r?~ r^^va^ > ■> 6 ?,;■>,^ :>->}» -^ ; » > » < ^»«, ,. #,Js Sjis?-iiL ■«-•- .f? 7;:;t'.'?E ."3 5»3 &I-1M \ 5> 0>^ xo V />S^» £*> >>^ V f<\lL rJP- ^THE SPHYtt l&tj tw-5 Entered according to the Act of Congress, in the year 1834, by Grigg 8c Elliot, in the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsyl- vania. PREF1C E. The instrument which the following pages are designed to introduce to the notice of the medical profession in this coun- try, has been very recently invented by a physician in Paris. He thinks it will be found an additional means of facilitating the investigations of the healing art, and at the same time of imparting to them an exactness, in which they are too often confessedly defective. A very great sensation has been excited by it in the French capital. The press teems with its praises, and with anticipations of the various circumstances in which it is expected to prove available. The Institute of France has, it appears, given to the inven- tion the sanction of its high literary authority. The celebrated Dr. Magendie, whose name alone is a guarantee for the accu- racy and impartiality of the opinions he expresses on this sub- ject, concludes his report with the proposal of "a vote of thanks to Dr. Herisson, the author of this most useful and in- genious discovery," which was immediately concurred in by the Academy of Sciences of the Institute of France. The translator having had the good fortune, through the kindness of a revered friend, to receive a copy of the Memoir, accompanied by one of the Instruments, the first that have crossed the Atlantic, hastens to communicate them to his med- ical brethren. He is also endeavouring to have the Instru- ments constructed here ; and should his efforts be successful, he will lose no time in conveying the information to the Med- ical Public. THE SPHYGMOMETER. TO THE INSTITUTE OF FRANCE. Gentlemen— After a variety of attempts not all equally satisfactory, but all sufficiently conclusive to establish the possibility of success, I determined to have an instrument made which should exhibit to the eye the whole action of the arteries. My next object was to find an artist sufficiently skilful to realize my ideas, and I was fortunate enough to meet one. Mr. Gamier, a young mechanician already known by his valuable discoveries in the art of clock making, was kind enough to assist me with his ta- lents, his dexterity, and his genius. The sphygmometer which I now have the honour of presenting, is as much his work as it is mine, and it is in our joint names that 1 now submit it for your approbation. 1 will in the first place, gentlemen, describe our instrument, and the mode of employing it; I will next have the honour to demonstrate its usefulness in the practice of medicine; and I will conclude this paper with the result of my researches into the study of the diseases of the heart. I flatter myself that in the clinical portion of this paper, you will find more than one motive for believing that my labours are already of some value to medical science. The instrument which I designate by the word sphygmome- ter is composed of a glass tube graduated on its anterior face, covered posteriorly with coloured paper, and terminating below in an excavated hemisphere of ivory or steel. The hemisphe- 6 THE SPHYGMOMETER. rical cavity contains a certain quantity of mercury, and is closed inferiorly by a very fine membrane, while above it opens into a capillary tube of the same material of which its own walls consist, continuous with the glass tube, and of similar dimen- sions. All communication between the graduated portion of the canal, and the cavity at its base, is interrupted at will by means of a small stop-cock. The mercury in the semi-globular receptacle, is susceptible, when the instrument is properly ap- plied on the course of the artery, of receiving and exhibiting all its action in the transparent tube. To investigate diseases of the heart, recourse is had to the same instrument constructed on a larger scale. It is proper to remark, however, that the truncated globe, the capillary tube, and the quantum of mer- cury, being the same in all sphygmometers for the arterial pulse, they are all uniform in power, and furnish an equal grade of measurement. The person whose pulse is to be examined, may be either in a sitting or recumbent posture: if sitting, the physician places himself outside or before the arm, the artery of which he is to consult, with that arm on his left hand, or on his thigh, or sup- ported by the arm of a chair. The instrument, held at its basis between the thumb and index of the right hand, is now placed on the course of the radial artery, so as to make it cross imme- diately the centre of the reservoir. The right hand will endea- vour, by pressure upon the artery, to discover its greatest de- gree of impulsion ; that point once determined, the inferior parts of the thumb and index rest upon the sides of the artery; its whole action is then transmitted to the column of mercury, which appears to be the continuation of it. If the patient is in bed, the physician will place himself op- posite the arm of his patient; this arm will be fixed in his left hand, while he will use his right hand as described in the sit- ting posture. I now arrive at the qualities of the instrument, and at this word quality, I am apprehensive you may suspect me, gentle- men, like all authors of new notions, of exaggeration. You may, however, be easy on that head. 1 shall proclaim only the ser- vices already rendered; as to those it may be destined to ren- THE SPHYGMOMETER. 7 der hereafter, I leave to your judgment the care of pointing them out. The positive advantages of this instrument, are to exhibit to the eye the whole of the motions of the heart, when applied over the anterior region of the thorax corresponding to that organ; and all the motions of the pulse, when applied to the course of an artery. Ought we to give it the preference over the sense of touch, when our object is to estimate the strength and rhythm of the pulse ? To resolve this important question, which should at once decide the fate of the sphygmometer, let us begin by examin- ing what is the sense of touch among those who exercise it in investigating the pulse, and let us candidly examine what re- sults it is likely to produce. What strikes me at once, is the diversity of sensation: to produce the same results on all, it would be necessary that the conditions of the organ exercising the touch, should be the same in all individuals, whereas the very reverse is the case; the hands are either young or old, co- vered with a delicate or coarse skin, either warm or cold ; they are either practised or inexperienced, &c, &c. The sensibility of each one is modified, therefore, by each particular circum- stance; consequently the judgment of all will vary, because there can be no similarity either in their perceptions, or in the conditions calculated to make it uniform. The sense of touch, as exercised in exploring the pulse, can only be useful to the physician who exercises it daily, without allowing the interference of any cause having a tendency to destroy its delicacy and tact; but is it infallible even for the individual, who renders no account of the sensations to any one but himself, and can the recollection of this sensation of the day before, or of several days, be sufficiently exact to allow a correct comparison to be drawn ? We do not hesitate to answer in the negative; and if this our opinion be correct, how can we, by the aid of the sense of touch alone, appreciate the changes of a pulse in the course of a disease. Let us suppose, for instance, that the pulse of a patient whom you see for the first time, appears to you strong, re- Q THE SPHYGMOMETER. gular, equal, &c.: I do not wish to burthen your memory with divers anomalies, which sometimes occur in a healthy as well as in a diseased state; let us suppose, again, that you find to- day your patient's pulse strong and regular, that to-morrow a slight change occurs in the frequency or slowness of the arte- rial action; will you be enabled to determine, even if you dis- cover any difference, the quantum of increase or diminution of the pulse, as well as the nature of its rhythmical state? No, you cannot; but you will reply, with a good memory and a clear head, that the pulse is rather stronger or weaker; its re- gularity is no more the same; in all that you have observed, there will be nothing exact or positive; you are aware of a change, but you cannot determine positively its character. Medicine gathers its valuable indications from precise observa- tions only; you therefore encounter the risk of losing these ad- vantages, and your patient that of becoming the victim of the imperfect result of the most attentive investigation. Is a consultation or meeting of physicians called, the same diversity of opinions, the same obscurity prevails: one will find a hard regular pulse, another thinks its impulse quite mo- derate, but remarks that there is irregularity; this one thinks it fast, another finds it intermittent; they cannot agree, and from different diagnostic views, will naturally result difference of treatment. The relations and the patient, too often wit- nesses of these first and inevitable discussions, which are always more or less imprudent, soon lose all confidence in those they have called to their assistance, and will be fortunate, if despondency and apprehension have not even aggravated the disease. Having thus rapidly demonstrated the insufficiency of the sense of touch as regards the pulse, we hasten to state that this insufficiency cannot be supplied by any other sense, that will enable us to estimate the form as well as the density or laxity of the arteries, and that consequently the instrument, the uses of which we are about to describe, could be of no service what- ever without the aid of this sense of touch. THE SPHYGMOMETER. 9 Utility of the Instrument. A. All medical practitioners are aware of the existence of anomalies of the circulation, and that some are so different from its natural type, that if they did not co-exist with a state of health, we should be induced to consider them as evidences of organic affections of the heart; and what is still more remark- able, if this state of health is disturbed, all these anomalies disappear, and the pulse resumes the physiological character- istic which it displays in other individuals. Nay, the phy- sician can never be positive of the cure of his patient, unless there be a restoration of these phenomena, which might have indicated a morbid state. This is a remark made without the aid of our instrument, but not with the precision that is de- sirable, and many peculiarities of pulse have not been detected for want of a convenient, correct, and faithful mode of inves- tigating them. You will discover later, gentlemen, that the sphygmometer exhibits to the observer certain phenomena which could not be perceived by the sense of feeling; but we leave this subject for the present, to occupy our attention with every day cases; this instrument is essential to make us familiar with the healthy pulse of those persons we may at some future period be called upon to prescribe for, when labouring under disease; for then we shall be enabled to form a much more correct opinion of the changes induced by disease in that pulse, the healthy state of which is familiar to us. The instrument will therefore present to the physician, in the first place, the advantage of recording in his note book the exact description of each patient's pulse. It is easily under- stood what uses are to be made of these notes, whenever dis- ease makes its invasion. A single case will suffice to show the importance of such data. M, setat. 30, and healthy; his pulse ex- amined in the morning exhibits by the sphygmometer 10 de- grees of elevation, and 60 pulsations in a minute; it is regular, equal, soft, &c. M is indisposed, his pulse now beats 70 in a minute, rises to 12 degrees, is no longer equal, and the inter- vals between the pulsations are irregular, and the pulse has become hard. It is evident, that by comparing these obser- B 10 THE SPHYGMOMETER. vations, we can judge at once, and with certainty, in what man- ner the circulation has deviated from the physiological state. All the efforts of the practitioner will tend therefore to restore it to its natural condition, by the assistance of those observa- tions made during health, and by comparing the latter with those presented by the state of disease. If at all times the pulse has been considered as the compass of the physician, I trust that the simile has now become af reality. B. The sphygmometer becomes of great value when applied to patients in a hospital destined to the instruction of students: the professor having placed it on the arm, every one can see and follow the remarks which the case requires, and judge with his own eyes ; otherwise he must take for granted : for his sense of touch can as yet not be sufficiently practised to justify a single reflection, in case the result of his examination does not coincide with that of his teacher. C. In a medical consultation, each one can in turn apply the instrument, and exhibit it to his colleagues : each one will therefore be enabled to satisfy himself as to the correctness of what he observed while he was a spectator. D. Consultation Memoirs* have hitherto afforded only ap- proximating data as to the circulation of the patient, who, at great expense, solicits the opinion of a foreigner of celebrity; the result therefore is, that little value is attached to those opinions, and that of the attending physician is adopted. Hereafter, more exactitude in the correspondence will be at- tainable, and the instrument being the same every where, the estimate formed at St. Petersburg will be understood in Paris. E. The changes which may occur in the course of a dis- ease, either during or subsequent to the operation of any the- rapeutic treatment, may be noted, or communicated with ac- curacy and precision. The physician who will visit his patient either daily or every other day, once enabled to estimate the • Consultation Memoirs are statements or histories of medical cases, drawn up by the attending physician, and transmitted to other physicians, generally of great celebrity, requesting their opinion as to the nature of the case, its- treatment, &c.—J. G. N. THE SPHYGMOMETER. 11 effects of the remedies he is using, will, upon solid data, con- tinue, modify, or change the treatment of the case.* I conclude here, gentlemen, the expose of the advantages afforded by the sphygmometer ; I was desirous only of tracing the outlines, and shall feel too happy, if, in the new route I have explored, my colleagues give me some credit for having indicated the means of finishing it more conveniently than I began it. With perseverance, good faith, and the assistance of those men who devote themselves to the natural sciences, we may hope one day to establish a good theory of the pulse ; a theory absolutely wanting in the practice of medicine, and which will spare many errors to those by whom it is prose- cuted. I will now lay before the Academy the result of my re- searches on the diseases of the heart. I have devoted six years of study to the labour of which this is the summary, and I in- dulge the hope that this work will be of some service in form- ing a correct diagnosis, and that it will demonstrate the use which medicine should derive from a method, which, by its nature, places the healing art by the side of the exact sciences. Diseases of the Heart. The affections of the heart are numerous, but the important diseases of this organ are more rare than is generally thought. This error proceeds from the fact, that its sympathetic modifi- cations are extremely diversified, and that the latter give rise to frequent disturbances in the exercise of its functions. These • I am in the habit of attending several persons, subject to apoplectic symp- toms. I often examine their pulses, and as soon as I discover that either has passed beyond the degree of impulse necessary to equilibrium, I remove blood, either by leeches or venesection. I have ascertained, that a certain quantity abstracted, is sufficient to restore the pulse to its healthy state : by means of this safeguard, and the accuracy of this method, my patients, heretofore living over a volcano, now pass with some security a peaceable life. The attacks of disease have ceased, and I might almost affirm, that they would experience no further accidents, if they did not deviate too far from the regimen prescrib- ed, and especially if they continued to maintain their circulation at that degree of moderation which the sphygmometer never fails to indicate. 12 THE SPHYGMOMETER. varied disturbances may last for a very long time without pro- ducing any lesion of texture: the greater portion of the medi- cal authors who have written on this subject, have, however, affirmed, that of all the viscerae, the heart was, next to the lungs, the most subject to organic diseases. I am of a different opinion. Corvisart and Laennec, Bouillaud, Kreysig, Burns, &c, &c, have undoubtedly thrown much light on the diagnosis of the diseases now under consideration ; but what value can we at- tach to their labours, if the only result be the faculty of ascer- taining the existence of a disease without hope, and for which medicine offers scarcely any relief? In fact, gentlemen, with all our knowledge, all our researches, and our means of inves- tigation, we have acquired the possibility of discerning and distinguishing organic diseases of the heart, only at that period when they are beyond the resources of our art. By the aid of my instrument, I can distinguish from its very commencement, the slightest disturbance in the general circu- lation, and I believe that it is not then impossible to oppose successfully the development of the evil threatening the prin- cipal organ. Nervous disturbances are often the only primary symptoms of lesions of texture, and without applying one doc- trine in preference to another to the explanation of this patho- logical phenomenon, I have satisfactorily ascertained, that most of the hypertrophies, indurations, vegetations, and strictures, have commenced by simple rhythmical aberrations. I shall not discuss this proposition ; satisfied that every con- scientious practitioner will readily admit its truth. The limits of a memoir, besides, forbid a discussion, the development of which would require half a volume; I will limit myself, accord- ing to my promise, to the mention of facts. Facts possess more value for science, than logic does of power to persuade the human mind. It is through the medium of percussion, of auscultation, of mensuration, and of the signs furnished by the whole organiza- tion, that medicine has hitherto progressed in the discovery of the different organic diseases to which the heart is liable. All these modes of investigation are often unfaithful: we will here- after examine their claims, and demonstrate that they scarcely THE SPHYGMOMETER. 13 ever exhibit the disease, until its existence can no longer be a question. We will demonstrate that they are especially insuf- ficient to enable us to ascertain and describe an organic affec- tion of the heart at its origin. In the first place, let me be allowed for one moment to ex- pose rapidly the causes which interfere with the accuracy of these modes of investigation. 1st. The different sounds produc- ed by the two sides of a healthy heart, are not constantly the same in all individuals. 2d. The cause of these varieties is owing to circumstances which we cannot at all times estimate, such for instance as a greater quantity of fat in the thoracic parietes, tubercles in the lungs, bronchial dilatations, &c, &c, &c. 3d. Several morbid states of the heart give rise to the same noise. 4th. And which is much more important, neuroses of the heart may present all the signs furnished by percussion and auscultation in organic affections. 5th. Mensuration, which is only an accessory means, can never be depended upon but in connexion with the other signs exhibited by percussion, auscultation, the facies, and the concomitant phenomena, and finally, becomes useful only in those extreme cases, where the increased size of the heart actually raises the ribs, and prevents all hope of cure. The investigation of the pulse appears to me calculated to remove the obscurity which exists, in the midst of the numerous means which have been suggested to enlighten our diagnosis. But the sense of feeling we resort to in this in- vestigation, is not possessed of that rigorous correctness we desire, and independent of this, it is insufficient to appreciate all the evolutions which a diseased or disturbed heart make it experience. It is therefore by the aid of the sphygmometer, with which we can detect the slightest motion of arterial cir- culation, that we can study and compare its healthy with its morbid state. It is true that the rhythm of the arteries is not similar in all subjects,—but it will be easier to detect this with the instrument, than it will be to estimate the divers noises produced by the stethoscope, even admitting, as was suggested in former days, that these sounds could be expressed by notes of music. The sphygmometer, independent of this advantage, has the 14 THE SPHYGMOMETER. faculty of disclosing certain arterial motions characteristic of pe- culiar lesions of the heart. I request, therefore, of the Acade- my, to bestow the utmost attention in verifying my observa- tions, promising beforehand to acknowledge my errors; and if in the survey already made, we make any new discoveries, I shall be most happy to be enabled to insert them in the work I am preparing, and for the publication of which, I am only waiting for an encouraging report from this body. Eight Heart. Stricture of the right auriculo-ventricular passage.— Whatever be the nature of the obstacle, black blood arrives with difficulty in the lungs, and then the following phenomena are exhibited : sensation of weight in the epigastric region, op- pression, painful digestion, spasms more or less continued : the motions of the heart are feeble; the pulse is small, irregular, intermittent; oedema of the superior extremities soon makes its appearance, it speedily extends to the lower ones,and'the patient expires after a long and painful agony. On examination post mortem, we generally find extreme distension of the auricle. The sphygmometer, in the stricture of the right auriculo-ven- tricular passage, presents this peculiar phenomenon; the co- lumn of mercury does not always fall down to its starting point, or it does not fall at once, it is arrested or checked about the middle by an incidental impulse. Stricture of the pulmonary ventricle.—A majority of the phenomena, which we have just related as occurring in the dis- ease of the right auricular ventricle, are observed in the stric- tures of the pulmonary ventricles: with this exception, that the ventricle making considerable efforts to overcome the obstacle which prevents the passage of the blood into the pulmonary artery, occasions in the heart those entire motions constituting what is understood by palpitations, palpitations which are ex- tremely violent, and which bear no relation to the arterial ac- tion ; thus the pulse is feeble, quivering, tumultuous; it pre- sents the same sphygmometrical signs. This species of lesions may end in two very different modes, and then they give rise THE SPHYGMOMETER. 15 to two organic alterations, which, however, are only the con- sequence of the mechanical cause of the primitive disease. If the obstacle be of minor importance, and of slow progress, the multiplied action of the ventricle increases its nutrition, and you then have hypertrophy; this latter terminates in pulmo- nary apoplexy, or an overwhelming haemoptisis. If, on the contrary, the obstacle speedily attains a considerable degree, it produces an aneurism, a genuine dilatation of the ventricle. Its parietes rapidly become thinner, and a rupture is inevitable, if the patient is not previously carried off by hydrothorax, or general oedema, a necessary consequence of the absence of san- guiferous circulation in the lungs. We cannot admit any hy- pertrophies of the right ventricle or auricle, without previous stricture; we have never met them isolated; they are always accompanied by vegetations or valvular indurations, as well as by strictures of one of the auriculo-ventricular, or the ventri- culo-pulmonary orifices. Left Heart. Stricture of the left auricular ventricle. —Continual dysp- noea, considerable oppression, occasioned by exercise in the slightest degree violent, the face assumes a purple colour, more especially the lips, nose, and the cheeks, which are usually covered with varicose vessels. The motions of the heart are soft, pulse feeble, irregular, intermittent, unequal, but much more so than in the strictures of the orifices on the right side; and the reason is, I believe, to be found in the chemical differ- ence of the blood which reaches the ventricle. In fact, if the blood arrives slowly in the lungs, their action is diminished; on the contrary, if it reaches them with facility, their action is increased. In the first case, the blood, being less oxygenated, and consequently less stimulating, will excite only a moderate degree of activity in the left cavities ; on the contrary, in the second case, this activity will be great, for the blood, having become regenerated by a more easy respiration and the im- pression it makes upon the left cavities, will there occasion a considerable activity, especially if any obstacle should be met 16 THE SPHYGMOMETER. in these cavities: the consequence will therefore be a greater irregularity of the pulse; it may also occur that the left ventri- cle may cease to act until it has been enabled to admit a certain quantity of blood. In both cases the arteries are almost empty, and this fact is proved by their sinking under the sphygmome- trical column, which falls below its level in the proportion of one, two, and even three degrees, according to the volume of the artery under consideration, and the importance of the ob- stacle impeding the passage of the blood into the left ventricle. Stricture of the aortic ventricle.—This stricture is un- doubtedly the most frequent of all; the numerous concentric and eccentric hypertrophies and dilatations of the left ventricle, prove it at once: and among the causes which occasion and give rise to these organic lesions, we must assign the first place to every thing which impedes the passage of the blood into the aorta: affections of the mind, either acute or concentrated ; ex- cesses of the table, either increase or constrain the action of the heart; the result is, therefore, that the organ receives an in- creased quantum of nutriment, or undergoes a forced excitation of its valves and orifices, and then you have a primitive or secondary hypertrophy, a primitive or secondary dilatation; but our present subject is the ventriculo-aortic strictures ; let us now examine the phenomena which accompany them : the oppression is greater than in the other strictures, the anxiety more horrible, and the other symptoms which we have de- scribed much more decided; the heart is agitated with extreme violence; its immoderate and almost continual efforts occasion inexpressible agony; the patient does not breathe, he chokes, and death threatens him every instant. The pulse is most usually quick, but without any development of impulsions; it is irregular, unequal, frequent, intermittent, and sinks each moment; the sphygmometer reveals even this sign of the emptiness of the arteries in a very remarkable manner. Post- mortem examination almost always exhibits the stricture of the aortic ventricle, accompanied with hypertrophy or dila- tation of the ventricle. Hypertrophy of the heart, without stricture of the ori- fices.—Strong and deep beating of the heart, vertigoes princi- THE SPHYGMOMETER. 17 pally after rest, glows of heat in the face on the least agitation of the mind, oppression produced by the slightest exercise, &c.; the pulse is regular as to its periods, but unequal in the degree of its contractions ; il presents this anomaly, that the column of mercury, after being forced to a certain number of degrees, to 3 or 4, for instance, suddenly ascends at intervals to 8, 10, or even 15 degrees. The simple hypertrophy of the left ventricle is always sufficient to produce this peculiar character of the pulse. The dilatation of the left ventricle, and of its auricle, exhibits the same sphygmometrical signs, as those of the stric- tures of the auricular ventricles and aortic ventricles. Auscul- tation, percussion, mensuration, and the examination of the other functions of life, serve to distinguish the advanced or- ganic lesions from strictures or vegetations in their incipient state. This is the limit of my sphygmometrical researches into the organic diseases of the heart; but before I conclude, I ask of the Academy permission to add, in support of what I have ad- vanced, the schedule of the different facts that I have observed. G IS THE SPHYGMOMETER. ORGANIC LESIONS. CHARACTER OF THE PULSE, AND SPHYG- MOMETRICAL SIGNS. POST MORTEM OBSERVATIONS. REMARKS. r Strictures of the auriculo ventricular orifice of the right side, and strictures of ^ the auriculo | pulmonary orifice. r 22 patients. Small, irregular, un- equal, intermittent, i Strictures of different sometimes impercepti- j kinds, and dilatations ble. The column of more or less advanced, mercury does not fall I of the auricle and the f In S of these cases, ' auscultation furnished I only a slight sound ; in 6 the cataire* sound was very evident ; in the 8 other cases, there was no morbid nound. Oppres- sion, and more or less down to its starting-^ ventricle. A slight hy--^ alteration of the features point, or falls in two pertrophy was found j and colour of the face, efforts; it is checked about half way by some incidental im- pulse. I in the right ventricle I were the only symptoms of 4 subjects. | which could have induc- I ed the belief of the dis- I ease.—4 died of pulmo- nary apoplexy, and the others m a state of gene- \_ral oedema. r Strictures of the auriculo ventricular passage of the left side, and strictures of the aortic ven- tricles. 27 patients. The pulse is feeble, irregular, intermit- tent, unequal, but much more so than in the strictures of the right orifices. The eo lumn of mercury 111 1 the sphygmometer incipient hypertrophy falls below its level, 1, 2, and even 3 degrees, in proportion to the extent of the obstacle. /^The pulse was extremely feeble; in the first 12 | cases they died of hydro- In 12 cases the heart i thorax,in a general state was not in a state of of oedema; of the last IS hypertrophy, but J casts, 8 perished from merely dilated: the j hemoptysis, 5 from va- other 15 exhibited an* rious affections of the lungs, and 2 died from cerebral hemorrhage, In these 15 cases, the pulse was tense, frequent, and j quick, but was only Lslightly developed. of the left auricle and ventricle. Hypertrophies of the heart, without stric- tures of the orifices. 18 patients. The pulse is regular as to time, but unequal in its contractions. It affords this anomaly, that the column of r The examination of 18 individuals, upon whom I had observed this sphygmometrical mercury, after having > sign, disclosed a con- i equality in its contrac- risen to a certain num-"S centric or eccentric^ tions. The signs afforded In those cases wherein concentric hypertrophy existed, the pulse dia not exhibit the same devel- opment which is observ- ed in eccentric hyper- trophy, but it presented the same character of in- ber of degrees, to 3 or 4 for instance, sudden- ly rises, by intervals, to 8, 10, or even 15 de- grees. hypertrophy of the j by auscultation were met left ventricle, without with in 8 cases ; in the stricture of the orifices, j remainder they were so indistinct as to afford no grounds by which a ie- sion of the heart, in an advanced stage, could Lhave been recognised. * Cataire bruissement, or fremissement cataire. A sensation which, when existing in the hearf, is excited by applying the hand to the region of this organ, and is analogous to the aensation produced by the saw and rasp sounds.—CorvUart, Laennec, and Copland.—J. G. N. THE SPHYGMOMETER. 19 CONCLUSION. Whenever the action of the heart becomes disturbed, and in exploring the pulse with the sphygmometer, we meet with none of the symptoms by which one or more of the organic lesions of that viscus are characterized, we may hope that the rhythmical aberration depends upon other causes than a lesion of its texture. We must then seek these causes in affections of those organs with which this centre of the circulation sympa- thizes. The treatment that may be requisite, must depend upon the result of this investigation. I can say with truth, that many affections considered organic, with the aid of the ordinary means alone, have, when examined in the mode now propos- ed, been easily relieved by a rational medical treatment. I shall have occasion, in a work specially devoted to this subject, which I intend to publish, to prove, by a great num- ber of anatomical facts, that changes in those organs which are closely connected by sympathy with the heart, almost always accompany its own lesions ; a circumstance which satisfacto- rily explains the derangements of the circulation, and conse- quently the organic diseases of the viscus which is at its centre. The health of the system depends upon an equilibrium of the parts of which it is composed. When one organ languish- es, or when, from being over excited, its action is increased, it does not suffer alone, but all the organs whose functions it influences in any degree, sustain an injury more or less consi- derable. We have heard it repeated till we are wearied, that the pas- sions are the most common causes of affections of the heart; but who dare assert that certain conditions of this viscus are not themselves the most powerful agitators of the passions ? Who can doubt that an overgrown heart predisposes to irrita- tions of the brain ? or even that the cases of monomania furi- osa, erotomania, &c, which have terminated in death, after many years of continued suffering, have been coincident with organic lesions of the heart? Violent passions are therefore 20 THE SPHYGMOMETER. not sufficient to produce organic affections of the heart ; but hypertrophies of the left ventricle, on the contrary, occasion such a degree of cerebral irritation, as will be manifested ei- ther in a simple transport of anger, or even in furious mad- ness ; in simple congestion, or in overwhelming apoplexy. The subjects of these dilatations and strictures are usually phlegmatic and indolent ; and almost all addicted to the plea- sures of the table. These two conditions, if they accompany an active sanguification, are not slow in furnishing a quantity of blood excessive in proportion to the capacity of the vascu- lar system at large. The evident result is, that the muscular action of the heart is increased ; next, that the organ experi- ences irritation, or that its cavities become enlarged. I believe that the most common cause of diseases of the heart, consists in the quantity of nutriment being greater than is proportioned to the amount of exercise, or in exercise carri- ed beyond our strength. Where the amount of fluids absorbed exceeds that of the excretions, engorgement ensues, and the reservoirs becoming impaired, dilate or burst. I ought, per- haps, gentlemen, to insist further upon these etiological con- siderations, for they are capable of leading us to therapeutical conclusions of the utmost importance ; but again I am com- pelled to restrain myself, and I shall finish by repeating, that an incipient affection of the heart has always appeared to me susceptible of cure ; and that during six years that I have oc- cupied myself attentively with the lesions of this organ, I have often been able to detect them when no one could even have suspected their existence, who was aided by those means alone that have been heretofore known. I have been enabled to ob- serve their progress, and, much to my regret, see them arrive at that stage, when they no longer admitted of a remedy. The invalids had rejected that advice which would have subjected them to privations, and when ultimately induced to seek for succour, the resources of the healing art proved insufficient for their relief. THE END. 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