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LECTURES ON THE THEORY AND PRACTICE OF PHYSIC,
630 where the
oculi does not mia of children, are app)icable to the treatment of the affection in those of one, two, or three years old, except that depletion must be more active. When the eye is bright red and painfiil, so as to prevent rest, 2, 3, or 4 leeches should be applied ; one application is usually sufficient. Cold lotions are to be used ; and purgatives of calomel with spect, if the cornea was clear when rhubarb or jalap, or followed by castorthe infant was first seen. If you have oil. In older subjects, up to the time of occasion to change the lotion, from the puberty, leeches snffice, as a means of de. eye being accustomed to the stimulus of pletion ; they may be employed mote the alum, you may advantageously resort freely in proportion as the patient is to the nitrate of silver, beginning with older, and should be quickly repeated if one or two grains to the ounce, and the symptoms are not checked. Aciive gradually increasing the strength to four treatment by leeches, purgatives and or six grains. This solution may be blisters cuts short the inflammation, and dropped between the lids two or three astringents finish the cure. I have, in a few instances of acute local congestion in times a day. Mr. Ware, whom I should have mention- a full habit, deemed cupping or vene. ed, by the bye, as having given the first section necessary before puberty. express description of this complaint in our own, or I believe in any language, particularly recommends an astringent solution of rather complicated preparation and composition, called Bates’s camphorLECTURES ated water. You may make it bypour- i
conjunctiva
yet participate in the inflammation, the astringent may be employed at once; we adopt this course in 49 cases out of 50 at our Infirmary, using no other means than magnesia internally, and the solution of alum locally ; and out of many hundred instances, I hardly recollect one where the eye has suffered in any re-
newly-born
ing eight ounces of boiling water on eight I ON THE grains of the sulphate of copper, the same quantity of Armenian bole, and two grains THEORY AND PRACTICE OF PHYSIC, of camphor; let it stand till cold, and then pour off the clear liquor for a lotion. BY DR. CLUTTERBUCK. This composition has no superiority over the solution of sulphate of copper or alum ; indeed I consider the latter the Theatre, General Dispensary, Aldersgatebest astringent, and a solution of it in street. rose water is the pleasantest form of the
remedv.
When the cornea has sloughed, the LECTURE XIII. violence of theinflammation’ ’abates, Gentlemen, being succeededby an unhealthy and destructive ulcerative process, which, if AT my last Lecture I was speaking of unchecked, soon penetrates the cornea, the various qualities of the pulse, as oband exposes the interior of the organ. The served in diseases; and I mentioned parseparation of the slough leaves a white ticularly, frequency and slowness, quickflocculent ragged ulcer, in which there is ness and sluggishness, and likewise fulno disposition to reparation. The con- ness ; the other qualities, I shall now ’stitutional symptoms undergo a corre- proceed to consider. sponding change, the infant becoming pale, restless, irritable and weak. Under Smallness of Pulse is the reverse of these circumstances the powers of the fulness; it shows that a small quantity, system must be supported’ Ly tonics, of only, of blood-is contained in the artery which bark is the best. The most con- under examination. This may arise either venient form of administering the remedy, from diminished impulse of the heart and is that of extract, which the infant will arteries behind, by which the blood is take easilv, when broken down and urged onwards with less force, or in less blended with milk : from 4 to 10 grains quantity than usual ; or from an increase may be given in this way every 4 or 6 of the tonic contraction of the artery itself. hours. It speedily renovates the powers Thns a small pulse may proceed from of the system, and produces. an equally general weakness of system, (in consebeneficial local influence. The solution quence of which, the propulsive action will of alum may be used to the eye. be diminished) ; and also from a deficient The foregoing observations, although quantity of blood in the vessels : as after directly referring to the purulent ophthal- large haemorrhages, or a deficient supply
’
631
Of nutriment.But on the other bind,. posture, and the differenie’is so striking, smallness of pulse is quite consistent with that frequently you cannot form a cor. v
great strength of system, and abundance rect opinion of the disease while the paof the circulating fluid : for it may be tient is in the erect posture, even sitting; occasioned by an increased tonic contrac- but especially if he has recently risen. The 4th quality of pulse which yon tion of the vessel merely. Now it is of’ the utmost moment, that you should know should notice, is its strengtla, and, the how to distinguish between these in prac- opposite to this, weakness. These are of tice : as in the one case, bloodletting is considerable importance, in relation to scarcely admissible, or at least, requires disease. Strength of pulse is measured by the great caution in its administration ; while in the other, it may be employed with force necessary to compress the sides of great freedom, if the disease be of a na- the artery together, so as to stop the ture to call for such a remedy. current of blood through it. It is deterSmallness of pulse, arising either from mined by the force with which the heart general weakness, or from inanition, may and arteries conjointly, are acting. A be ascertained by inquiry into the pre- strong pulse is not always afull one ; for vious circumstances of the patient, and fulness depends upon a disposition to by the soft relaxed state of the solids dilate, in the artery under examination :c altogether. When it arises from such while strength of pulse is occasioned by causes, it will necessarily be permanent; the force of the current of blood behind, with the exception, ’that a powerful in- i endeavouring to force open the vessel; ternal stimulus, or the application of the and which force is derived from the joint hot bath, may give rise to an externalaction of the heart and arteries, as just determination of blood, which will pro.mentioned. duce, while it lasts, a fulness of pulse ; Strength of pulse in disease, does not but this effect will be of very short dura- always, (as in health is commonly’ the tion, and will probably be followed by a case) indicate general strength of system; still greater degree of smallness and becauseit may be the effect of a tempoof the heart and arteries. feebleness of pulse, and perhaps by syna state of pulse, if permanent, such cope. But On the other hand, smallness of pulse isaproof of general strength ; and will occasioned by contraction of the artery bear loss of blood, if called for by the merely, will be accompanied by general symptoms. On the other hand, weakness of pulse, marks of strength of system at the time, or immediately previous ; and also by which is judged of by the small force firmness of the solids when grasped. This required to stop it, is always a sign of a state of pulse, too, will commonly be at- weak system, and demands caution in the tended with a sense of oppression aboutuse of bloodletting, as well as other dethe heart and lungs, or in the brain, thebilitating means. Smallness and weakresult of over-fulness of vessels in theseness of pulse combined, argue the highest degree of general debility, and which parts. This contracted state of the artery att will scarcely admit of loss of blood. The the wrist is exceedingly common at the pulse at the wrist may be greatly weakcommencement of inflammation, and is ened, and even annihilated, by paralysis, relieved by bloodletting, which renders as in hemiplegia (for examples of which, the pulse fuller, or, as it is commonly I may refer you to several cases related expressed, makes the pulse rise:that is, hy Dr. Storer in the third volume of the the bloodletting lessens the tonic con- Transactions of a Society for promoting traction. Medical and Surgical Knowledge). So In long protracted diseases, such as that in order to judge correctly of the fevers, -and also in chronic affections of general state of the circulation in such various kinds, we judge by the fulness of cases, we must examine the pulse on the pulse, (that is, by the size of the both sides of the body, in the sound as artery,) the progress the disease is mak- well as in the uaralvtic limb. ing towards a fatal termination. Here 5th. Hardness and softness of pulse, are the change is gradual. In acute inflam- also important qualities, in relation to mation, also, we determine chiefly by disease. Hardness is denoted by ai-i ’fd this test, (fulness of pulse) the extent to cord-like, feel of the artery, and wllicb which bloodletting cap bp safely carried. gives to the mind, on touching it, the effect of sensation of a solid body pulsating under We must nevertheforget here,as the well as the the finger, rather than a vessel containposture upon fulness, frequency of the pulse. The pulse is ing a fluid in motion. generally rendered smaller, and at the Hardness of pulse appears to depend same time more frequent, by the erect upon a rigid, contracted state of the musr
rary excitement
’.
’
632
cular fibres of the arteryA hard pulse ought always to inquire, whether it may
is necessarily a small one;for the tonic not have been induced by such a cause. contraction exists in a high degree in The heart and arteries do not always this case; and it is generally a quick one correspond, as to regularity. For exalso. This state of pulse is induced by ample, palpitation of heart is not always long conxinued inflammation, especially productive of irregular pulse : and this of membranous structures. shows the influence of the arteries on the A preternatural degree of softness ofmotion of the blood. pulse, is the result of a peculiar condition A Redoubling of the Pulse (pulsus diof the arterial coats, the reverse of the crotus) is sometimes observed; that is, former. It is commonly accompanied a second stroke, (generally a weaker with softness or flabbiness of the solids one), follows immediately the former; in general. It attends inflammation of after which, there is a longer interval. the medullary substance of the brain; It seems as if the heart were unable to and is, therefore, constantly observed in empty itself by a single contraction, which simple fever. But in membranous in- is, therefore, renewed ; as takes place in flammation of the brain, as well as other an enlarged and weakened state of membranous structures, the pulse is com- the ventricle. Or it may, perhaps, arise monly hard. Inflammation of the sub- from some impediment existing to the stance of the lungs also, occasions soft. passage of the blood into the aorta; as ness ofoutse. from contraction or stricture at this part; 6th. Irregularity of pulse is very va- or from a diseased state of the valves; rious. The pulse may be irregular, either or ossification of the aorta. Diseased in regard to ff/rce or frequency. Thus, lungs, by creating an obstacle to the one beat may be stronger than another; passage of the blood from the right venwhereas in health, the beats are all equal tricle, may likewise disturb the regular in respect to force; or the pulsations action of the whole heart. There is an irregularity of pulse that may follow one another at different intervals ; and sometimes there is the loss has been little noticed ; which is, a trecf a stroke altogether, constituting what mulous, vibratory stroke, and which gives is called the intermitting pulse. On some the idea of a fluid moving under the finoccasions, the intermission occurs every ger, which a healthy pulse does not. third or fourth stroke ; at others, not till Such a pulse is generally observed it) after twenty or thirty. strongly marked simple fever, and ap. Irregularity of pulse is derived from pears to be occasioned by the want of a irregularity in the action of the heart. simultaneous action of the individual This irregularity in the action of the heart fibres of the muscular coat of the artery, may depend upon organic, or other pri- which in health, act at the same instant, mary disease, in the heart itself; or it so as to produce a distinctness of stroke. may be produced by disease in the brain, Such a state of the pulse may be comdisturbing the regular supply of nervous pared with the tremors of the muscles, power to the heart. The distinction is to that take place in such fevers, in their drawn from the attending symptoms. I advanced stage; and probably is owing Thus if the irregularity arises from the to the same remote cause, namely, the heart primarily, there will be pain or disordered condition of the brain; ocsome kind of uneasiness felt in the re- casioning an irregular supply of nervous gion of the heart, and generally other influence to the svstem at large. marks of thoracic disease: while, if it Many other conditions of pulse have from a brain affection, other been noticed by writers, and said to inproceed signs of this will generally be found on dicate certain approaching changes in examination. Hydrocephalus (or rather the system ; as that of h2emorrhage; the the cerebral inflammation which leads to approach of crisis in acute diseases, &c., it) in children, and fever in adults, are but they are little to be relied upon, ac. frequently attended with irregularity of cording to modern observation. pulse. In judging of the qualities of the pulse, Distention of the stomach by flatns, it is necessary to be aware of several cir· sometimes seems to induce irregularity cumstances which influence it, and unof pulse, which disappears when the less attended to, may mislead our judge flatus is expelled. How this operates, it ment. I shall enumerate the principal ill difficult to sav. I of these : Irregularity of pulse, it is proper to 1. Obesity. In fat subjects, the pulse observe, is often induced by narcotics of is so deeply buried, that it is difficult to alt kinds, as opium : but more especially obtain an accurate knowledge of it. The by the digitalis. When you meet, there- pulse in such, is apt to appear weaker sere, with such a state of pulse, you and smaller than it really is. In corpu, ’
be
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;
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633 we should make a case of pneumonia, in which the pulse minute and attentive examination at the wrist was hardly perceptible ; this of this, to prevent our falling into error : deterred the practitioner from bleeding, the artery should be strongly pressed upon although the patient was suffering great with two or three fingers, in order to pain in the chest, with so much difficulty judge of its size, and the real strength of of breathing, as to seem to call for bloodthe beats. letting to a great extent. The patient 2. Emaciation. In thin and emaciated was young and vigorous, and,immediately we can more easily examine the before the attack was in good general his countestate of the pulse than in fat ones. In the health. The expression former, we can, as it were, get round the nance did not at all indicate general de-vessel, and examine it thoroughly. In bility. These circumstances gave rise to a suspicion of preternatural conformation corpulent persons this cannot be done. 3. In old age not only is the artery of the artery ; and upon a more minute thinly covered as just observed, but the examination, this was found to be the pulse is hard from another cause. The case. The principal artery was discoveredsolids altogether become more rigid as taking an unusual direction. The artelife advances, and this gives a degree of ries of the other parts of the body, were hardness and apparent strength to the found beating strongly. I need not add, pulse, which are very fallacious, and that we had no longer any fear of taking might easily mislead us by making us sup- away blood. 6. Tumours pressing upon the artery. pose the disease to be of a more active character than it really is, and to use You will easily comprehend the effect of bloodletting with too great freedom, and this, in diminishing the size and fulneSi which might prove injurious to the pa- of the pulse. tient. 7. Mental emotion has a considerable 4. Idiosyncrasy. Indi vidnals differ influence on the pulse; fear and terror greatly, both in respect to the size and oftentimes prodnce great quickness and strength of the pulse ; and this arises irregularity of the pulse. The mere sight from an original difference in the vascular of the medical practitioner will, in those system. In some, the bloodvessels are termed irritable subjects, occasion much comparatively small, and in such the pulse disturbance of the pulse. Those unacwill of course be small also. This can customed to the visits of a medical praconly be known by a previous knowledge titioner, are very apt to be affected in of the individual ; or, as it is vulgarly this way; and if we draw our opinion termed, " knowing the constitution." from an immediate examination of the This kind of knowledge, is advantageous pulse, we shall most probably come to a in several respects. In some persons, the wrong conclusion. In such cases it is nepulse is intermittent, even in health. cessary to wait a few minutes, and repeat Now in general an intermittent state of our examination once or twice, in order pulse indicates danger, and is consequent. to avoid falling into error. ly calculated to produce alarm ; but in 8. Sudden changeof posture, will often those individuals in whom the pulse na- greatly increase the frequency of the turally intermits, intermission is of no pulse, and which will last for several mtmoment. I have seen the pulse in some nutes. In an erect posture, the pulse persons intermittent in health, but regular will often be 5 or 10 strokes more than in in disease ; and in such, when health re- a recumbent one. Any kind of bodily turned, the pulse again became inter- exertion may produce the same effect. The pulse of the arm which is most mittent. 5. Unusual distribution of the radial used, is frequently larger and stronger artery, is another source of error to be than in the opposite side. Now as most guarded against; and this may take place persons are right-handed, it follows that either in one or both arms. Thus, instead in general, the pulse of the right arm will of the principal artery pursuing its usual be found stronger and larger than that of course, a division of it takes place above, the left. In left-handed persons, the reand a very small branch only, will be verse is observed. found in the usual situation. In some in10. The temperature of the skin also, stances, none at all will be found there. will have a great influence over the pulse, In these cases, if the pulse were examined by increasing or diminishing the tonic hastily, we might suppose, that the pa- contraction of’the artery. tient was in a state of extreme weakness, Thus, you see, that the examination of such as to prohibit altogether the loss of the pulse is not so trivial a thing, as you blood. I have myself been more than might at first suppose; a number of cironce deceived in this way. I remem- cumstances require to be taken into conber a striking instance of this. It was sideration.
tent persons, therefore, a more
subjects,
of
*
634
Of the Indications afforded by ila Pulse, strong and bounding; yet Moodkttingiiis in regard to the Diagnosis, Plognosis, not always useful in such cases. and Treatment of Diseuses. Extremse frequency of the pulse is ra. Great frequency of pulse generally indi- titer adverse to bloodletting, and calls cates a febrile state of system, or pyrexir; for narcotics, as opium and digitalis. Pre. and as this again is always the rcsult of ternatural slowness, on the contrarv, ge. inflammation, a frequent pulse, so far, nerally calls for bloodletting ; unless it serves to show the existence oi’ inflammation. If attended with heat of’ skin, and fnrred tongue, it may be unplicitty relied upon. Preternatural slowness generally indicates an oppressed state of brain, whether produced, as it may be, by inflammation in that organ, or any other cause. The pulse may become preternaturally slow, even in the early stage of cerebral inflammation; but more commonly it is in the advanced stage of the disease that this takes place; and sometimes it is only observed after the inflammation has apparently ceased: effiision (the consequence of the inflammation) onty, remaining. It is of importance, in regard to the treatment, to determine whether the slowness of pulse proceeds from the one cause or the other, or from both com. bined. This is to be learned from the attending symptoms, as the state of the tongue, skin, &c., which generally shows the presence of inflammation. Quickness of pulse is also generally a sign of existing inflammation. Sluggishness, the reverse. Fulness shows the determination of the blood to the particular part ; as smallness does the contrary. But the smallness may arise also from general weakness of
system, or from inanition. Strength and weakness indicate corresponding states of system, with the ex-
ception which I mentioned to you. Hardness is a sign of long continued inflammation ; as in hectic fever. Where the pulse is hard, it will generally be
found that the crassamentum of the blood is buffed and cupped. Softness of pulse is indicative of a relaxed state of solids, and is generally combined with weakness of system. Irregularity of pulse commonly excites alarm, and, in most cases, with reason; for it most frequently arises from organic diseases, either of the heart or brain, and which seldom admit of cure. If occasioned by narcotics, it is of little moment; and the same if constitutional. The most useful indications derived from the pulse, are in regard to the use of bloodletting in inflammatory diseases. Afull, strong, and moderately frequent pulse, generally speaking, admits of bloodletting to the greatest extent, and with’out hesitation. Yet there are exceptions, as in acute rheumatism. In’ apoplexy, also, the pulse will often continue full and
should arise from effusion m the brain simply. without existing inflammation. , Ouickreess (as distinguished from fre&mid ot; qnency) often calls for bloodletting ; but does not in general require it to any con. siderable amount; because such a state of pulse mostly occurs in diseases that have been of long standing, and which are probably incurable. This state of pulse is generally relieved by the digita. talis, and by opium, especially whele bloodletting is premised. Softness of pulse generally admits of the use ot’tonics; hard. ness the reverse. The digitalis is very powerful in taking off hardness of pulse. Weakness of pulse, when it exists in a moderate degree onty, is not prohibitory of bloodletting, if the nature and magnitude of the disease seem to call for it. Caution and moderation as to quantity, are, however, required in such cases. Weakness combined with smallness and softness of pulse, are altogether adverse to this evacuation. Irregularity of pulse, in itself, is hardlp a guide, in regard to bloodletting ; but must be taken in conjunction with other circumstances. A regular and natural state of the pulse is no reason why bloodletting should nut be employed, supposing the case to be of such a nature as to require it; as inflammation in important organs; which may ’ call for bloodletting, although the general system, and therefore the pulse, may not as yet be disturbed by it. I may instance here, a case, in which there was abdominal pain and tenderness, indicating inflammation; yet the practitioner would not bleed, because the pulse was not disturbed. The disease increased, and five or six bleedings became neces’ sary, where, perhaps, a single one might have sufficed. I have now, gentlemen, enumerated the principal qualities of the pulse, both in health and disease, and the inferences which we draw from its different states. This brings us to the subject of inflammation ; the doctrine of which involves that of almost all other diseases. It isa subject of great extent; and if we con sider it either in regard to the frequency of the disease, the suffering it occasions, or the danger that attends it, we shall find it well deserving of our closest at. tention. The next and several of the following lectures will, therefore, be devoted to this most important subject. ’
oculi does not mia of children, are app)icable to the treatment of the affection in those of one, two, or three years old, except that depletion must be more active. When the eye is bright red and painfiil, so as to prevent rest, 2, 3, or 4 leeches should be applied ; one application is usually sufficient. Cold lotions are to be used ; and purgatives of calomel with spect, if the cornea was clear when rhubarb or jalap, or followed by castorthe infant was first seen. If you have oil. In older subjects, up to the time of occasion to change the lotion, from the puberty, leeches snffice, as a means of de. eye being accustomed to the stimulus of pletion ; they may be employed mote the alum, you may advantageously resort freely in proportion as the patient is to the nitrate of silver, beginning with older, and should be quickly repeated if one or two grains to the ounce, and the symptoms are not checked. Aciive gradually increasing the strength to four treatment by leeches, purgatives and or six grains. This solution may be blisters cuts short the inflammation, and dropped between the lids two or three astringents finish the cure. I have, in a few instances of acute local congestion in times a day. Mr. Ware, whom I should have mention- a full habit, deemed cupping or vene. ed, by the bye, as having given the first section necessary before puberty. express description of this complaint in our own, or I believe in any language, particularly recommends an astringent solution of rather complicated preparation and composition, called Bates’s camphorLECTURES ated water. You may make it bypour- i
conjunctiva
yet participate in the inflammation, the astringent may be employed at once; we adopt this course in 49 cases out of 50 at our Infirmary, using no other means than magnesia internally, and the solution of alum locally ; and out of many hundred instances, I hardly recollect one where the eye has suffered in any re-
newly-born
ing eight ounces of boiling water on eight I ON THE grains of the sulphate of copper, the same quantity of Armenian bole, and two grains THEORY AND PRACTICE OF PHYSIC, of camphor; let it stand till cold, and then pour off the clear liquor for a lotion. BY DR. CLUTTERBUCK. This composition has no superiority over the solution of sulphate of copper or alum ; indeed I consider the latter the Theatre, General Dispensary, Aldersgatebest astringent, and a solution of it in street. rose water is the pleasantest form of the
remedv.
When the cornea has sloughed, the LECTURE XIII. violence of theinflammation’ ’abates, Gentlemen, being succeededby an unhealthy and destructive ulcerative process, which, if AT my last Lecture I was speaking of unchecked, soon penetrates the cornea, the various qualities of the pulse, as oband exposes the interior of the organ. The served in diseases; and I mentioned parseparation of the slough leaves a white ticularly, frequency and slowness, quickflocculent ragged ulcer, in which there is ness and sluggishness, and likewise fulno disposition to reparation. The con- ness ; the other qualities, I shall now ’stitutional symptoms undergo a corre- proceed to consider. sponding change, the infant becoming pale, restless, irritable and weak. Under Smallness of Pulse is the reverse of these circumstances the powers of the fulness; it shows that a small quantity, system must be supported’ Ly tonics, of only, of blood-is contained in the artery which bark is the best. The most con- under examination. This may arise either venient form of administering the remedy, from diminished impulse of the heart and is that of extract, which the infant will arteries behind, by which the blood is take easilv, when broken down and urged onwards with less force, or in less blended with milk : from 4 to 10 grains quantity than usual ; or from an increase may be given in this way every 4 or 6 of the tonic contraction of the artery itself. hours. It speedily renovates the powers Thns a small pulse may proceed from of the system, and produces. an equally general weakness of system, (in consebeneficial local influence. The solution quence of which, the propulsive action will of alum may be used to the eye. be diminished) ; and also from a deficient The foregoing observations, although quantity of blood in the vessels : as after directly referring to the purulent ophthal- large haemorrhages, or a deficient supply
’
631
Of nutriment.But on the other bind,. posture, and the differenie’is so striking, smallness of pulse is quite consistent with that frequently you cannot form a cor. v
great strength of system, and abundance rect opinion of the disease while the paof the circulating fluid : for it may be tient is in the erect posture, even sitting; occasioned by an increased tonic contrac- but especially if he has recently risen. The 4th quality of pulse which yon tion of the vessel merely. Now it is of’ the utmost moment, that you should know should notice, is its strengtla, and, the how to distinguish between these in prac- opposite to this, weakness. These are of tice : as in the one case, bloodletting is considerable importance, in relation to scarcely admissible, or at least, requires disease. Strength of pulse is measured by the great caution in its administration ; while in the other, it may be employed with force necessary to compress the sides of great freedom, if the disease be of a na- the artery together, so as to stop the ture to call for such a remedy. current of blood through it. It is deterSmallness of pulse, arising either from mined by the force with which the heart general weakness, or from inanition, may and arteries conjointly, are acting. A be ascertained by inquiry into the pre- strong pulse is not always afull one ; for vious circumstances of the patient, and fulness depends upon a disposition to by the soft relaxed state of the solids dilate, in the artery under examination :c altogether. When it arises from such while strength of pulse is occasioned by causes, it will necessarily be permanent; the force of the current of blood behind, with the exception, ’that a powerful in- i endeavouring to force open the vessel; ternal stimulus, or the application of the and which force is derived from the joint hot bath, may give rise to an externalaction of the heart and arteries, as just determination of blood, which will pro.mentioned. duce, while it lasts, a fulness of pulse ; Strength of pulse in disease, does not but this effect will be of very short dura- always, (as in health is commonly’ the tion, and will probably be followed by a case) indicate general strength of system; still greater degree of smallness and becauseit may be the effect of a tempoof the heart and arteries. feebleness of pulse, and perhaps by syna state of pulse, if permanent, such cope. But On the other hand, smallness of pulse isaproof of general strength ; and will occasioned by contraction of the artery bear loss of blood, if called for by the merely, will be accompanied by general symptoms. On the other hand, weakness of pulse, marks of strength of system at the time, or immediately previous ; and also by which is judged of by the small force firmness of the solids when grasped. This required to stop it, is always a sign of a state of pulse, too, will commonly be at- weak system, and demands caution in the tended with a sense of oppression aboutuse of bloodletting, as well as other dethe heart and lungs, or in the brain, thebilitating means. Smallness and weakresult of over-fulness of vessels in theseness of pulse combined, argue the highest degree of general debility, and which parts. This contracted state of the artery att will scarcely admit of loss of blood. The the wrist is exceedingly common at the pulse at the wrist may be greatly weakcommencement of inflammation, and is ened, and even annihilated, by paralysis, relieved by bloodletting, which renders as in hemiplegia (for examples of which, the pulse fuller, or, as it is commonly I may refer you to several cases related expressed, makes the pulse rise:that is, hy Dr. Storer in the third volume of the the bloodletting lessens the tonic con- Transactions of a Society for promoting traction. Medical and Surgical Knowledge). So In long protracted diseases, such as that in order to judge correctly of the fevers, -and also in chronic affections of general state of the circulation in such various kinds, we judge by the fulness of cases, we must examine the pulse on the pulse, (that is, by the size of the both sides of the body, in the sound as artery,) the progress the disease is mak- well as in the uaralvtic limb. ing towards a fatal termination. Here 5th. Hardness and softness of pulse, are the change is gradual. In acute inflam- also important qualities, in relation to mation, also, we determine chiefly by disease. Hardness is denoted by ai-i ’fd this test, (fulness of pulse) the extent to cord-like, feel of the artery, and wllicb which bloodletting cap bp safely carried. gives to the mind, on touching it, the effect of sensation of a solid body pulsating under We must nevertheforget here,as the well as the the finger, rather than a vessel containposture upon fulness, frequency of the pulse. The pulse is ing a fluid in motion. generally rendered smaller, and at the Hardness of pulse appears to depend same time more frequent, by the erect upon a rigid, contracted state of the musr
rary excitement
’.
’
632
cular fibres of the arteryA hard pulse ought always to inquire, whether it may
is necessarily a small one;for the tonic not have been induced by such a cause. contraction exists in a high degree in The heart and arteries do not always this case; and it is generally a quick one correspond, as to regularity. For exalso. This state of pulse is induced by ample, palpitation of heart is not always long conxinued inflammation, especially productive of irregular pulse : and this of membranous structures. shows the influence of the arteries on the A preternatural degree of softness ofmotion of the blood. pulse, is the result of a peculiar condition A Redoubling of the Pulse (pulsus diof the arterial coats, the reverse of the crotus) is sometimes observed; that is, former. It is commonly accompanied a second stroke, (generally a weaker with softness or flabbiness of the solids one), follows immediately the former; in general. It attends inflammation of after which, there is a longer interval. the medullary substance of the brain; It seems as if the heart were unable to and is, therefore, constantly observed in empty itself by a single contraction, which simple fever. But in membranous in- is, therefore, renewed ; as takes place in flammation of the brain, as well as other an enlarged and weakened state of membranous structures, the pulse is com- the ventricle. Or it may, perhaps, arise monly hard. Inflammation of the sub- from some impediment existing to the stance of the lungs also, occasions soft. passage of the blood into the aorta; as ness ofoutse. from contraction or stricture at this part; 6th. Irregularity of pulse is very va- or from a diseased state of the valves; rious. The pulse may be irregular, either or ossification of the aorta. Diseased in regard to ff/rce or frequency. Thus, lungs, by creating an obstacle to the one beat may be stronger than another; passage of the blood from the right venwhereas in health, the beats are all equal tricle, may likewise disturb the regular in respect to force; or the pulsations action of the whole heart. There is an irregularity of pulse that may follow one another at different intervals ; and sometimes there is the loss has been little noticed ; which is, a trecf a stroke altogether, constituting what mulous, vibratory stroke, and which gives is called the intermitting pulse. On some the idea of a fluid moving under the finoccasions, the intermission occurs every ger, which a healthy pulse does not. third or fourth stroke ; at others, not till Such a pulse is generally observed it) after twenty or thirty. strongly marked simple fever, and ap. Irregularity of pulse is derived from pears to be occasioned by the want of a irregularity in the action of the heart. simultaneous action of the individual This irregularity in the action of the heart fibres of the muscular coat of the artery, may depend upon organic, or other pri- which in health, act at the same instant, mary disease, in the heart itself; or it so as to produce a distinctness of stroke. may be produced by disease in the brain, Such a state of the pulse may be comdisturbing the regular supply of nervous pared with the tremors of the muscles, power to the heart. The distinction is to that take place in such fevers, in their drawn from the attending symptoms. I advanced stage; and probably is owing Thus if the irregularity arises from the to the same remote cause, namely, the heart primarily, there will be pain or disordered condition of the brain; ocsome kind of uneasiness felt in the re- casioning an irregular supply of nervous gion of the heart, and generally other influence to the svstem at large. marks of thoracic disease: while, if it Many other conditions of pulse have from a brain affection, other been noticed by writers, and said to inproceed signs of this will generally be found on dicate certain approaching changes in examination. Hydrocephalus (or rather the system ; as that of h2emorrhage; the the cerebral inflammation which leads to approach of crisis in acute diseases, &c., it) in children, and fever in adults, are but they are little to be relied upon, ac. frequently attended with irregularity of cording to modern observation. pulse. In judging of the qualities of the pulse, Distention of the stomach by flatns, it is necessary to be aware of several cir· sometimes seems to induce irregularity cumstances which influence it, and unof pulse, which disappears when the less attended to, may mislead our judge flatus is expelled. How this operates, it ment. I shall enumerate the principal ill difficult to sav. I of these : Irregularity of pulse, it is proper to 1. Obesity. In fat subjects, the pulse observe, is often induced by narcotics of is so deeply buried, that it is difficult to alt kinds, as opium : but more especially obtain an accurate knowledge of it. The by the digitalis. When you meet, there- pulse in such, is apt to appear weaker sere, with such a state of pulse, you and smaller than it really is. In corpu, ’
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633 we should make a case of pneumonia, in which the pulse minute and attentive examination at the wrist was hardly perceptible ; this of this, to prevent our falling into error : deterred the practitioner from bleeding, the artery should be strongly pressed upon although the patient was suffering great with two or three fingers, in order to pain in the chest, with so much difficulty judge of its size, and the real strength of of breathing, as to seem to call for bloodthe beats. letting to a great extent. The patient 2. Emaciation. In thin and emaciated was young and vigorous, and,immediately we can more easily examine the before the attack was in good general his countestate of the pulse than in fat ones. In the health. The expression former, we can, as it were, get round the nance did not at all indicate general de-vessel, and examine it thoroughly. In bility. These circumstances gave rise to a suspicion of preternatural conformation corpulent persons this cannot be done. 3. In old age not only is the artery of the artery ; and upon a more minute thinly covered as just observed, but the examination, this was found to be the pulse is hard from another cause. The case. The principal artery was discoveredsolids altogether become more rigid as taking an unusual direction. The artelife advances, and this gives a degree of ries of the other parts of the body, were hardness and apparent strength to the found beating strongly. I need not add, pulse, which are very fallacious, and that we had no longer any fear of taking might easily mislead us by making us sup- away blood. 6. Tumours pressing upon the artery. pose the disease to be of a more active character than it really is, and to use You will easily comprehend the effect of bloodletting with too great freedom, and this, in diminishing the size and fulneSi which might prove injurious to the pa- of the pulse. tient. 7. Mental emotion has a considerable 4. Idiosyncrasy. Indi vidnals differ influence on the pulse; fear and terror greatly, both in respect to the size and oftentimes prodnce great quickness and strength of the pulse ; and this arises irregularity of the pulse. The mere sight from an original difference in the vascular of the medical practitioner will, in those system. In some, the bloodvessels are termed irritable subjects, occasion much comparatively small, and in such the pulse disturbance of the pulse. Those unacwill of course be small also. This can customed to the visits of a medical praconly be known by a previous knowledge titioner, are very apt to be affected in of the individual ; or, as it is vulgarly this way; and if we draw our opinion termed, " knowing the constitution." from an immediate examination of the This kind of knowledge, is advantageous pulse, we shall most probably come to a in several respects. In some persons, the wrong conclusion. In such cases it is nepulse is intermittent, even in health. cessary to wait a few minutes, and repeat Now in general an intermittent state of our examination once or twice, in order pulse indicates danger, and is consequent. to avoid falling into error. ly calculated to produce alarm ; but in 8. Sudden changeof posture, will often those individuals in whom the pulse na- greatly increase the frequency of the turally intermits, intermission is of no pulse, and which will last for several mtmoment. I have seen the pulse in some nutes. In an erect posture, the pulse persons intermittent in health, but regular will often be 5 or 10 strokes more than in in disease ; and in such, when health re- a recumbent one. Any kind of bodily turned, the pulse again became inter- exertion may produce the same effect. The pulse of the arm which is most mittent. 5. Unusual distribution of the radial used, is frequently larger and stronger artery, is another source of error to be than in the opposite side. Now as most guarded against; and this may take place persons are right-handed, it follows that either in one or both arms. Thus, instead in general, the pulse of the right arm will of the principal artery pursuing its usual be found stronger and larger than that of course, a division of it takes place above, the left. In left-handed persons, the reand a very small branch only, will be verse is observed. found in the usual situation. In some in10. The temperature of the skin also, stances, none at all will be found there. will have a great influence over the pulse, In these cases, if the pulse were examined by increasing or diminishing the tonic hastily, we might suppose, that the pa- contraction of’the artery. tient was in a state of extreme weakness, Thus, you see, that the examination of such as to prohibit altogether the loss of the pulse is not so trivial a thing, as you blood. I have myself been more than might at first suppose; a number of cironce deceived in this way. I remem- cumstances require to be taken into conber a striking instance of this. It was sideration.
tent persons, therefore, a more
subjects,
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Of the Indications afforded by ila Pulse, strong and bounding; yet Moodkttingiiis in regard to the Diagnosis, Plognosis, not always useful in such cases. and Treatment of Diseuses. Extremse frequency of the pulse is ra. Great frequency of pulse generally indi- titer adverse to bloodletting, and calls cates a febrile state of system, or pyrexir; for narcotics, as opium and digitalis. Pre. and as this again is always the rcsult of ternatural slowness, on the contrarv, ge. inflammation, a frequent pulse, so far, nerally calls for bloodletting ; unless it serves to show the existence oi’ inflammation. If attended with heat of’ skin, and fnrred tongue, it may be unplicitty relied upon. Preternatural slowness generally indicates an oppressed state of brain, whether produced, as it may be, by inflammation in that organ, or any other cause. The pulse may become preternaturally slow, even in the early stage of cerebral inflammation; but more commonly it is in the advanced stage of the disease that this takes place; and sometimes it is only observed after the inflammation has apparently ceased: effiision (the consequence of the inflammation) onty, remaining. It is of importance, in regard to the treatment, to determine whether the slowness of pulse proceeds from the one cause or the other, or from both com. bined. This is to be learned from the attending symptoms, as the state of the tongue, skin, &c., which generally shows the presence of inflammation. Quickness of pulse is also generally a sign of existing inflammation. Sluggishness, the reverse. Fulness shows the determination of the blood to the particular part ; as smallness does the contrary. But the smallness may arise also from general weakness of
system, or from inanition. Strength and weakness indicate corresponding states of system, with the ex-
ception which I mentioned to you. Hardness is a sign of long continued inflammation ; as in hectic fever. Where the pulse is hard, it will generally be
found that the crassamentum of the blood is buffed and cupped. Softness of pulse is indicative of a relaxed state of solids, and is generally combined with weakness of system. Irregularity of pulse commonly excites alarm, and, in most cases, with reason; for it most frequently arises from organic diseases, either of the heart or brain, and which seldom admit of cure. If occasioned by narcotics, it is of little moment; and the same if constitutional. The most useful indications derived from the pulse, are in regard to the use of bloodletting in inflammatory diseases. Afull, strong, and moderately frequent pulse, generally speaking, admits of bloodletting to the greatest extent, and with’out hesitation. Yet there are exceptions, as in acute rheumatism. In’ apoplexy, also, the pulse will often continue full and
should arise from effusion m the brain simply. without existing inflammation. , Ouickreess (as distinguished from fre&mid ot; qnency) often calls for bloodletting ; but does not in general require it to any con. siderable amount; because such a state of pulse mostly occurs in diseases that have been of long standing, and which are probably incurable. This state of pulse is generally relieved by the digita. talis, and by opium, especially whele bloodletting is premised. Softness of pulse generally admits of the use ot’tonics; hard. ness the reverse. The digitalis is very powerful in taking off hardness of pulse. Weakness of pulse, when it exists in a moderate degree onty, is not prohibitory of bloodletting, if the nature and magnitude of the disease seem to call for it. Caution and moderation as to quantity, are, however, required in such cases. Weakness combined with smallness and softness of pulse, are altogether adverse to this evacuation. Irregularity of pulse, in itself, is hardlp a guide, in regard to bloodletting ; but must be taken in conjunction with other circumstances. A regular and natural state of the pulse is no reason why bloodletting should nut be employed, supposing the case to be of such a nature as to require it; as inflammation in important organs; which may ’ call for bloodletting, although the general system, and therefore the pulse, may not as yet be disturbed by it. I may instance here, a case, in which there was abdominal pain and tenderness, indicating inflammation; yet the practitioner would not bleed, because the pulse was not disturbed. The disease increased, and five or six bleedings became neces’ sary, where, perhaps, a single one might have sufficed. I have now, gentlemen, enumerated the principal qualities of the pulse, both in health and disease, and the inferences which we draw from its different states. This brings us to the subject of inflammation ; the doctrine of which involves that of almost all other diseases. It isa subject of great extent; and if we con sider it either in regard to the frequency of the disease, the suffering it occasions, or the danger that attends it, we shall find it well deserving of our closest at. tention. The next and several of the following lectures will, therefore, be devoted to this most important subject. ’