
 ments, 227 
 
 Irritability of the heart, non-existent dur- 
 ing systole, Kronecker's discovery, 227 
 
 JANEWAY'S sphygmomanometer, described, 
 216 
 
 KENT, STANLEY and His, Atrio-ventricu- 
 lar bundle of, 215; in relation to 
 coordination of heart-beats experi- 
 ments on, of Kronecker and others, 
 229 
 
 Kleinenberg and Ranvier's observations 
 on the neuro-muscular cells in the 
 fresh-water hydra, 212 et seq. 
 
 Kronecker, Professor, notes by (Appen- 
 dix D), 225 et seq. 
 
 Kronecker and Algina, experiments of, 
 on stimulus required to keep ventri- 
 cles of frog's heart working, 227 
 
 Kronecker and Hamel, experiments of, 
 on rhythm of pulse and its advan- 
 tages, 230 
 
 Kronecker and Imchanitzky's experiments 
 on coordination of heart-beats, 228-31 
 
 LEUCOCYTES of higher animals functions 
 exercised by every part of, 212 
 
 Livingstone, experiments of, on the func- 
 tions of vegetable protoplasm, 211 
 
 Lizards' hearts, nerves and ganglia in, 
 governing coordination of heart-beats, 
 discovered by Imchanitzky, 229 
 
 Lomakina, Dr., observations of, on dis- 
 turbance of coordination of heart- 
 beats in animals' heart by ligature 
 not affecting the atrio-ventricular 
 bundle, 230 
 
 Ludwig, Prof., experiments of, on effect 
 of muscular action on lymph-flow, 225 
 
 Ludwig, Prof., and Sadler, observations 
 of, on circulation through the mus- 
 cles two antagonistic factors in, 223, 
 224 
 
 Lymph-flow, effect on, of muscular ac- 
 tion, shown by Ludwig, 225 
 
 MACAIRE-PRINSEP, experiments of, on the 
 functions of vegetable protoplasm, 211 
 
 Marcet, experiments of, with chloroform, 
 on the sensitive plant, 211 
 
 Martin's (C. J.) new modification of Riva- 
 Rocci's sphygmomanometer, 217 de- 
 scription, directions, etc., 218-9 
 value and cheapness of, 222 
 
 Massage, internal, rhythmical pulse act- 
 ing as, 232 
 
 Mercurial manometer, for testing accu- 
 racy of Von Basch's or Potain's 
 sphygmomanometers, 222 
 
 Mesoderm in fresh-water hydra, function 
 connected with Ranvier on, 213, 214 
 
 Motor nerve, stimulation of amount of 
 blood before, during and after, on 
 what dependent, 223 
 
 Mummery (Lockhart), modification of, by 
 Riva-Rocci's sphygmomanometer, 220 
 
 Muscle (s), circulation through, two an- 
 tagonistic factors in, 223 
 
 conduction of stimuli by, modern view 
 on, 225 
 
 embryonic striation in, 214 
 
 involuntary, of dog's bladder, slight 
 striation in (Schwalbe), 214 
 
 transverse (hypothetical), contractility 
 of, 214
 
 INDEX TO APPENDIX 
 
 269 
 
 Muscular action, effect of, on lymph-flow, 
 shown by Ludwig, 225 
 
 Myogenic view of coordination of heart- 
 beats, contrary deductions from Kro- 
 necker's experiments, 228 et seq. 
 
 NERVE-PLEXUSES, accompanying the bun- 
 dle of Stanley, Kent and His, dis- 
 covery concerning of Paukul, 229 
 
 non-medullated, effecting coordination 
 of heart-beats, effects of paralysis of, 
 228 
 
 Nerves, conduction of stimuli by, evi- 
 denced by Kronecker's notes, 225 et 
 seq. 
 
 in lizards' hearts discovered by Im- 
 chanitzky function of, 229 
 
 Nervous system in plants, author's prize 
 essay cited on, 211-2 
 
 Neuro-muscular cells in fresh-water hy- 
 dra, Ranvier's description, 212 et seq. 
 
 Notes by Professor Kronecker (Appen- 
 dix D), 225 et seq. 
 
 (EDEMA, caused by continuous pressure 
 
 on vascular walls, 232 
 Oliver's new sphygmomanometer, 220 
 Oxygen, not an increase of work done 
 
 by heart, 226 
 
 PAIN in heart enfeebled by arterial dis- 
 ease, how caused, 223-4 
 
 Paralysis of non-medullated nerve-plex- 
 uses effecting coordination of heart- 
 beats consequences, 228 how over- 
 come, Kronecker's experiments, 229 
 
 Paukul, Dr., discovery of, on Stanley, 
 Kent and His's bundle, in connec- 
 tion with coordination of heart-beats, 
 229 
 
 Poisons, how acting on vegetable organ- 
 isms gain derivable from discover- 
 ing, 212 
 
 Polygraph, Gibson's clinical, 221 
 
 Portal venous system of rabbit Kro- 
 necker's experiment on, with saline 
 solution various conditions, 232 
 
 Potain's sphygmomanometer, ease with 
 which applied, 222 
 
 Pressure, continuous, on vascular walls 
 oedema caused by, 232 
 
 Protoplasm, functions of, 211 
 
 Protoplasm, animal higher and lower 
 functions of, 212 et seq. 
 
 vegetable, contractility and conduction 
 of stimuli by, author's experiments, 
 211 
 
 Pulsations, auricular and ventricular 
 coordination of function in regard 
 to, of Purkinje's cells, 215 
 
 stimuli, in relation to Bowditch's law 
 Kronecker's proof of, 226-7 
 
 Pulse rhythm in advantages of exper- 
 iments of Kronecker and Hamel 
 proving, 231-2 
 
 Purkinje's cells, functions of recent 
 views, 215, (.fig.) 214 
 
 RABBIT portal venous system _ of Kro- 
 necker's experiment on, with saline 
 solution various nressures, etc., 232 
 
 Rabbits' hearts, fibrillation in, sometimes 
 spontaneously overcome, 228 
 
 Ranvier's description of the neuro-mus- 
 cular cells in the fresh-water hydra, 
 212 et seq. 
 
 Refractory period of the heart, Kroneck- 
 er's discovery, 227 
 
 Rest of vascular walls secured by rhythm 
 in pulse, advantages of, 232 
 
 Rhythm in pulse, advantage of. experi- 
 ments of Kronecker and" Hamel 
 proving, 231-2 
 
 Riva-Rocci's sphygmomanometer, 
 
 Martin's modification of, 217, 222 
 
 description, directions, etc., 218-9 
 
 Mummery's modification of, 220 
 
 SADLER, see Ludwig and Sadler 
 
 Saline solutions, effect of, on cardiac en- 
 ergy, 226 
 
 in portal venous system of rabbit, 
 
 flow of various conditions Kro- 
 necker's experiment, 232 
 
 Schwalbe, observation by, on slight stria- 
 tion in involuntary muscle of dog's 
 bladder, 214 
 
 Self-massage of heart, Kronecker on, 225, 
 226 
 
 Sensitive plant (Mimosa ptidica), au- 
 thor's experiments on the effects on, 
 of stimuli, 2ii 
 
 Serum as a restorative of cardiac en- 
 ergy, 226 
 
 Serumalbumin, sole material enabling the 
 heart to beat, 225 
 
 Serumglobulin, in relation to the beating 
 of the heart, 225 
 
 Solutions of inorganic salts effect of, on 
 pulsation of heart, 225 
 
 Splanchnic system, circulation in, Kro- 
 necker's experiment, 231-2 
 
 Stimuli, 
 
 conduction of, 
 from auricles to ventricles, present 
 
 view, 215 
 in heart, 230-1 
 
 by nervous (as well as muscular) 
 
 channels, evidenced by Kroneck- 
 er's notes, 225 et seq. 
 by vegetable "rotoplasm, author's ex- 
 periments, 211 
 
 constant (e. g., chemical) intermitting 
 effect of, how proven, Kronecker's 
 experiments, 227 
 
 frequent (intermitting) reaction to, of 
 the heart one consequence, 227 
 
 in relation to pulsations, Bowditch's 
 law, Kronecker's proof of, 226-7 
 
 Stopcock for use with Von Basch s in- 
 strument, 222 
 
 striation in muscle of dog's bladder 
 (Schwalbe), 214 
 
 of embryo, 214 
 
 of Purkinje's cells, 2ie, (.fig.) 214 
 
 Suction-action of cardiac systole, indi- 
 cated by Briicke, 225 
 
 Systole in amphibian hearts, effect of, on 
 nutrition, Kronecker on, 226 
 
 in auricje, immediate sequence of the 
 same in ventricle, 229 
 
 non-irritability of the heart during, 
 Kronecker's discovery, 227 
 
 - suction-action of, indicated by Brucke, 
 225 
 
 TETANIZING of the heart, 228 why im- 
 possible, 227 
 
 VAGUS(I), 
 
 cardiac non-effective on heart cavities 
 under local stimulation, 230
 
 2/0 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Vagus, inhibition by (when stimulated) .of 
 ventricle, while not affecting auricles 
 Kronecker's experiment showing, 
 230 
 
 not an anabolic nerve how proved, 
 230 
 
 Vascular walls, rest of, secured by 
 rhythm of pulse, advantage of, 232 
 
 Vegetable organisms effects on, of poi- 
 sons, advantage of discovering, 212 
 
 protoplasm functions of author's ex- 
 periments and (.unpublished) essay 
 on, 2 1 1-2 
 
 Ventricles, conduction of stimuli to. from 
 auricles, 215 Kronecker's (and 
 others') experiments deductions as 
 to coordination of heart-beats, 229 
 
 frog's heart, stimulus required to keep 
 working,. Kronecker's and Algina's 
 experiments, 227 
 
 Ventricles, inhibition of, by vagi, while 
 auricles not affected Kronecker's 
 experiment, 230 
 
 locally stimulated, irresponsive to in- 
 hibitory action of vagus, 230 
 
 no true automatism in how deduced, 
 227 
 
 Ventricular septum, center in, for inner- 
 vation of coronary vessels, Kronecker 
 on, 229 
 
 Verdin, Ch., maker of sphygmomanom- 
 eter, his successor, 222 
 
 Von Basch's sphygmomanometer, ease 
 with which applied, 222 
 
 WALKING on the flat and uphill in angina 
 cases phenomena of how explica- 
 ble, 224 
 
 Work, the, of the heart, Kronecker on, 
 225
 
 CLASSIFIED LIST OF ILLUSTRATIONS 
 
 ACCORDING TO SUBJECTS 
 
 NOTE. The first numerals after the word (Fig.) refer to the number of the illustra- 
 tions, and the second to the page. 
 
 ABDOMEN, in normal state, and in ad- 
 vanced dropsy diagrammatic section 
 of, fig. 179, 152 
 
 Abdominal contents, see position in re- 
 gard to, infra 
 
 Amoeba quickly changing its form, fig. 
 27, 26 
 
 Aorta, atheroma of sound indication 
 usual position of diagram to show, 
 fig. 152, 123 
 
 Aortic regurgitation (see also under 
 Pulse), occurrence in, of syncope 
 diagram to illustrate, fig. 217, 195; 
 tendency in, to syncope diagram 
 illustrating, fig. 153, 124 
 
 Atheromatous cerebral artery section of, 
 fig. 128, 98 
 
 Atrio-ventricular bundle of Stanley, Kent 
 and His, seen from right ventricle, 
 fig. 213, 215 
 
 BLOOD, amount of, flowing from veins of 
 biceps of dog during tetanus, fig. 239, 
 223 
 
 distribution of, in the body, four great 
 areas for diagram showing, fig. 13, 
 1 6 
 rapidity of flow of, through vessels of 
 
 muscles, fig. 12, 14 
 
 Blood-pressure in dog, normal, fig. 183, 
 156 
 
 as affected by digitalis, earlier stage, 
 
 fig. 184, 156; later stage, fig. 185, 157 
 
 as affected by electrical stimulation 
 
 of vagus before administration of 
 digitalis, fig. 186, if; after this, 
 fig. 187, 158 
 effect on, of amyl nitrite, fig. 190, 164 
 
 of digitalis, fig. 188, 159, and see 
 
 figs. 183-7, 156-8 
 
 of hydroxylamine hydrochlorate, fig. 
 
 191, 165 
 
 of isobutyl nitrite, fig. 189, 164 
 
 of massage, fig. 165, 136 
 
 equal nervous apparatus to which due 
 
 diagram showing, fig. 1 i, 13 
 Blood-pressure measuring instruments, 
 
 Brunton's apparatus for ascertaining 
 
 correctness or amount of error in 
 an aneroid sphygmomanometer, fig. 
 103, 83 
 
 arrangement for using a broad 
 
 Riva-Rocci band with Von 
 Basch's or Potain's sphygmoma- 
 nometer, instead of a mercurial 
 manometer, fig. 101, 80 
 
 method of combining Ludwig's and 
 
 Pick's kymographs for register- 
 ing blood-pressure and pulse, fig. 
 76, 59 
 
 2 7 
 
 Blood-pressure measuring instruments 
 
 continued 
 Brunton's modified Riva-Rocci band, 
 
 fie. 100, 79 
 
 Burdon-Sanderson's cardiograph for 
 apex-beat, fig. 107, 86 
 
 cardiac sounds, by which tracings in 
 
 fig. 108 were obtained, fig. 105, 85 
 Dudgeon's sphygmograph, fig. 123, 94 
 for estimating blood-pressure in cap- 
 illaries, fig. 80, 62 
 
 Pick's apparatus for measuring and 
 recording changes in volume of 
 organs, fig. 89, 68 
 kymograph, fig. 75, 58 
 Gaertner's tonometer, fig. 95, 74 
 portable form of the same, fig. 96, 
 75 
 
 mode of using the latter, fig. 97, 
 
 75 . 
 
 Gibson's clinical polygraph, fig. 238, 
 
 221 
 
 Herison's sphygmomanometer, fig. 81, 
 
 62 
 
 for indicating mode of contraction 
 
 of heart or nature of pulse-wave, 
 82 et seq. 
 Janeway's sphygmomanometer, fig. 
 
 234, 216 
 
 Laulanie's digital sphygmograph, fig. 
 124, 95 
 
 manometer, fig. 9, 12 
 
 Ludwig's kymograph, fig. 8, 1 1 ; fig. 
 
 7i, 56 
 
 Marey s apparatus for measuring 
 
 blood-pressure in a finger, fig. 92, 
 7i 
 
 cardiograph, fig. 106, 86 
 
 hsemodynamometer, fig. 70, 55 
 improved metallic manometer, fig. 
 1 02, 8 1 
 
 registering metallic manometer, fig. 
 
 72, 57 
 
 sphygmograph, fig. 120, 92; mode 
 of applying the same, fig. 121, 
 
 93 
 
 transmitting form of the above, 
 
 fig. 122, 93 
 
 tambour, tracings of oscillations 
 
 made with, fig. 74, 58 
 
 for recording movements, fig. 
 
 104, 82 
 transmitting sphygmograph, /J. 122, 
 
 93 
 
 Martin's modification of Riva-Rocci's 
 
 sphygmomanometer, fig. 235, 217 
 
 mercurial manometer oscillations in, 
 
 fig. 73, 58 
 
 Mosso s ergograph. fig. 164, 135
 
 272 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Blood-pressure measuring instruments 
 
 continued 
 Mosso's plethysmograph, fig. 90, 69; 
 
 combination of the above, with 
 
 Marey's metallic manometer, fig. 
 
 91, 70 
 
 sphygmomanometer, fig. 93, 72 
 
 Mummery's modification of Riva- 
 
 Rocci's sphygmomanometer, fig. 
 
 236, 220 
 Oliver's sphygmomanometer, fig. 88, 
 
 67 
 
 new sphygmomanometer, fig. 237, 
 
 220 
 
 one in which movements of spring 
 
 are magnified and read off on dial, 
 fig- 79. 6 1 
 
 plethysmograph of Hallion and Combe, 
 
 fig, Q4, 73 
 
 Potain's modification of Von Basch's 
 
 aneroid sphygmomanometer, fig. 
 85, 66 mode of applying the fore- 
 going, fig. 86, 66 
 
 Potain's and Gaertner's apparatus 
 
 combined, fig. 98, 76 
 
 Riva-Rocci's sphygmomanometer, fig. 
 
 99. 78 
 
 simple instrument for measuring 
 
 blood-pressure in an artery, and 
 improvement on the same, fig. 77 
 a and b, 60 
 
 sphygmomanometer, simple, mode of 
 
 applying direct, on palpating fin- 
 srer instead of pressing it on artery 
 and feeling artery nearer the hand, 
 fig- 78, 6 1 
 
 Von Basch's sphygmomanometer, (a) 
 
 early form of, (b) author's cheap 
 modification of, fig. 82, 63 
 and stand, fig. 8-?, 64 
 aneroid pattern, fig. 84, 65 most 
 
 recent form, fig. 87, 67 
 Blood-pressure and secretion of urine, 
 relation between, after administra- 
 tion of erythrophlceum diagram to 
 show, fig. 182, 155 
 
 Blood-vessels in frog's foot, normal con- 
 dition, fig. 50, 47; fig. 195, 173 the 
 same, after irritation, fig. 51, 48; fig. 
 196, 173 
 Brain, in relation to senile decay 
 
 cell from that of woman aged TOO 
 
 years, being devoured by macro- 
 phags, fig. 227, 207 
 
 cerebral cortex, showing distribution 
 
 of functions, fig. 226, 206 
 
 distribution of arteries in, fig. 225, 
 
 206 
 
 CARDIAC dulness before and after a bath 
 
 diagram of, fig. 218, 197 
 sounds, by which tracings in fig. 108 
 
 were obtained, fig. 105, 85 
 Carotid, temporal and occipital arteries 
 
 diagrams of in normal state, fig. 
 
 149, 118 in migraine, fig. 150, 118; 
 
 fig. 151, 119 
 Cells taken from a heart in fibrillation, 
 
 fig. 240, 231 
 Circulation of the blood see also Lymph 
 
 Brunton's schema of, fig. 69, 55 
 
 diagram of, fig. 7, 10 
 
 flow of blood through vessels of mus- 
 cles rapidity of diagram show- 
 ing, fig. 12, 14 
 increased rapidity of, in carotid of 
 
 horse during mastication, fig. 192, 
 169 
 Circulation of the blood, artificial, 
 
 effect on beat of frog's heart fed 
 
 with NaCl solution, by addition of 
 a trace of calcium chloride, fig. 
 172, 144 
 
 of simple NaCl solution in weak- 
 ening pulsations of apex of frog's 
 heart tracings showing, fig. 171, 
 144 
 
 maintenance of, Ludwig and Coats* 
 
 frog-heart apparatus, fig. 170, 142 
 
 through liver ^effect of, at different 
 
 pressures diagram to show, fig. 
 14, 17 
 - entero-hepatic diagram to illustrate, 
 
 fig- 215, 192 
 portal veins forming part of, fig. 201, 
 
 179 
 Cold, effect of, on the arteries, fig. 135, 
 
 IO 3 fiS- 200, 176 
 Cold and heat, effect of, on the heart, 
 
 figs. 58-67, 52-3 
 
 Conduction in heart atrio-ventricular 
 bundle of Stanley, Kent and His, 
 seen from the right ventricle, fig. 
 233. 215 
 
 Congestion of lung diagram to show, 
 fig. 198, 176 
 
 effect on, of counter-irritants, fig. 
 
 199, 176 
 
 DIGITALIS, action of, 
 
 on dog, first stages of dog's blood- 
 pressure before and after admin- 
 istration of tracings of, figs. 183- 
 84, 156; fig. 185, 157 
 
 on frog's heart diagram to show, 
 
 fig. 174, 147. 
 
 on muscular rings of cardiac orifices 
 
 cases in which called for, and 
 effects of, figs. 175-7 (for legend, 
 see Valves, figs. 46-48), 151 
 
 Digitalis-poisoning, pulse-tracings from 
 case of, figs. 140-44, in 
 
 Dropsy, Ranvier's experiment on dia- 
 gram of, fig. 180, 153 
 
 EXOPHTHALMIC goitre- 
 185 
 
 case of, fig. 202, 
 
 FEVER, effect of, on pulse, fig. 137, 106 
 Fibrillation, cells taken from a heart in, 
 
 fig. 240, 231 
 Flatulence, effect of, on heart, fig. 169, 
 
 140 
 Frog, foot of vessels in 
 
 (a) normal condition, fig. 50, 47; 
 
 fig- 195, 173 
 
 (fc) after irritation, fig. 51, 48; fig. 
 
 196, 173 
 
 gastrocnemius of contraction in, enor- 
 mous, due to solution of caffeine, fig. 
 173, 144 
 
 normal contraction of, fig. 54, 50 
 
 heart of, action on, 
 
 of digitalis diagram to show, fig. 
 
 174, 147 
 
 of drugs Williams' apparatus for 
 
 investigating, fig. 22, 23 
 of heat, cold, and poisons au- 
 thor's instrument for showing, 
 fig. 20, 21 
 
 apex, effect of simple NaCl solution 
 
 on pulsations of, fig. 171, 144
 
 CLASSIFIED LIST OF ILLUSTRATIONS 
 
 273 
 
 Frog, heart of, action on continued 
 of the same, with trace of cal- 
 cium chloride, fig. 172, 144 
 auricle, effects on, of electrical stim- 
 ulation of auricle itself and of ven- 
 tricle, fig. 41, 36 
 auricular septum in, view of (seen 
 
 from left side), fig, 24, 24 
 auriculo-ventricular groove in effect 
 of compression of Gaskell's ex- 
 periment diagram to illustrate, 
 fig- 37, 32 
 
 diagram of, fig. 15, 20 
 
 difference in mode of experimenting 
 with, and with apex alone, dia- 
 gram to show, fig. 31, 28 
 ligatured in auriculo-ventricular 
 
 groove diagram of, fig. iSf, 20 
 at junction of venous sinus with 
 auricles diagram of, fig. 170, 
 20 
 
 at junction of venous sinus with 
 auricles, and at auriculo-ventric- 
 ular groove diagram of, fig. 
 17 c, 20 
 round middle of auricles diagram 
 
 of, fig. i8<?, 20 
 round venous sinus diagram of, 
 
 fig. i8d, 20 
 
 movements of -investigation of in- 
 struments for 
 Bowditch's, fig. 21, 22 
 Brunton's, for showing effects on, 
 of heat, cold, and noisons, fig. 
 20, 21 
 
 Kronecker's perfusion cannula, 
 with anterior part removed so 
 as to show the septum, fig. 23, 
 23 
 
 Ludwig and Coats' apparatus, 
 
 fig. 170, 142 
 
 Williams' apparatus for investi- 
 gating action of drugs on, figs. 
 22, 23 
 
 periodic rhythm of pulsations occur- 
 ring in groups, separated by inter- 
 vals .of complete quiescence, fig. 
 43. 36 
 
 in which sections have been made at 
 
 junction of venous sinus with auri- 
 cles, and at auriculo-ventricular 
 groove diagram of, iyb, 20 
 successive contraction of cavities in 
 diagram to show, fig. 16, 19 
 
 ventricle of, with Bidder's ganglia, 
 
 fig. 30, 27 
 
 effect on, of electrical stimulation, 
 
 fig- 38, 35 
 
 of electrical stimulation applied 
 
 during diastole (reduplication 
 of beat), fig. 40, 35 
 
 of electrical stimulation after re- 
 fractory period has passed (re- 
 duplication, etc.), fig. 39, 35 
 increasing contractions of, with 
 successive stimuli, fig. 33, 28 
 
 pulsations of, when separated from 
 
 auricles by section at auriculo- 
 ventricular groove tracing of, 
 fig. 44, 37 
 
 spiral ganglion cell from pneumogas- 
 
 tric of, fig. 26, 25 
 
 venous sinus effects on, of electrical 
 
 stimulation, fig. 42, 36 
 
 lungs of, effect of heat and cold on 
 author's apparatus for ascertaining, 
 fig- 68, 54 
 
 19 
 
 HEAT and cold, as affecting pain of in- 
 flammation diagram to show, fig. 
 197, 174 
 
 Heart of healthy man before exertion, 
 fig- 157. 125; after exertion, fig. 158, 
 125 
 
 in fibrillation, cells taken from a, fig. 
 240, 231 
 
 Hydra, fresh-water neuro-muscular cells 
 from, fig. 229, 212 
 
 INFLAMMATION, effect on, pain of, of heat 
 and cold, fig. 197, 174 
 
 KIDNEY, effect on, of venous congestion 
 and of obstruction of ureter or 
 tubules on the kidney diagram to 
 show, fig. 178, 152 
 
 LIVER, artificial circulation through, of 
 blood effect of, under different pres- 
 sures diagram to show, fig. 14, 17 
 return through, of venous blood from 
 stomach and intestines diagram to 
 show, fig. 181, 154 
 
 Lung, see Congestion and Frogs' Lungs 
 Lymph circulation, muscular action in aid 
 of longitudinal sections of muscles 
 (i) in relaxation, (2) in contraction 
 effects of, on lymph circulation 
 diagram of, fig. 3, 8 
 
 transverse section of voluntary mus- 
 cle, to show pumping action ex- 
 erted on muscle-juice and waste 
 products, during action diagram 
 of, fig. 2, 7 
 
 Lymph spaces, injected, from fascia lata 
 of dog, fig. 4, 8 
 
 MACROPHAGS, at work, figs. 227-8, 207 
 
 Massage, effect of, on blood-pressure, 
 first causing slight rise, then distinct 
 fall tracing to show, fig. 165, 136 
 on flow of blood through muscle 
 
 diagram to show, fig. 163, 133 
 in relief from fatigue tracing to 
 show, fig. 166, 135 
 
 mechanical exerciser, for use in combi- 
 nation with Mosso's ergograph, fig. 
 166, 137 
 
 Massage and graduated movements, effect 
 of pulse-tracing showing, fig. 132, 
 102; fig. 167, 138; fig. 219, 198 
 
 Medusae, action on, of poisons method 
 of localizing, diagrammatic represen- 
 tation of, fig. 35, 30 
 
 (Aurelia aurita) from which ganglia 
 have been removed, and bell cut into 
 long strip with cross cuts, to block 
 passage of contractile and tentacular 
 waves, fig. 36, 31 
 
 contractions in tissue of, increasing 
 when stimulated by repeated weak 
 shocks of same intensity, fig, 32, 28 
 
 (Sarsia), natural size, fig. 28, 27, the 
 same inverted, fig. 29, 27 
 
 (Tiaropsis), about one-third natural 
 size, with strip of contractile tissue 
 cut from bell, but left attached at 
 one end diagram of, fig. 34, 28 
 
 Mental activity, effect of, on volume of 
 blood in arm diagram to show, fig. 
 146, 114 
 
 Migraine, arteries concerned in dia- 
 grams of, in normal state, fig. 149, 
 118
 
 274 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 Migraine, arteries concerned in dilata- 
 tion and contraction of, during at- 
 tacks, fig. 150, 118; fig. 151, 119 
 
 Muscles, longitudinal section of, in re- 
 laxation and in contraction diagram 
 of, fig. 3, 8 
 
 vessels of rapidity of flow of blood 
 through, fig. 12, 14 
 
 Muscular contraction, 
 
 as affected by fatigue, fig. 56, 50 
 
 by heat and cold, '. 55, 50 
 
 apparatus for registering, fig. 52, 50 
 
 of gastrocnetnius of frog, (a) normal, 
 
 fig- 54. 5. (W enormous, of the 
 same due to caffeine, fig. 173, 144 
 
 of a muscle with stimuli of .increas- 
 ing strength, fi". 57, 50 
 
 pumping action exerted on muscle- 
 juice and waste products during 
 diagram of transverse section of 
 voluntary muscle to show, fig. 2, 7 
 
 revolving cylinder for recording 
 
 movements, fig. 53, 49 
 
 transverse (hypothetical) diagram 
 
 to illustrate, fig. 49, 46 
 
 NERVOUS apparatus, by which action of 
 heart and vessels is coordinated so 
 as to maintain an equal blood-pres- 
 sure diagram to show, fig. 11, 13 
 
 hypothetical, in the heart author's 
 
 diagram of, fig. 19, 20 
 
 mechanism by which action of heart 
 may be depressed by irritation of 
 stomach diagram to show, fig. 168, 
 139; fig- 203, 187 
 
 Neuro-muscular cells from the fresh-water 
 hydra, fig. 229, 212 
 
 PLEURAL and pericardial cavities pres- 
 sure of walls of, against each other 
 in expiration and cardiac diastole 
 diagram of transverse section of 
 thorax showing, fig. 127, 97 
 
 tendency to formation of vacuum 
 
 in, during inspiration and car- 
 diac systole diagram of trans- 
 verse section of thorax showing, 
 fig. 126, 97 
 
 Pleural and oeritoneal fluids in pleura 
 and diaphragm effect on, of move- 
 ments of respiration 
 
 section of central tendon of diaphragm 
 in rabbit, fig. 5, 9 
 
 section of pleura, fig. 6, 9 
 
 Pneumogastric of frog spiral ganglion 
 cell from, fig. 26, 25 
 
 Position of body, as affecting volume of 
 blood-pressure in the brain, fig. 147, 
 114 
 
 application of this to prevent faint- 
 ing, fig. 148, 115 
 
 as affecting work of diaphragm on 
 abdominal contents, figs. 160 and 
 161, 133 
 
 Posterior cardiac nerve, part of, highly 
 majjnified, showing ganglia, fig. 25, 24 
 
 Primitive bundle from a mammalian em- 
 bryo (about third month), examined 
 in strongly iodized serum, fig. 230, 
 213 
 
 Pulsations of fontanelle in infant of six 
 weeks old, while sucking, fig. 198, 
 176 
 
 Pulse, see also under Valvular Disease, 
 
 Pulse, in angina pectoris tracings of, 
 figs. 204-14, 190 
 
 aortic slow, due to feebleness in alter- 
 nate beats of left ventricle tracing 
 from it and from aorta, fig. 138, 109 
 
 tracings of, fig. 108, 87 cardiac 
 
 sounds with which obtained, fig. 
 105, 85 
 
 aortic and ventricular systole, fig. 108, 
 87 
 
 aortic regurgitation case of showing 
 hook at top of tracing, fig. 115, 90 
 
 dichrotism tracing showing, fig. 116, 
 
 effect on, by (Nauheim) baths, figs. 
 
 221-4, J99 
 of digitalis poisoning, figs. 140-4, in 
 
 of exercises, fig. 220, 198 
 
 of fever, fig. 113, 89 
 
 of increased tension sphygmogram 
 
 showing, fig. no, 89 
 
 of intermittent fever various stages, 
 
 fig. 114, 89 
 
 of massage and graduated movements, 
 
 fig. 132, 102; fig. 167, 138; fig. 219, 
 198 
 
 healthy three tracings of, with var- 
 ious degrees of tension highest due 
 to cold lessened due to warm cloth- 
 ing, fig. 112, 88 
 
 irregularity of, caused by digitalis poi- 
 soning, figs, ido-4, in 
 
 normal tracing of, fig. in, 88 
 
 radial, before and after haemorrhage, 
 same patient, figs. 117 and n8_, 91 
 
 retardation of, in different arteries, fig. 
 119, 91 
 
 senile analogy of, to ventricular beat 
 diagram to show, fig. 109, 88 
 
 slow, in aorta, due to each alternate 
 beat of ventricle being too weak to 
 overcome pressure within aorta and 
 lift the aortic valves tracing from 
 left ventricle and aorta, showing, 
 fig. 138, 109 
 
 Purkinje's fibers, from a sheep s heart, 
 fig. 232, 214 
 
 RENAL tubule invaded with microphags 
 old man aged 90 fig. 228, 207 
 
 Rabbit's ear vaso-motor nerves of dia- 
 gram of, fig. 194, 172 
 
 SELF-MASSAGE of artery (ies), 
 
 arterial pulse effect of, in aiding 
 
 onward flow of venous blood and 
 lymph by a process of what may 
 be called self-massage, fig. i, 6; 
 fig. 129, 99 
 
 of artery and nerve in sheath of con- 
 nective tissue diagram of, to illus- 
 trate, fig. 162, 134 
 
 Self-massage of the heart, Brucke's view 
 of suction-action of ventricular sys- 
 tole in drawing blood from the veins 
 into the auricle -diagram to illus- 
 trate, fig. 125, 96 
 
 thorax, transverse section of, during 
 expiration and cardiac diastole dia- 
 gram of, showing pressure of walls 
 of pleural and pericardial cavities 
 against one another, fig. 127, 97 
 
 inspiration and cardiac systole 
 
 diagram of, showing tendency 
 to formation of a vacuum in 
 pleural and pericardial cavities, 
 fig. 126, 97
 
 CLASSIFIED LIST OF ILLUSTRATIONS 
 
 275 
 
 Shock, effects of on the heart and its 
 action, Goltz's experiments diagram 
 to illustrate, fig. 145, 113 
 
 Stannius, experiments of, Brunton's dia- 
 grams illustrating, figs. 17 and 18, 20 
 
 Stoppage of heart by stimulation of 
 vagus (q. v.), fig. 130, 100 
 
 Striation, traces of, cells of involuntary 
 muscle from bladder of dog show- 
 ing, fig- 231, 214 
 
 Syncope, causation of diagram to show, 
 fig. 10, 12 
 
 occurrence of, in aortic regurgitation 
 diagram to illustrate, fig. 217, 195 
 
 tendency to, in aortic regurgitation, 
 fig. 153, 124 
 
 VAGUS nerve, 
 
 afferent channels through which it 
 
 may be stimulateu diagram to 
 show, fig. 139, no 
 
 stimulation of 
 
 diminished amplitude of contrac- 
 tion without slowing or stoppage, 
 during, fig. 133, 103 
 
 diminished amplitude and slowing 
 
 of pulsations without complete 
 stoppage, during, fig. 131, 101 
 
 increased cardiac action from, fig. 
 
 134, 103 , 
 
 stoppage of heart from, fig. 130, 
 
 100 
 
 Valves of the heart, 
 mitral and tricuspid 
 competence of author's simple instru- 
 ment for ascertaining, and illus- 
 trating action of musculi papillares 
 diagram of, fig. 45, 38 
 
 heart in full systole, showing these 
 
 orifices so diminished by muscular 
 contraction that they close easily, 
 fig- 46, 39, and fig. 176, 151; same 
 heart from another point of view, 
 fig- 47, 39, and fig. 177, 151 
 heart fully distended, showing in- 
 
 sufficiency of, to close these ori- 
 fices, fig. 48, 39 (the same fig.), 
 fig- 175, 151 
 
 Valves, sigmoid work of, in defence of 
 auricle and ventricle in diastole 
 diagram of healthy heart showing, fig. 
 154, 124 
 
 Valvular disease of the heart 
 
 aortic regurgitation tendency in, to 
 syncope diagram to illustrate, fig. 
 153, "4 
 
 atheroma of aorta usual position of 
 murmur indicating diagram to show, 
 fig. 152, 123 
 
 healthy heart in diastole, fig. 154, 124 
 
 heart of healthy man before and after 
 violent exertion skiagraphs of, figs. 
 157 and 158, 125 
 
 with incompetent aortic valves, fig. 
 
 155, 124 
 
 with incompetent aortic and mitral 
 
 valves, fig. 156, 124 
 
 pulse, in case of mitral incompetence 
 tracing of, fig. 159, 128 
 
 Vaso-motor nerves of rabbit's ear dia- 
 gram of, fig. 194, 1/2 
 
 Venous blood, return of, from stomach 
 and intestines through liver dia- 
 gram to show, fig. 181, 154 
 
 circulation and lymph circulation dia- 
 gram showing effect of arterial pulse 
 in aiding, fig. i, 6 
 
 Ventricular systole suction-action of, in 
 drawing blood from veins into auri- 
 cle Brucke's view diagram to illus- 
 trate, fig. 125, 96 
 
 tracings of, tig. 108, 87 cardiac sounds 
 with which obtained, fig. 105, 85 
 
 Vomiting center afferent nerves by 
 which it may be excited to action, 
 fig. 216, 194 
 
 WARM clothing, effect of, in dilating ar- 
 terioles, quickening pulse, and reduc- 
 ing high tension, fig. 136, 106
 
 LIST OF ILLUSTRATIONS 
 
 IN NUMERICAL ORDER 
 
 FIG. i. Diagram to show effect of ar- 
 terial pulse in aiding onward flow of 
 venous blood and lymph, by a process 
 of what may be called self-massage, 6 
 
 FIG. 2. Diagram of transverse section of 
 voluntary muscle, to show pumping ac- 
 tion exerted on muscle-juice .and waste 
 products during action, 7 
 
 FIG. 3. Diagram of longitudinal sections 
 of muscles I. in relaxation, and II. in 
 contraction, 8 
 
 FIG. 4. Injected lymph spaces from the 
 fascia lata of the dog, after Ludwig 
 and Schweigger-Seidel, 8 
 
 FIG. 5.- Section of central tendon of dia- 
 phragm in rabbit, after Ludwig and 
 Schweigger-Seidel, 9 
 
 FIG. 6. Section of pleura, after Ludwig 
 and Dybkowsky, 9 
 
 FIG. 7. Diagram of the circulation, 10 
 
 FIG. 8. Ludwig' s kymograph, 1 1 
 
 FIG. 9. Laulanie's manometer, 12 
 
 FIG. 10. Diagram to show causation of 
 syncope, 12 
 
 FIG. ii. Diagram to show nervous appa- 
 ratus by which action of heart and 
 vessels is coordinated so as to maintain 
 equal blood-pressure, 13 
 
 FIG. 12. Shows rapidity with which blood 
 flows through vessels of muscles, after 
 Ludwig, 14 
 
 FIG. 13. Diagram showing four great 
 areas for distribution of blood in the 
 body, 1 6 
 
 FIG. 14. Diagram to show effect of arti- 
 ficial circulation of blood through liver, 
 under different pressures, 17 
 
 FIG. 15. Diagram of frog's heart, 19 
 
 FIG. 16. Diagram to show successive con- 
 traction of cavities in frog's heart, 19 
 
 FIG. 17 and 18. Author's diagrams to 
 illustrate experiments of Stannius, 20 
 
 FIG. 19. Author's diagram of hypothet- 
 ical nervous apparatus in heart, 20 
 
 FIG. 20. Author's instrument for show- 
 ing action of heat, cold and poisons on 
 frog's heart, 21 
 
 FIG. 21. Bowditch's apparatus for exper- 
 iments on frog's heart, 22 
 
 FIG. 22. Diagram of Williams' apparatus 
 for investigating action of drugs on 
 heart of frog, 23 
 
 FIG. 23. Kronecker's perfusion cannula, 
 with anterior part removed so as to 
 show septum, 23 
 
 FIG. 24. View of auricular septum in 
 frog (seen from left side), after Ran- 
 vier, 24 
 
 FIG. 25. Part of posterior cardiac nerve, 
 highly magnified, showing ganglia, after 
 Ranvier, 24 
 
 FIG. 26. Spinal ganglion cell from pneu- 
 mogastric of frog, after Ranvier, 25 
 
 FIG. 27. Amoeba quickly changing its 
 form, 26 
 
 FIG. 28. Medusa (Sarsia), natural size, 
 27 
 
 FIG. 29. Medusa (Sarsia), natural size 
 (inverted), 27 
 
 FIG. 30. Ventricle of frog's heart with 
 Bidder's ganglia, 27 
 
 FIG. 31. Diagram to show difference in 
 mode of experimenting with heart and 
 with apex alone, 28 
 
 FIG. 32. Shows increasing contractions of 
 tissue of medusa when stimulated by 
 repeated weak induction shocks of same 
 intensity (Romanes), 28 
 
 FIG. 33. Increasing contractions of ven- 
 tricle of frog's heart with successive 
 stimuli, after Bowditch, 28 
 
 FIG. 34. Diagram of a medusa (Tiarop- 
 sis), about one-thkd natural size, with 
 strip of contractile tissue cut from bell, 
 but left attached at one end, 28 
 
 FIG. 35. Diagrammatic representation of 
 method of localizing action of poisons 
 on medusae, 30 
 
 FIG. 36. Medusa (Aurelia aurita), from 
 which ganglia have been removed and 
 bell cut into long strip, with cross cuts 
 to block passage of contractile and ten- 
 tacular waves, after Romanes, 31 
 
 FIG. 37. Diagram to illustrate Gaskell's 
 experiment (compression of auriculo- 
 ventricular groove in frog's heart), 32 
 
 FIG. 38. Tracing showing effect of elec- 
 trical stimulation upon ventricle of 
 frog's heart, Brunton and Cash, 35 
 
 FIG. 39. Effect of electrical stimulation 
 of frog's ventricle after refractory 
 period has passed, Brunton and Cash, 
 
 35 
 
 FIG. 40. Shows reduplication of beat of 
 ventricle of frog's heart, from electrical 
 stimulation applied to it during dias- 
 tole, Brunton and Cash, 35 
 
 FIG. 41. Shows effect of stimulation of 
 auricle (frog's heart) on beats of 
 auricle itself and of ventricle, Brunton 
 and Cash, 36 
 
 FIG. 42. Shows effect of electrical stimu- 
 lation of venous sinus, Brunton and 
 Cash, 36 
 
 FIG. 43. Periodic rhythm of frog's heart, 
 the pulsations occurring in groups sep- 
 arated by intervals of complete quies- 
 cence, Brunton and Cash, 36 
 
 FIG. 44. Tracing of pulsations of ven- 
 tricle separated from auricles by sec- 
 tion at auriculo-ventricular groove, 
 after Ranvier, 37 
 
 FIG. 45. Diagram of author's instrument 
 for ascertaining competence of mitral 
 or tricuspid valves, and illustrating ac- 
 tion of musculi papillares, 38 
 
 277
 
 2 7 8 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 46: Heart in full systole, showing 
 mitral and tricuspid orifices so dimin- 
 ished by muscular contraction that the 
 valves close them easily, 39 
 
 FIG. 47. Same heart as in Fig. 46, from 
 another point of view, 39 
 
 FIG. 48. Heart fully distended, showing 
 insufficiency of valves to close mitral 
 and tricuspid orifices, 39 
 
 FIG. 49. Diagram to illustrate hypothet- 
 ical transverse contraction of muscle, 46 
 
 FIG. 50. Vessels in web of frog's foot in 
 normal condition, after Lister, 47 
 
 FIG. 51. Same vessels as in Fig. 50, after 
 irritation, 48 
 
 FIG. 52. Apparatus for registering mus- 
 cular contraction, 48 
 
 FIG. 53. Revolving cylinder for record- 
 ing movements, 49 
 
 FIG. 54. Tracing of normal contraction 
 of gastrocnemius of frog, 50 
 
 Fig. 55. Effect of heat and cold on mus- 
 cle, 50 
 
 FIG. 56. Effect of fatigue on muscle, 50 
 
 FIG. 57. Tracing of contractions of mus- 
 cle with stimuli of increasing strength, 
 5 
 
 FIGS. 58-67. Effects of cold and heat on 
 heart, 52-53 
 
 FIG. 68. Author's apparatus for ascer- 
 taining effect of heat and cold on ves- 
 sels of frog's lungs, 54 
 
 FIG. 69. Author's schema of the circula- 
 tion, 55 
 
 FIG. 70. Marey's haemodynamometer, 55 
 
 FIG. 71. Ludwig's kymograph, 56 
 
 FIG. 72. Registering metallic manometer 
 of Marey, 57 
 
 FIG. 73. Tracing of oscillations in mer- 
 curial manometer, 58 
 
 FIG. 74. Tracing made with one of 
 Marey's tambours (oscillations), 58 
 
 FIG. 75. Fick's kymograph, 58 
 
 FIG. 76. Diagram to illustrate author's 
 method of combining Ludwig's and 
 Fick's kymographs for registering blood- 
 pressure and pulse, 59 
 
 FIG. 77. (a) Simple instrument for 
 measuring blood-pressure in artery, (&) 
 improvement on this, 60 
 
 FIG. 78. Shows mode of applying simple 
 sphygmomanometer by pressing it di- 
 rectly on palpating finger instead of on 
 artery, and feeling artery nearer hand, 
 61 
 
 FIG. 79. Shows instrument (for measur- 
 ing blood-pressure) in which movements 
 of spring are magnified and read off on 
 dial, 6 1 
 
 FIG. 80. Instrument for estimating pres- 
 sure of blood in capillaries, 62 
 
 FIG. 8 1. Sphygmomanometer of Heris- 
 son, after Marey, 62 
 
 FIG. 82. (a) Early form of Von Basch's 
 sphygmomanometer, (b) author's cheap 
 modification of, 63 
 
 FIG. 83. Von Basch's sphygmomanometer 
 and stand, drawn from one in author's 
 possession, 64 
 
 FIG. 84. Von Basch's sphygmomanom- 
 eter, aneroid pattern, from specimen in 
 possession of author, 65 
 
 FIG. 85. Potain's modification of Von 
 Basch's aneroid sphygmomanometer, 66 
 
 FIG. 86. Mode of applying Potain's ane- 
 roid sphygmomanometer, 66 
 
 FIG. 87. Most recent form of Von Basch's 
 aneroid sphygmomanometer, 67 
 
 FIG. 88. Oliver's sphygmomanometer, 67 
 
 FIG. 89. Picks' apparatus for measuring 
 and recording changes in volume of 
 organs, after Marey, 68 
 
 FIG. 90. Mosso's plethysmograph, 69 
 
 FIG. 91. Combination of plethysmograph 
 with Marey's metallic manometer, 70 
 
 FIG. 92. Marey's apparatus for measur- 
 ing blood-pressure in finger, 71 
 
 FIG. 93. Mosso's sphygmomanometer, 72 
 
 FIG. 94. Plethysmograph of Hallion and 
 Combe, 73 
 
 FIG. 95. Gaertner's tonometer, 74 
 
 FIG. 96. Gaertner's tonometer, portable 
 form, 75 , 
 
 FIG. 97. Mode of using Gaertner's tono- 
 meter, 75 
 
 FIG. 98.- Combined Potain's and Gaert- 
 ner's apparatus for estimating blood- 
 pressure, 76 
 
 FIG. 99. Riva-Rocci's sphygmomano- 
 meter, 78 
 
 FIG. 100. Author's modified Riva-Rocci 
 band, 79 
 
 FIG. 101. Author's arrangement for using 
 broad Riva-Rocci band with Von Basch's 
 or Potain's sphygmomanometer, instead 
 of mercurial manometer, 80 
 
 FIG. 1 02. Marey's improved metallic 
 manometer, 81 
 
 FIG. 103. Author's apparatus for ascer- 
 taining correctness or amount of error 
 in aneroid sphygmomanometer, 83 
 
 FIG. 104. Marey's tambour for record- 
 ing movements, 84 
 
 FIG. 105. Cardiac sounds, by which the 
 tracings, Fig. 108, were obtained, 85 
 
 FIG. 1 06. Marey's cardiograph, 86 
 
 FIG. 107. Burdon-Sanderson's cardio- 
 graph for apex-beat, 86 
 
 FIG. 1 08. Tracings of ventricular systole 
 (i) and of aortic pulse (2), 87 
 
 FIG. 109. Diagram to show analogy of 
 senile pulse to ventricular beat, after 
 Marey, 88 
 
 FIG. 1 10. Sphygmogram showing effect 
 of increased tension on pulse, after 
 Marey, 88 
 
 FIG. in. Tracing of normal pulse, 88 
 
 FIG. 112. Shows three tracings of healthy 
 pulse, with varying degrees of tension, 
 after Marey, 88 
 
 FIG. 113. Effect of fever on pulse, after 
 Marey, 89 
 
 FIG. 1 14. Tracings of pulse at different 
 stages of intermittent fever, 89 
 
 FIG. 115. Tracing from case of aortic 
 regurgitation, showing hook at top of 
 tracing, 90 
 
 FIG. 116. Tracing showing dichrotism, 90 
 
 FIG. 117. Radial pulse before haemor- 
 rhage, after Marey, 91 
 
 FIG. 118. Radial pulse from same pa- 
 tient, after haemorrhage, after Lorain, 
 91 
 
 FIG. 119. Retardation of pulse in differ- 
 ent arteries, after Marey, 91 
 
 FIG. 120. Marey's sphygmograph, 92 
 
 FIG. 121. Mode of applying Marey's 
 sphygmograph, 93 
 
 FIG. 122. Marey's transmitting sphygmo- 
 graph, 93 
 
 FIG. 123. Dudgeon s sphygmograph, 94 
 
 FIG. 124. Laulanie's digital sphygmo- 
 graph, 95
 
 LIST OF ILLUSTRATIONS 
 
 2/9 
 
 FIG. 125. Diagram to illustrate Brucke's 
 view of suction action of ventricular 
 systole in drawing blood from veins 
 into auricle, 96 
 
 FIG. 126. Diagram of transverse section 
 of thorax during inspiration and car- 
 diac systole; shows tendency to forma- 
 tion of vacuum in pleural and peri- 
 cardial cavities, 97 
 
 FIG. 127. Diagram of transverse section 
 of chest during expiration and cardiac 
 diastole, showing pressure of walls of 
 pleural and pericardial cavities against 
 each other, 97 
 
 FIG. 128. Section of atheromatous cere- 
 bral artery, after Ziegler, 98 
 
 FIG. 129. (Same as Fig. i.) Artery and 
 vein in common sheath, to show effect 
 of arterial pulse in aiding venous cir- 
 culation, 99 
 
 FIG. 130. Tracing showing stoppage of 
 heart by stimulation of vagus (Gaskell), 
 100 
 
 FIG. 131. Tracing showing diminished 
 amplitude and slowing of pulsations 
 without complete stoppage, during irri- 
 tation of vagus, 101 
 
 FIG. 132. Pulse-tracing showing effect of 
 massage and gradual movements, 102 
 
 FIG. 133. Tracing showing diminished 
 amplitude of contraction without slow- 
 ing or stoppage during irritation of 
 vagus, after Gaskell, 103 
 
 FIG. 134. Showing increased cardiac ac- 
 tion from stimulation of vagus, after 
 Gaskell, 103 
 
 FIG. 135. Showing effect of cold upon 
 arteries, after Winternitz, 103 
 
 FIG. 136. (Same as Fig. 112.) Shows 
 effect of warm clothing in dilating ar- 
 terioles, quickening pulse, and reducing 
 high tension of I to low tension of 3, 
 after Marey, 106 
 
 FIG. 137. (Same as Fig. 113.) Effect of 
 fever on pulse, 106 
 
 FIG. 138. Tracings from left ventricle 
 and aorta, showing slow pulse in aorta, 
 due to each alternate beat of ventricle 
 being too weak to overcome pressure 
 within aorta and lift aortic valves, after 
 Marey, 109 
 
 FIG. 139. Diagram to show afferent chan-. 
 nels through which the vagus may be 
 stimulated, no 
 
 FIGS. 140-4. Pulse-tracings from case of 
 poisoning by digitalis, showing pulse 
 variations, in 
 
 FIG. 145. Diagram to illustrate Goltz's 
 experiments (effect of shock on heart), 
 
 113 
 FIG. 146. To show contraction of vessels 
 
 in left arm produced during process of 
 
 multiplying 245 by 15, 114 
 FIG. 147. Tracing from brain, upright 
 
 position and inclined forward, 114 
 FIG. 148. Attitude to prevent fainting, 
 
 US 
 
 FIG. 149. Diagram of carotid, temporal, 
 and occipital arteries in normal state, 
 118 
 
 FIG. 150. Diagram of arteries during mi- 
 graine, showing dilatation of carotid 
 and spasmodic contractions of temporal 
 arteries, 118 
 
 FIG. 151. -Diagram of arteries during 
 migraine, showing dilatation of carotid 
 and temporal arteries, and spasmodic 
 
 contraction of ascending frontal branch 
 of anterior temporal artery, 119 
 
 FIG. 152. Diagram to show usual posi- 
 tion of murmur which indicates ather- 
 oma of aorta, 123 
 
 FIG. 153. (Same as Fig. 10.) Diagram 
 to illustrate tendency to syncope in 
 aortic regurgitation, 124 
 
 FIG. 154. Diagram of healthy heart in 
 diastole, 124 
 
 FIG. 155. Diagram of heart with incom- 
 petent aortic valves, 124 
 
 FIG. 156.- Diagram of heart with incom- 
 petent aortic and mitral valves, 124 
 
 FIG. 157. Photograph by Rontgen rays 
 (skiagram), showing heart in healthy 
 man before exertion, after Schott, 125 
 
 FIG. 158. Skiagram (photographed by 
 Rontgen rays) of heart of same man 
 as Fig. 157, after violent exertion, 
 showing temporary dilatation, after 
 Schott, 125 
 
 FIG. 159. -Tracing of pulse from case of 
 mitral incompetence, after Marey, 128 
 
 FIG. 160. To show lifting of abdominal 
 contents during inspiration in supine 
 position, 133 
 
 FIG. 161. Diagram to show horizontal 
 motion of abdominal contents in upright 
 position, 133 
 
 FIG. 162. Diagram of artery and nerve 
 in sheath of connective tissue, to illus- 
 trate self-massage of artery and nerves, 
 
 J 34 
 
 FIG. 163. Diagram to show effect of 
 massage on flow of blood through mus- 
 cle, by Brunton and Tunnicliffe, 135 
 
 FIG. 164. Mosso's ergograph, 135 
 
 FIG. 165. Tracing showing effect of mas- 
 sage on blood-pressure, first causing 
 slight rise and then distinct fall, by 
 Brunton and Tunnicliffe, 136 
 
 FIG. 1 66. To show relief from fatigue 
 produced by massage, after Maggiora 
 and Vinaj, 137 
 
 FIG. 167. (Same as Fig. 132.) Pulse- 
 tracing showing effect of massage and 
 graduated movements, 138 
 
 FIG. 1 68. Diagram to show nervous mech- 
 anism by which action of heart may be 
 depressed by irritation of stomach, 139 
 
 FIG. 169. Diagram to show effect of 
 flatulence on heart, 140 
 
 FIG. 170. Ludwig and Coats' frog-heart 
 apparatus, 142 
 
 FIG. 171. Tracings showing effect of sim- 
 ple NaCl solution in weakening pulsa- 
 tions of apex of frog's heart, after 
 Ringer, 144 
 
 FIG. 172. Shows effect produced upon 
 beat of frog's heart fed with NaCl solu- 
 tion, by addition of trace of calcium 
 chloride, after Ringer, 144 
 
 FIG. 173. Tracing showing enormous 
 contraction of gastrocnemius of frog 
 by solution of caffeine, 144 
 
 FIG. 174. Diagram to show action of 
 digitalis on frog's heart, 147 
 
 FIG. 175. (Same as Fig. 48.) Heart 
 fully distended, showing insufficiency of 
 valves to close mitral and tricuspid 
 orifices, 151 
 
 FIG. 176. (Same as Fig. 46.) Heart in 
 full systole, showing mitral and tri- 
 cuspid orifices so diminished by muscu- 
 lar contraction that valves close them 
 easily, 151
 
 280 
 
 THERAPEUTICS OF THE CIRCULATION 
 
 FIG. 177. (Same as Fig. 47.) Same 
 heart as in Fig. 176, from another point 
 of view, 151 
 
 FIG. 178. Diagram to show effect of 
 venous congestion and of obstruction of 
 ureter or tubules on kidney, 152 
 
 FIG. 179. Diagrammatic section of ab- 
 domen (a) normal state, (b) in ad- 
 vanced dropsy, 152 
 
 FIG. 1 80. Diagram of Ranvier's experi- 
 ment on dropsy, 153 
 
 FIG. 181. Diagram to show return of 
 venous blood from stomach and intes- 
 tines through liver, 154 
 
 FIG. 182. Diagram to show relation be- 
 tween blood-pressure and secretion of 
 urine after administration of erythro- 
 phloeum, 155 
 
 FIG. 183. Tracings to show first stages 
 of action of digitalis (Brunton and 
 Meyer), 156 
 
 FIG. 184. Tracing from same animal 
 (dog) after administration of digitalis, 
 156 
 
 FIG. 185. - Tracing from same animal 
 when action of digitalis is more pro- 
 nounced, 157 
 
 FIG. 1 86. Tracing of blood-pressure of 
 dog during arrest of heart by electrical 
 stimulation of vagus before injection 
 of digitalis, 157 
 
 FIG. 187. Same experiment as in Fig. 
 186, but after injection of digitalis, 158 
 
 FIG. 1 88. -Tracings of blood-pressure 
 showing action of digitalis, 159 
 
 FIG. 189. Tracing showing action of iso- 
 butyl nitrite on blood pressure, 164 
 
 FIG. 190. Tracing showing action of amyl 
 nitrite on blood-pressure, 164 
 
 FIG. 191. Action of hydroxylamine hy- 
 drochlorate on blood-pressure, 165 
 
 FIG. 192. Tracing to show increased ra- 
 pidity of circulation in carotid of 
 horse during mastication (Marey), 169 
 
 FIG. 193. Pulsations of fontanelle in in- 
 fant six weeks old while sucking 
 (Salathe), 170 
 
 FIG. 194. Diagram of vaso-motor nerves 
 of rabbit's ear, 172 
 
 FIG. 195. (Same as Fig. 50.) Blood- 
 vessels in normal condition (Lister), 
 
 FIG. 196. (Same as Fig. 51.) Same 
 vessels after application of irritant and 
 commencement of inflammation (Lis- 
 ter), 173 
 
 FIG. 197. Diagram to show effects of 
 heat and cold in lessening pain of in- 
 flammation, 174 
 
 FIG. 198. Diagram to show congestion of 
 the lung, 176 
 
 FIG. 199. Diagram to explain action of 
 counter-irritation, 176 . 
 
 FIG. 200. Showing effect of cold upon 
 arteries, 176 
 
 FIG. 20 1. Rectum and haemorrhoidal 
 plexus diagram of veins forming part 
 of portal circulation, 179 
 
 FIG. 202. Case of exophthalmic goitre, 
 185 
 
 FIG. 203. (Same as Fig. 168.) Diagram 
 to show nervous mechanism by which 
 action of heart may be depressed by 
 irritation of stomach, 187 
 
 FIGS. 204-14. Tracings of pulse in an- 
 gina pectoris, 190 
 
 FIG. 215. Diagram to illustrate entero- 
 hepatic circulation, 192 
 
 FIG. 216. Diagram showing afferent 
 nerves by which vomiting center may 
 be excited to action, 194 
 
 FIG. 217. Diagram to illustrate occur- 
 rence of syncope in cases of aortic 
 regurgitation, 195 
 
 FIG. 218. Diagram of cardiac dulness 
 before and after a bath (Schott), 197 
 
 FIG. 219. Pulse-tracing, showing effect 
 of massage and graduated movements 
 (Hamel), 198 
 
 FIG. 220. Pulse-tracing to show effect of 
 exercises, 198 
 
 FIGS. 221-4. Tracings from pulse of pa- 
 tient aged 62, with gouty kidney, of 
 failing heart, effect on, of Nauheim 
 baths, 199 
 
 FIG. 225. Distribution of arteries in brain 
 (Ross), 206 
 
 FIG. 226. Cerebral cortex showing dis- 
 tribution of function (Osier), 206 
 
 FIG. 227. Cell from brain of woman aged 
 100 years, being devoured by macro- 
 phags (Metchnikoff), 207 
 
 FIG. 228. Section of renal tubule in- 
 vaded by macrophags, from body of old 
 man aged 90 years (Metchnikoff), 207 
 
 FIG. 229. Neuro-muscular cells from the 
 fresh-water hydra, 212 
 
 FIG. 230. Primitive bundle from a mam- 
 malian embryo (about third month), 
 examined in strongly iodized serum, 
 213 
 
 FIG. 231. Cells of involuntary muscle 
 from the bladder of the dog, showing 
 traces of striation, 214 
 
 FIG. 232. Purkinje's fibers, from a sheep's 
 heart, 214 
 
 FIG. 233. Atrio-ventricular bundle of 
 Stanley, Kent and His, seen from the 
 right ventricle, 215 
 
 FIG. 234. Janeway's sphygmomanometer, 
 216 
 
 FIG. 235. C. J. Martin's modification of 
 Riva-Rocci's sphygmomanometer, 217 
 
 FIG. 236. Lockhart Mummery's modifica- 
 tion of Riva-Rocci's sphygmomanometer, 
 220 
 
 FIG. 237. Oliver's new sphygmomano- 
 meter, 220 
 
 FIG. 238. Gibson's clinical polygraph, 221 
 
 FIG. 239. Amount of blood flowing from 
 veins of biceps of dog during tetanus, 
 223 
 
 FIG. 240. Cells taken from a heart in 
 fibrillation, 231
 
 UNIVERSITY OF CALIFORNIA LIBRARY 
 
 Los Angeles 
 This book is DUE on the last date stamped below. 
 
 SEP 3() 
 B 
 
 1 8 19S5 
 
 Form L9-25m-9,'55(B4283s4)444
 
 3 1158 01044 6952