No. 2730

DECEMBER 25, 1875.

A Clinical LectureON

THE PULSE: ITS DIAGNOSTIC, PROGNOSTICAND THERAPEUTIC INDICATIONS.

Being Lecture III. delivered at St. Mary’s Hospital in theSummer Session of 1875,

BY W. H. BROADBENT, M.D., F.R.C.P.,PHYSICIAN TO THE HOSPITAL.

GENTLEMEN,—I come now to Renal Disease as a cause ofhigh arterial tension. This condition is most marked inconnexion with contracted granular kidney, but is presentin a greater or less degree in all affections of the kidneys,except, perhaps, in amyloid disease, when, unless there isdesquamative nephritis as a complication, or general arterialdegeneration, the tension may not be great. In tubercular

or scrofulous disease of the kidneys there appear to be dif-ferences ; for I have sometimes found the arterial tensionhigh, sometimes not.

It is with respect to the state of the vessels in contracted

granular disease of the kidneys that there has been a con-troversy between Dr. George Johnson and Sir Wm. Gulland Dr. Sutton. Dr. Johnson, in his original investigationswhich first gave us precise knowledge of the different formsof kidney disease, noted the thickening of the minute ar-teries of the kidney in this affection. More recently hefound that not only were the branches of the renal arterythickened, but that a similar condition of the minute ar-teries existed throughout the body-in the meninges of thebrain, in the skin, in the gastro-intestinal mucous mem-brane, and elsewhere; he found, moreover, that the thick-ening consisted primarily and chiefly of hypertrophy of themuscular coat. These were no barren discoveries in hishands, but became the basis of a theory which linked to-gether by a consistent physiological or pathological explana-tion the previously isolated phenomena of this form of dis-ease. According to this the kidneys, from gradual loss of thesecreting epithelium, fail to remove effectually the urinaryconstituents, leaving the blood contaminated thereby. Thearterioles, to protect the tissues from blood thus renderedimpure, resist its passage by contracting, while the heart,meeting with unwonted resistance, puts forth increasingenergy; and the result of this contest between the heart,on the one hand, and the minute arteries, on the other, ishypertrophy of the muscular tissues of both.My way of describing the mode of causation of this hyper-

trophy is a very imperfect representation of Dr. Johnson’sviews, and is open to objection on various grounds, as in-volving unproven theory, and as teleological, assuming thata process is because it is useful, or that a process is usefulbecause it is; but I have had to sacrifice exactness of ex-pression and completeness of exposition to brevity. Itseems, again, a reductio ad absurdum to represent the heartand arteries as engaged in this contest, which is damagingto both alike, in the interests of the system generally; butthe high arterial tension thus generated, though ultimatelytending to shorten life, is, after all, conservative, for by in-creasing the flow of urine and producing the diuresis whichaccompanies this disease it postpones the catastrophe ofursemia which would otherwise speedily overtake the patient.The rival theory of Sir W. Gull has a clinical basis. At

a certain time of life it is very common for men to begingradually to lose flesh, colour, and strength; they sufferfrom indigestion, the appetite fails, and the bowels actsluggishly; they become apathetic or irritable, disinclinedfor exertion and incapable of it; the muscles waste; theskin is thin, loose, and dry; some remains of colour persistperhaps in the cheeks from enlarged capillaries, but thetemples and the rest of the face acquire a somewhat sallowhue, and the lower eyelids are more or less puffy ; often themucous membrane of the mouth is more anssmio than mightbe expected from the colour of the face, and there is a defi-ciency of buccal fluid and a slightly furred tongue. All

this time the urine is abundant and clear-perhaps a sub-ject of self-gratulation to the patient ; bnt it will be paleand have a low specific gravity ; there may for a long timebe no albumen in it, or a trace may come and go from timeto time, but eventually albumen is habitually present, andthe case resolves itself into well-characterised Bright’sdisease.

Sir W. Gull and Dr. Sutton, like Dr. Johnson, find in acase of this kind the arterioles thickened, but, say they,the thickening is not hypertrophy, but degeneration. The

change in the arterioles they describe as hyaline-fibroid,the disease they name arterio-capillary Rbrosis, and thesequence of events they consider to be primarily arterio-capillary degeneration, and secondarily a general fibroidchange, in which the kidneys share, so that the kidney dis-ease is not the cause, but the consequence, of the conditionof the vessels.

Now of the truth of this clinical ’history, with the com-paratively late appearance of albuminnxa in many casesof chronic Bright’s disease, there can tre no doubt; butI agree with Dr. Johnson in disputing the inferencedrawn from it. First as to the fundamental fact-thenature of the change in the arterial walls as revealedby the microscope after death : is it hypertrophy, or isit degeneration ? P On the one hand, Dr. Johnson shows anincrease in number, size, and distinctness of the nucleiof the muscular fibre-cells, which cannot be mistaken foranything else, and cannot be manufactured by any modeof preparation; on the other, he shows that the swollen,translucent, structureless, or finely fibrillase appearancewhich Sir W. Gull and Dr. Sutton exhibit as hyaline-fibroiddegeneration is, to say the least, producibJe by the methodsof preparation they adopted, and is probably the result ofobliteration of the structural characters of the arterial coats.We are asked to suspend our judgment pending the pro-duction of further evidence; but I do not see how the un-equivocal demonstration of increased muscular tissue can beexplained away. With the muscular tissue there will alsoinevitably be increase of fibrous tissue, which may swell upand obscure the muscular fibres under the use of certain re-agents ; but this does not prevent the hypertrophy of mus-cular structure from being real. -

But the question does not rest simply on microscopicevidence. , If the change in the arterioles were degenera-tive, the usual physiological and pathological contractionand relaxation of their muscular fibres could not possiblyoccur, and there could be no changes in the diameter of thevessels or variations of the arterial tension so caused. Nowit is certain that the arterial tension is subject to modifica-tions even in advanced Bright’s disease. My attention wasfirst forcibly called to this fact in an interesting case whichwas the subject of a clinical lecture in the winter session of1871-72 * The patient was a woman, six months pregnant,under treatment for albuminuria, who died shortly after-wards of apoplexy, and was found to have contracted granu-lar disease of the kidneys. She presented the phenomena ofextreme arterial tension, and I was in the habit of demon-strating in her case the characters of the pulse attendingthis condition. One day, after telling my class as we ap-proached the bed what to expect, I found, on placing myhand on the wrist, that all the indications of high tensionhad vanished. This was because she was suffering from asmart attack of pyrexia, with the subsidence of which thetension returned, ultimately, as I said, p.roving fatal bygiving rise to apoplexy. I have repeatedly made similarobservations since, and when the subject of arterio-capillaryfibrosis was coming on for discussion, at the Medico-Cbirurgical Society, these cases suggested tiD me an experi-ment which was entirely confirmatory. This was to ad-minister nitrite of amyl in a case of well-marked chronicBright’s disease, and note the effects on the pulse. Pulsetracings taken before and after the inhalation demon-strated unequivocally the relaxation of the arterioles.The truth is, or, I ought rather to say, my firm conviction

is, that the clinical history, traced by Sir William Gull asthat of arterio-capillary fibrosis, which I have just im-perfectly reproduced, is a history, not of arterial degenera-tion, but of arterial tension. From the first the pulse issmall, long, and hard, and the cardiac signs of arterialtension first interpreted by Dr. Sibson are present; the

* THE LANCET, Feb. 1872.C o

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first sound is reduplicated over the interventricular septum, being prominent among them, and the patient died a shortand at the right second space the first sound is muffled, the time ago.second (aortic) intensified or aocentuated. But the ab- I am reminded of another case in which I was called innormal state of the circulation can be reversed, and consultation to a case of periodic vomiting in an old lady.that not only by pyrexia, but by treatment. Allowed to Her pulse, small and weak, but with all the characters ofcontinue long enough, it may give rise to arterial degene- tension, suggested an examination of the urine, which, as Iration, and this degeneration becomes the great source of had anticipated, was found to be albuminous. The vomitingdanger, but the degeneration is not primary, and can be was uraemic.

prevented. One of the cases I related in my last lecture is The examination of the urine is almost a matter of routine,a typical illustration of the clinical history under considera- but in both these cases it happened to be omitted. You aretion. aware, however, that albumen is not always present in the

’ The kidney disease, then, is not a result of vascular urine in contracted granular disease of the kidneys; in thedegeneration. But there is another point to be considered- early stages it comes and goes, and later may occasionallyIs it the result of arterial tension ? The arterial tension is disappear. You will see, therefore, the importance ofantecedent in point of time to the renal disease. Does it having so clear an indication in the state of the pulse.stand in a causal relation to it ? or are the two conditions- Gout and allied conditions of system as a cause of arterialthe arterial tension and the structural change in the tension.—The term "suppressed gout" is a convenient refugekidneys-concomitant results of a common cause ? The in- for ignorance and uncertainty; it is accepted by the publicteresting facts adduced by Dr. Mahomed in his paper on the as a sufficient explanation of any chronic or recurrent ailment,pre-albuminuric stage of acute Bright’s disease-that after or, indeed, of anything and everything, and accordingly itscarlet fever there is, with rising intravascular pressure, is freely used by medical men. The expression, often spokenfirst escape of blood-crystalloids, and then of blood- of contemptuously, has, however, considerable vitality,albumen-would seem to point in the direction of a causal because it carries a certain amount of truth. Originallyrelation between the two; but I have come to the conclusion it embodied a conclusion formed from profound clinical ob-that an impure state of the blood is the cause both of the servation, and, if it were not abused by indiscriminate appli-resistance in the capillaries and arterioles which gives rise to cation to all kinds of complaints, would be very useful andhigh arterial tension, and of the morbid change in the valuable. In gout, as you are aware, the oxidation of

kidneys. nitrogenised waste, instead of going on to the formation ofA subordinate question is whether the resistance to the urea, has stopped short at uric acid, which accumulates in

circulation of contaminated blood is primarily in the capil- the blood and constitutes a poison to which the attackslaries or arterioles - whether, that is, there is first of gouty inflammation are due. This, at any rate, is theobstruction in the capillaries, the contraction of the theory which, if not demonstrably true in every point, is anarterioles being secondary, or whether the narrowing of excellent working hypothesis. But the destructive meta-the minute arteries is the sole cause of the obstruction. Of morphosis may fall short even of uric acid, and the bloodcourse this brings up the entire subject of the capillary cir- may be contaminated by a variety of imperfectly oxidisedculation, how far the mutual attraction of the blood and matters. The presence of these impurities in the bloodtissues operates to facilitate or binder the passage of the gives rise to the most varied consequences : frank acuteblood, and this is not to be discussed within the limits of a gout, chronic gout with the formation of gouty concretionsclinical lecture; but I may say that I have come to believe in the joints, on the ears, in the conjunctiva; the less honestthat, while as a rule the action of the arterioles is direct, forms of gout, pains in the toe, the heel, the loins, the head;and not merely secondary to resistance in the capillaries, attacks of vertigo, irritability of temper, loss of the facultythere are cases in which the resistance is capillary, the of attention, palpitation of the heart, cough and shortnessarteries yielding to the pressure of the blood within them. of breath, dyspepsia, gravel or stone, inflammation or

I shall not occupy you long by illustrations of the asso- irritability of the bladder, eczema, and other skin affec-ciation of high arterial tension with disease of the kidneys. tions. Besides these there are the so-called attacks ofThe subject is one which I have considered here before, but gout in the stomach or head, and sudden and extensive con-it is strictly within the scope of this lecture to refer to gestion of the lungs. After this list you will no longercases in which the pulse has at once given the clue to the wonder that everything is referred to suppressed gout.kidney disease. Most of you will remember the case I There is one feature, however, common to the whole rangehave already mentioned of a man, Henry C-, aged of these affections-high arterial tension. Nitrogenisedthirty-three, who applied for admission suffering from pain waste, at whatever stage of arrested oxidation, appears toin the head, vomiting, and impairment of vision; he reeled provoke resistance to the passage of the blood through theand staggered also, exactly like a drunken man, and could capillaries and minute arteries, and this affords us the cluenot walk without support; his speech, again, was thick. He which guides us through the maze and gives precision topresented a complete picture of cerebellar disease. I sent our ideas.him to the ward at once, with the remark that there was We are now dealing, as you will see, with the main causeapparently disease of the cerebellum, probably, from his of the two serious forms of disease we have already con-age and appearance, syphilitic, postponing examination till sidered-degeneration of arteries and chronic granular con-we could go into the case fully. When I came to his bed- traction of the kidneys; and what makes it more importantside, however, expecting the symptoms and history of an is, that at this stage we have the opportunity, not for pal-intracranial affection, I had scarcely placed my hand upon liative only, but for remedial treatment. The arterial de-the pulse when my first-sight diagnosis fell to the ground. generation is a direct result of the strain up0n the walls ofI saw I had to deal with renal disease; the urine was ex- the vessels by excessively high tension. As to the renal dis-amined and found to be albuminous, the ophthalmoscope ease, we cannot, as I have already said, speak so positively;showed us albuminuric retinitis, instead of optic neuritis or we cannot say definitely whether it is produced by the stateischæmia; the headache, the vomiting, the loss of vision of the blood acting injuriously on the epithelium of thewere ursemic, and ultimately we had post-mortem demon- tubules, or whether it also is a consequence of high arterialstration of contracted granular kidneys. tension.In November, 1873, a former student of this hospital, one The following are some of the cases I have seen which

of our very best men, sent a clergyman to consult me on may serve to illustrate different phases and stages of sup-account of headache, attacks of giddiness, and impaired pressed or spurious gout.sight. Prepossessed with the idea of cerebral mischief, he I was called in March, 1873, to see a gentleman aged abouthad overlooked the contingency of renal disease, and had sixty-four, who was suffering from cough. He held a highnever examined the urine. Here, again, the pulse, long and position in the Colonial Service, and had spent a great parthard, the artery standing out among the surrounding struc- of his life in hot climates. He was supposed, on that ac-tnres, at once suggested the diagnosis of kidney disease, count, to be susceptible to cold. He was stout, good-looking,which was confirmed by the presence of retinal haemorrhages, and of very dignified appearance, but singularly stolid, dull,a clouded disc, and the familiar white spots round the disc and uncommunicative. I permitted myself, indeed, to makeand yellow spot. The diagnosis thus made was verified by certain mental reflections on the kind of King Log sent outthe state of the urine, in which, however, at this time there to administer our colonies. His symptoms, however, werewas the merest trace of albumen. Later the symptoms of not fully accounted for by the slight bronchial catarrh whichBright’s disease became more marked, obstinate vomiting was all I found on examination of the chest. More par-

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ticularly my attention was arrested by a high degree ofarterial tension, shown by the long, hard, labouring pulseof 84, and by the vessel remaining full between the beats.’There were also the cardiac signs of high tension, a re-duplicated first sound near the apex, and an accentuatedaortic second sound. By pushing my inquiries, I graduallylearnt that my patient bad for some little time been moreeasily fatigued than usual, had been often greatly flushedafter dinner, unaccountably irascible, with lapses of memoryat times, and, finally, it came out that in a letter written’shortly before my visit there had been the most extraordi-nary anomalies of spelling, many words having been speltbackwards. Nothing could have been more significantthan this train of symptoms associated with arterial tension;they were the premonitions of impending apoplexy; and

- .apoplexy, as I learnt later, was the natural mode of deathin his family at about his age. The urine had a specificgravity of 1014, but had a good deep colour, and con-tained no albumen. The object to be attained, in order to- escape the threatened danger, was to bring down the arterialtension. I gave calomel (three grains), with colocynth and.colchicum, followed by a saline draught as a purgative, andiodide and citrate of potash with taraxacum ; reduced theproportion of meat in the diet, snbstituting milk and fish,and for a time made dinner a midday meal; no restrictionswere needed with regard to stimulants, the patient’s habitsbeing almost abstemious. This line of treatment was con-tinued for some little time with the effect of removing allthe unpleasant symptoms, and I found I had done my pa-’tient’s mental power and social qualifications great injustice.I saw little of him till Feb., 1874, when I was urgently.-called one evening, and found that, after similar warnings,he had partially lost power in his left limbs; the left sideof the face was slightly paralysed, and the speech verythick and indistinct; there had been some mental confusion,but no loss of consciousness. A similar line of treatmentwas adopted, and now the dinner hour was permanently- established at 2 P M. Improvement again followed, but itwas long before the face recovered itself, and, indeed, aslight inequality is still to be detected. In Feb., 1875, my,patient lost all appetite, and the tongue was much furred;there was a certain degree of tension in the pulse, but notso much in my judgment at the time as to warrant the freepurgation I had previously employed. I gave aperients andbitter tonics without much effect. My patient fasted strictlythrough Lent, and lost considerably in weight. After Easter Iwas asked to see him on account of slight bronchial catarrh.While recovering from this he was seized with severe in-fluenza; and just as he seemed to have shaken off this, andbefore he left his bedroom, a sudden and violent attack ofcongestion of the lungs supervened, which nearly provedfatal within twenty-four hours. My treatment of the last- complication was dictated by my previous knowledge of thecase, and was of a kind I should not have ventured to adoptwithout it. The congestion of the lungs was simply anotherconsequence of the blood-contamination, of which the ar-terial tension had formerly afforded evidence; but the ten-sion had lately been less manifest in consequence of weak-ness-had, in fact, been disguised. Recognising this, Iresorted as before to very free purgation, and relief camewhen this was obtained. Here we reach one of the most

interesting points in the case. The convalescence was notsatisfactory; the temperature subsided, there was free andloose expectoration of rusty muco-purulent matter, but theappetite did not return, the tongue did not clean, the pulsewas weak but long, and there was no recovery of strengthtill one day there was pain in the ball of the great toe. Amustard poultice was applied, and the patient had his firstattack of gout, which was perfectly characteristic, and, con-sidering the circumstances, remarkably severe. After this,he was well almost at once, and remains well up to the pre-sent time. Here residence in a hot climate, a vegetablediet, and abstinence from the heavier wines, had preventedthe full development of gout in a constitution strongly pre-disposed by hereditary tendency ; but a. return to this countryand to English habits of life, the consumption of more animalfood, and the diminished cutaneous excretion, had speedilyled to the accumulation in the blood of imperfectly oxidisednitrogenised waste and its consequences. The truth of theinferences I had drawn as to the danger arising from thearterial tension, and as to the cause of this tension, wasfully established by the course of events. The occurrence

of a first attack of gout after the treatment pursued wasremarkable, and indicated, in my opinion, that the meta-morphosis of nitrogenised matter had stopped short of theformation of uric acid.

I have had another interesting case under observationrecently, which I may briefly relate. A medical man in thecountry returned home one day last April, about 2 P.M.,from an unusually long and cold ride. He took some soupand a glass of sherry, and found, as he thought, that thewine got into his head, for he felt giddy and had to liedown; his speech was thick; he was violently sick; and itwas some little time before he could proceed to the remain-der of his day’s work; and when he tried to walk it wasnoticed that his left limbs had lost power in some degree;they felt numb, also, at first, and later were in a state ofhyperassthesia. One medical friend said it was biliousness";another thought more seriously of his condition, and he cameto town to consult me a week after the attack. He was theyoungest of a healthy family of sixteen-healthy, that is,except as to a strong gouty tendency. He had a largecountry practice, was of active habits, worked very hard,was abstemious both as to food and alcoholic drinks; butnotwithstanding this he had become decidedly stout, andhad from time to time had gouty symptoms. The vertigoand sickness might, of course, have been due to gastric orhepatic derangement, had they been the only symptoms;but the loss of power and sensibility and subsequent hyper-seathesia, and the thickness of speech, remains of whichexisted when I saw him, were significant of some cerebralmischief; and the pulse gave evidence of very high arterialtension, being hard, long, and rather small. Here, restfrom worry, mercurial purgatives, potash salts, a farinaceousand fish diet, with weak spirit-and-water, or water only, asdrink, have resulted in an effectual lowering of the vasculartension, loss of redundant fat, and removal of the symptoms.A too rigorous application of the principles laid down, in-deed, led to a,ttacks of giddiness from imperfect supply ofblood to the brain; and I found it necessary to recommendcitrate of quinine and iron for a time, with iodide of potas-sium.In the following case, I have no special reason for saying

that there was gout, but the patient was, I believe, on theverge of apoplexy. He was seventy-seven years of age, butremarkably hale and vigorous, and would have passed wellfor sixty. He had been suffering for six weeks from sleep-lessness and a feeling of extreme restlessness; naturally,also, he felt weak and worn in consequence. Tonics hadbeen prescribed, but had not suited him; and he had takenchloral and bromide of potassium, obtaining by their meansan occasional night’s rest, but no efficient relief. His appe-tite was good and the bowels regular-indeed he ratherprided himself on his management of the bowels; he com-plained a little, however, of indigestion. I found in the pulseevidences of an extraordinary degree of tension, togetherwith senile change in the vessels, though less than mighthave been expected; the artery large, cord-like, slightlyuneven, firm, capable of being rolled under the fingers, andit could be followed half-way up the forearm, the pulsationbeing long and strong. Nothing could be more full of dan-ger than this condition at the time of life. I gave, there-fore, purgatives more freely than usual. After three orfour dosea the evacuations became so frequent and free thatI feared I had carried the treatment too far. I found, how-ever, that they were not liquid, but simply extremelycopious, soft, dark stools ; there had evidently been greatFaecal accumulation, notwithstanding my patient’s assiduityin his attention to his bowels. It was some little time beforehis system regained its equilibrium; but the tension wasquickly reduced, and the restlessness passed off. I attri-buted the sleeplessness to the high blood-pressure, whichovercame the tonic contraction of the cerebral arteries, bywhich the ansemic condition of the brain essential to sleepis secured. Persistence of this degree of pressure must, Ithink, have resulted in rupture.But apoplexy is not the only danger to which the arterial

tension of retained nitrogenised waste gives rise. The heartmay cease to be equal to the struggle against the increasedresistance and become dilated, especially if there be degene-ration of its structure. You know the usual consequencesof this condition : breathlessness on exertion, then cough,with paroxysmal and habitual dyspnoea, cedema, generaldropsy and all its miseries. In an early stage, with short-

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ness of breath and cough, it is not uncommon for dyspnoeato come on at 3 or 4 A.m., compelling the patient to sit up.and perhaps pass the remainder of the night in this posi.tion. This speedily leads up to further symptoms; bu1when it depends on arterial tension, as is often the case, i1

may be relieved by treatment which removes this conditionI have now under observation a gentleman, aged seventy.eight, who, notwithstanding his years, is gradually recover.ing (has now, September, quite recovered) from severe noc.turnal dyspiœa. He is crippled by chronic gout, has a

well-charauterised senile pulse, and a weak heart. ThEtreatment has been a free resort to aperients and a cautiousadministration of digitalis and iron. In the case of a ladyaged sixty-four, first seen in January of this year, who suf.fered greatly from this form of dyspnœa, together wittharassing cough, complete relief was afforded by the reomoval of arterial tension by similar means. These casesare worthy of relation in detail had I the time, and I havEnotes of many others equally worthy of your attentionone, for example, in which I have in the course of six oeight years watched the gradual development of disease ojthe aortic valves under the influence of strain from arteriatension in a gentleman, the subject of gout. In anothercase, sent to me from the country in May, the patient hacsuddenly become liable to dyspnoea, a,ttended with lividityof face on the slightest exertion; the mode of life ancclinical history having been exactly that of imperfect nitro.genised elimination and arterial tension. This gentlemathad been seriously injured by Bantingism. I can onlymention these few illustrations; but I may put in a feawords the lesson to be learnt from them. It is, that wherthe heart shows signs of weakness, and especially wherthere is reason to believe that there is dilatation of itscavities and degeneration of its muscular walls, if there hany degree of arterial tension, the most effectnal relief youcan afford is to diminish the peripheral resistance. Tbi!can best be done by aperients, and by none so well as b3pills containing one or other of the mercurial preparationsafterwards iodide and citrate of potash, or iron and digi.talis, or tonics may be given. There is often a degree oj

debility which seems to contra-indicate purgatives alto.gether; but it will be found that the powers are oppressecrather than depressed, and that the weakness is apparen1rather than real. Tonics in these cases only do harm untiaft-erthe action of purgatives- and other eliminants, wheralso digitalis may find its opportunity; but frequentlywhen you cannot strengthen the weak heart, you can giveit less to do, and so make it equal to its work.

I proceed to illustrate other effects of retained nitro.genised effete matters with peripheral resistance to thEcirculation and high arterial tension.A barrister, thirty-five years of age, consulted me it

November, 1874. He was beginning to succeed in his pro.fession, but his prospects were threatened by his state ojhealth. After any heavy work, or an appearance in Courthe had palpitation of the heart and throbbing in the nectand head, with a feeling as if he were about to faint, ren.deririg it necessary to take some stimulant; he would als(be-entirely sleepless at night. This had been attributed t(weakness, and he had been taking meat three times a dayrather largely at each meal, with a liberal allowance 01sherry. Notwithstanding this bis symptoms increased uponhim. His appetite was good, his bowels regular, but thEtongue was white and indented. I found the pulse fulllong, and hard, and the aortic second sound unduly loudand took these as my indications for treatment. I gave hima gentle aperient pill for four nights in succession, ancafterwards every second night. In addition, I orderec

phosphate and carbonate of soda, with tincture of gingerin infusion of calumba, and revolutionised his diet, allowingmeat and wine (claret) only once a day ; breakfast and lunctto consist of milk and farinaceous food. He got well at onceIn the last case there were no specially gouty famil3

antecedents, and the choking of the blood with nitrogenisecwaste was a direct result of the mode of life. When therEis hereditary tendency to gout, imperfect metamorphosis ancelimination of nitrogenised matters occur much more readily.and sedentary habits, without any mistaken system of diet.or very moderate indulgence in beer or the stronger wineswith a liberal, but not excessive, amount of flesh meat, willin spite of an active out-door life, result in the developmentof a gouty or pseudo-gouty state of system. I have beer

astonished to see how early in life arterial tension is metwith in the children of a gouty parent. I have found itwell marked at twenty-one, and seen prominent and tor-tuous tempora,l arteries at twenty-four, associated with un-accountable feelings of weakness, weariness, and depression,headaches, loss of application and of interest in the ordinarypursuits and enjoyment of life, and other like symptoms.I will not give these cases in detail, but, instead of them,the following, which illustrates the same point.A young surgical friend, about thirty-two years of age,

consulted me on account of lassitude, inaptitude for work,.loss of energy, headache, and other vague symptoms. I

gave him the advice we always give each other-hat is, to,,take a holiday. He took one, and was better. By-and-byhe came back again with the same story, and he was nowuneasy about his heart and lungs, had morning cough, andwas sooner out of breath than usual. He could not always.be going away on holiday, and I went more carefully intohis case. He was remarkably strong physically, but had,not quite the colour he ought to have had, took lpss exerciseperhaps than formerly, but still played cricket. His appetitewas good and bowels regular. There was nothing par-ticularly wrong that I could see till I placed my fingers on.the pulse, when I fonnd a largish cord-like artery standing-out among the other structures, and traceable far up the-forearm, the pulsation of course long. It instantly flashedupon me that his father was the subject of old-standing-gout ; the cause of his ailments was clear, fortunately the-cure also. I recommended the treatment with which you.must now be sufficiently familiar, and forbade my young-friend his beer. In a week his arterial tension was reduced,and the symptoms were gone. Upon my happening toremark that beer would at once send up the tension again-he volunteered with great alacrity to make the experiment,but to this I did not give my sanction, and he confessesgthat he is amply compensated by his improved health forthe sacrifice I imposed on him.

It is time now that I should say something more definiteof the treatment you have seen me so often recommend, andgive my reasons for adopting it. The aperient pills are’sometimes the ordinary calomel and colocynth, or blue pilland colocynth or rhubarb pills, with perhaps hyosoyamuspsometimes colchicum or ipecacuanha is added. One or two

pills will be taken nightly for two, three, or four consecutive-nights, or on alternate nights, or twice a week, followed inthe morning by a saline draught-sulphate or phosphate of’soda, a Seidlitz powder, a dose of some aperient minerat’water or of white mixture. The strength of the purgativeand the frequency of its repetition will depend on the-urgency of the symptoms, the degree of constipation, andmany other circumstances. At the same time, I have gene--rally given a mixture containing potash salts; the iodide,two to five grains; and citrate, fifteen to twenty-five grains,with spirit of ammonia and some vegetable bitter, as ta-raxacum, calumba, hop, gentian, or the like; or, instead ofpotash, soda salts, the carbonate or phosphate in a similar-vehicle. The object in view is the reduction of the arterialtension, and this is effected to some extent by purgation as.such, which withdraws a certain amount of fluid from the-blood, and relaxes the vascular system of the gastro-intes-tinal mucous membrane. But while any purgative will doso much, the effect will be imperfect and temporary unless,the nitrogenised waste, which is the cause of the obstruc-tion in the capillaries and arterioles, is eliminated. Nowthe liver isthe great organ andinstrumentof metamorphosis;urea and uric acid are believed to be formed here, and on the-Pfficiency of its functional action certainly depends the due-elimination in the urine of the products of the disintegra-tion of nitrogenised compounds. Mercury has long beensupposed to act specially on the liver, and though experi-ments on animals have appeared to negative this idea,it is matter of observatian that mercurial purgativesbring away darker and more bilious stools ; it is also-matter of observation that they produce a more marked andlasting effect on undue tension in the arterial circulation.I was taught as a student that other purgativps would doall the good which could be obtained from blue-pill andcalomel without the risks said to attend the administrationof mercury, and for a long time I was altogether scepticalwhen people who called themselves bilious insisted on the

, superiority of their favourite blue-pill. After a time, how-ever, I was compelled to admit that the mercurial purga-

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tives afforded a relief which no others did, but I only under- One or two other illustrations of the therapeutic indica-stood it when I began to observe that they had a greater tions given by high arterial tension, and we have done with- effect on arterial tension. At present we must take our this part of our subject. I have already mentioned the casestand simply on the clinical fact that purgatives containing of a courier now in hospital, who came in with a history of,some preparation of mercury have this effect of lowering Roman fever, which was not apparently, as we generallyarterial tension. The explanation—namely, that this is find, a euphemism for typhoid fever contracted at Rome.produced through the influence of the metal on the liver He complained of extreme weakness and depression, andconducing to a more perfect metamorphosis of nitrogenised this, with the probably malarial origin of his fever, inducedmatters—we hold less firmly. We may, if we prefer it, trace me to give quinine. He did not improve, however; andthe good results to removal of bile from the upper part of after a time I determined to take the state of the pulse asthe small intestine, which would otherwise have been re- my guide, marked high tension having been observed fromsorbed and again separated from the portal blood by the the first. I gave accordingly aperients and iodide of potas-liver. The potash salts are given as eliminants, their effects sium, with very good effect.in this respect having been abundantly demonstrated. Diet Another case is that of a gentleman, advanced in life, whois of. the greatest importance. Meat should be consumed was hemiplegic from cerebral haemorrhage, whose helplesssparingly, its place in supplying nitrogenised food being to condition was made worse by extreme despondency and mosta great extent taken by milk and fish. Soups are forbidden. distressing delusions. The arterial tension was very high,Little alcohol should be taken, and only in the form of the and, notwithstanding a state of great weakness, I recom-light wines or freely diluted spirit. Water, free from lime mended free purgation and iodide of potassium, with smallsalts, should be drunk in large amount. doses of belladonna. Hie mental and emotional conditionWe have by no means exhausted the subject of gout, improved greatly, and for some time he was much better.

pseudo gout, suppressed gout, and allied conditions. I have After a time, however, he had a series of severe epileptiformmentioned lead poisoning as a cause of arterial tension-it attacks, traceable to, or at any rate associated with, a returnis in effect a cause of real subacute or chronic gout, with all of high arterial tension. Treatment of the same kind directed,its attendant evils : chalk-stones, deformity of the hands to the removal of the tension was followed by cessation of- and feet, contracted granular kidney, heart disease, arterial the convulsions, which up to this time had been increasinglytension and degeneration of the large and small blood-, frequent and severe.’vessels, apoplexy, &c. It is of course among hospital Affections of the nervous system as a cause of arterial tension.patients, painters, and other workers in lead, that gout’ I have left myself scanty time for the consideration of thisirom lead-poisoning is met with, and they have furnished part of my subject, and yet it is of considerable importance.,some of the most terrible examples of gouty disease I have In the early stages of acute affections of the brain, andmet with. There is a "gout pill" which these artisan throughout chronic affections, there may be very great arte-.clasaes obtain from chemists, which appears to be most rial tension, due to the influence of the nervous system on- effectual in suppressing gouty paroxysms and pain; there the arterioles ; it has been very remarkable in some cases ofis not, therefore, the check on habits tending to produce cerebral tumour which I have observed. The arterial ten-,gout which the paroxysms would impose, while the poison, sion resulting from the disease of the brain may be taken-never eliminated or destroyed by attacks of acute gout, for arterial degeneration, the cause of the disease. Moreaccumulates in the system in an extraordinary degree. I. than once I have seen this mistake made, and there is anhave seen several cases of gangrene of the lungs in indi- instance in a foot-note to p. 457 of vol. ii. ef Reynolds’sviduals saturated in this way with gout, and believe the System of Medicine. Occasionally anilateral arteriole spasmlung affection to have been due to this condition of system, is found in hemiplegia on the paralysed side; the tensionin which there is apparently a tendency to thrombosis in is not, as a rule, very great, and of course cannot be higherthe pulmonary vessels. It is interesting and suggestive to on one side than on the other, but the artery at the wristnote that in the case of gangrene of the lungs recently will be smaller and the sphygmographic tracing different.’Under my care in the hospital we found high arterial In many so-called functional nervous affections there istension. The patient, an ostler, was only thirty-eight years fugitive or persistent contraction of the minute arteries,of age, had enjoyed good health, said he had been tem- and consequent tension. In the hysteric paroxysm theperate, had not had gout or rheumatism, and was not the arterial spasm is remarkable, and it is the cause of thesubject of lead-poisoning. He died on June 5th, the day pale, limpid, watery urine which is secreted during anafter his admission, and the gangrene was found to be due attack. In locomotor ataxy the general condition of theto thrombosis in the pulmonary artery. It would thus minute arteries is one of contraction, which, during theappear that the state of blood which leads to thrombosis . paroxysms of pain to which such cases are liable, amountsogives rise to high tension. to spasm. I have met with this condition of the vessels in

I have not time to enter at all fully upon the subject of what was apparently incipient insanity, in a lady, as shownhigh arterial tension in pregnancy. It has been well worked by jealous delusions, unfounded general suspicions, and vio-- out by Dr. Mahomed (to whose paper I would refer you) and lent and eccentric conduct Here, treatment suggested byby Dr. Galabin. The illustration afforded by pregnancy of the state of the arteries (Calabar bean, iodide of potassiumthe relation between a condition of the blood and arterial with arsenic, and cod-liver oil) was followed by restora-tension, and between this latter and kidney disease, con- tion of the mental equilibrium. I have seen it againvulsions, thrombosis, &c., is, however, too important and in a lady subject to epileptoid paroxysms attended withtoo instructive to be passed over. You are aware that mental confusion, but not hy loss of consciousness. In most,during pregnancy the blood of the mother has to carry cases of nervous breakdown from overwork there is arteriolenutrient material to the rapidly growing, foatus, and to con- contraction and high tension, which, however, often fluc-vey away the effete products of its active tissue changes; it tuate greatly ; in one case lately under my care, that of ais therefore more highly charged both with raw material distinguished Oxford undergraduate, the fluctuations wereand waRte, and a high tension prevails in the arterial sys- remarkable, and were associated with equally strikingtem. You know also that albuminuria is not uncommon in variations in his nervous symptoms. Where, in cases ofpregnancy ; not only is this the case, but contracted gra- this kind, the vascular tension is persistent, I have notnular kidney is sometimes met with in women, for which no found the treatment by purgatives and elicninants successful.,cause but pregnancy can be assigned. These are exactly I have before me notes of cases in which high arterialthe results we have seen to arise from retained nitrogenised tension was associated, in a gentleman aged forty-three,waste. But the parallel can be continued much further. with giddiness and staggering, emotional weakness, loss ofPuerperal convulsions, if not uraemic, are closely allied to the power of attention, and occasional attacks of vertigo,uræmic convulsions, and in the production of both, high followed by vomiting and stupor; in another gentleman,arterial tension is an important factor. Puerperal throm- aged fifty-two, of remarkable natural energy and activity,bosis, again, whether cardiac, giving rise to sudden death with loss of vigour and endurance, excitability and giddi-,,&c., or in the iliac veins, producing phlegmasia dolens, is iness. On one occasion he passed urine in my consulting-the precise equivalent of the thrombosis we have just been room which had a specific gravity of only 1002. Thespeaking of in the pulmonary artery. You will understand specific gravity of his urine at other times was found to befrom what I have just been saying that the old practice of 1025 and 1018. It contained neither albumen nor sugar.bleeding pregnant women was not always injurious; to Other notes relate to a youth of eighteen who, for nearly’some it must have been of immense benefit. twelve months, suffered from continuous headache with

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exacerbations; the cardiac and arterial signs of tensionwere very marked ; he had no vomiting, but at one time Ithought optic neuritis was setting in. He ultimately re-covered.My experience would lead me to say that while nervous

breakdown from overwork is attended with arterial tension,when it is brought on by anxiety, grief, or worry, this is notthe case. I do not, however, speak positively on this point.

I must not forget to mention a fact to which Dr. Mahomedcalled my attention, and which I have verified-namely,that excitement or agitation sends up the arterial tensionat once. I think it is simply from the increased frequencyand force of the heart’s action, which drives blood into thearterial system faster than it can run off by the capillaries atthe normal pressure.

Arterial relaxation and low tension.-I have still to considerthe conditions of system associated with an unnatural degreeof relaxation of the minute arteries and an absence of thenormal tension in the arterial system. For the production oftension in the bloodvessels, vis a tergo-thatis, a certain degreeof vigour in the action of the heart-is required; and whenthe pulse is weak, it is not always easy to say whether this isdue to the heart or to the arteries, more especially as theheart loses strength when the arterial tension is habituallylow, both because it has less work to do on account of theabnormally diminished resistance to the blood in the capil-laries and arterioles, and because its nutrition must directlysuffer from the imperfect supply of blood it will receivewhen the general arterial tension is low. You will remem-ber that we have low arterial tension in most febrile condi-tions, but wa exclude these from the consideration. Thecharacteristic feature of the pulse of arterial relaxation andlow tension is its shortness or quickness. In the intervalsthe vessel cannot be felt at all; it allows itself to be flat-tened and obliterated and lost among the structures, with-out offering any appreciable resistance ; and when thepulsation comes, the artery seems to start into existencefor a fraction of a second, and is gone again. I am speak-ing now, of course, of cases in which the arteries are notkept full by frequent and powerful action of the heart, asin pyrexia &c. The pulsation may be more or less strongwhen it comes, and the artery may vary in size, but thedistinctive character is the quick or short unsustained tidalwave. In describing the pulse of arterial relaxation, I saidit was large, but when the heart is acting so feebly that itdoes not fill out the vessels it will feel small. A pulsehaving the characters produced by a combination of a weakheart and relaxed arteries is no doubt what is meant whena pulse is called " shabby."

I cannot speak so definitely of the diagnostic, prognostic,and therapeutic indications of arterial relaxation, as oftension; but one thing I have learnt respecting the casesin which this condition exists is, that they are most un-satisfactory cases to have to treat. It has appeared to methat undue relaxation of the small arteries is sometimes acause of weakness and nervous depression by permittingundue lose of heat. It is the duty of the arterioles to shutoff the blood from the surface of the body on exposure tocold, and so to protect it from being cooled down. Whenthis function is imperfectly performed, the skin and theextremities may be warm, in spite of very low externaltemperature, but the body must lose heat rapidly from ex-posure to cold of successive portions of blood sent to theskin, and either the temperature will fall or increased oxida-tion will be required to keep it up. In either case there isa heavier tax on the system, and only a very vigorous con-stitution can support it with impunity. A sufferer fromdepression so produced will exhibit his warm hands and skinas proofs of his excellent circulation. I had some years agounder my care for several successive winters a melancholygiant, almost the very tallest man I ever saw, and pro-portionately stout. During the summer he was well ; noday was too hot for him, and he was capable of considerableand sustained exertion; but in cold weather he was de-

pressed, miserable, incapable of giving his attention to hisduties, and continually under the necessity of resorting tostimulants. All this time he was unconscious of externalcold, and did not take cold, never wore an overcoat, and hishands were always comfortably warm. He could not under-stand that this very warmth was a cause and a mark ofweakness, and refused to seek the protection from coldwhich he did not feel to need.

A clergyman, aged fifty-one, having a small countryparish, consulted me in October, 1874. He was formerlyrobust, and had been a boating man at college, but he hadbeen ailing for ten or twelve years, complaining chiefly ofindigestion, with low spirits, sleeplessness, and a variety ofsymptoms and sensations about the head and heart, of whichI should fail to convey to you any idea. The appetite wasgood, and the bowels acted regularly but inefficiently, themotions being pellety; urine apparently normal, but de-composing quickly. He looked thin, pale, and haggard,and his tissues were excessively lax. Pulse 90, soft, short,weak, and with no tension at all.

I could not find any cause for the break-down in my pa-tient’s health. He was not overworked, lived wholesomely,and was not unduly sedentary in his habits.

I may tell you what I recommended, but little impressionwas made on his symptoms. I obtained a better action ofthe bowels by means of a mild aloetic pill, and this havingno good effect, tried blue pill, ipecacuanha, and rhubarb.I gave at different times iron, arsenic, digitalis, phosphorus,cod-liver oil, bromide of potassium, sulphate of zinc andextract of hop pills, securing also from time to time sleepby chloral, &c. You will trace the ideas which dictatedthis treatment; they were to improve the nutrition of thenerve-centres, and of the body generally, to raise the toneof the heart and minute arteries, to remove or quell nervousirritability, and to give rest. The diet was of course regu-lasted: I should add that he could not take stimulants. Hegave himself a holiday also, while under my care, but withonly temporary benefit.Another case, essentially similar, came under my observa-

tion about the same time. The patient, aged forty-five,had been complaining for three years of a dull pain in thehead, which set in at 11 AM:., and went on through the day;with it was a kind of pain in the right leg, and, when worsethan usual, also in the right arm. He did not sleep well, andwas full of apprehensions; was emotional, and cried whiledescribing his sufferings. Appetite good; bowels not open;.pulse frequent, very weak, soft, short, and shabby. I onlysaw him twice, and do not think he was any the better forthe treatment I ordered.These cases would come under the term hypochondrissis,

but there were fewer fancied ailments and more deteriora-tion of health than usual. Hypochondriacs go about fromone physician to another with their cardiac, hepatic, in-testinal, or sexual woes, and one comes to take less note ofstates of pulse, urine, &c., than one would if they wereexpected to remain under observation; but I am always gladwhen I find a pulse of high tension in such cases, as I thinkthere is a better chance of doing good.

I must not leave you under the impression that want oftone in the arteries is always accompanied with pallor andleanness. I have noted it in stout, pale, flabby people, witha soft and inelastic, or a firm brawny skin. I have met withit also in individuals not only decidedly stout, but of anunnaturally high colour, associated with a number andvariety of nervous sufferings and nervous symptoms, ofwhich I could give you no idea. No patients are to be morecommiserated than some of these, who, looking to the un-instructed eye the picture of health, are the victims ofmiseries from which actual pain would be an agreeable dis-traction. What makes it worse is, that so little can be donefor their relief. These cases are in special danger fromalcohol.One of the most marked cases of arterial relaxation I ever

saw was in a gentleman who a few weeks later became in-sane. He was then in an extremely nervous condition,apprehensive of sudden death, and often thinking he wasdying, causing great alarm and excitement to his family,unwilling for his wife to be a moment out of sight, but

; irritable, tyrannical, and unkind in his behaviour towardsher. He had lost all energy, slept badly, was weak, andsoon fatigued. He was tall and well built, looked strong,but his voice was weak, toneless, and monotonous, and hisarticulation careless or slovenly. His pulse was small, weak,short, and shabby, to an extraordinary degree, and his.hands were damp and clammy. He had lived a fast life-when young. Accounts as to his recent habits with regard)to alcohol were contradictory. I only saw him once, andthe next news I had of him was that he was suffering fromunmistakable melancholia.In acute dementia, again, the pulse has been, in the oases

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I have seen, exceedingly weak, soft, and short, and theaction of the heart frequent and irregular, indicating anentire absence of tone in the vascular system. I have founda marked deficiency of arterial tension in many cases ofepilepsy, and have at present two cases under observa-tion in which it is very striking. The pulse is very softand short, but large and fairly strong, the blood seeming toshoot through the small arteries and capillaries withoutresistance. Another noteworthy point is that a deep breathor a change of position has an unusually great effect on theheart’s action, which is hurried for a few beats, while, ifthe patient stoops, the face is flushed immediately, as ifthe arterioles were incapable of resisting the greater pres-sure due to the lowering of the head, and allowed the capil-laries to be flooded with blood. It is difficult to say whetherthese patients are epileptic by reason of the relaxation ofthe arterioles or of the absence of the normal cohesion be-tween the blood and tissues, or have this deficient vasculartone because of the condition of the nervous system whichgives rise to the epileptic attacks; but, however this may be,I consider that the pulse affords an indication for treat-ment. Whatever is found to effect permanent improve-ment in the tone of the arteries and to raise the vasculartension may be expected to do good. If the epilepsy is aneffect of the want of arterial tone, the restoration of thismay cure the epilepsy; if it is the epileptic condition of thenerve centres which is the cause of the want of tone, aremedy which removes the effect will probably have a

favourable influence on the cause. May we not have heresome explanation of the good effect of bromide of potassiumwhich has been found experimentally to cause contractionof arterioles Also of Trousseau’s favourite remedy, bella-donna? My attention has not been drawn sufficiently longto the connexion between epilepsy and low arterial tensionto enable me to bring forward evidence as to the effects inepilepsy of remedies which improve the arterial tone. Yearsof careful observation will be needed for this. Nor do I findmuch assistance from looking over my notes of cases ofepilepsy. I may refer here to the interesting case of ,who has just left the hospital. He has worked in lead, andhas the blue line on his gums, but has had no colic or othersaturnine diseases. He came into the hospital because onstooping, and especially to lift any weight, he became giddyand confused, and almost lost consciousness; and we atonce saw, on causing him to bend down, that his bald head,face, and ears became crimson. He was liable also to heatand flushing of the head and face without this excitingcause, and at these times we have found the lobules of theears of a deep purple colour, and very hot. In this patientthe fluctuations of the arterial tension were most remark-able ; and our notes, taken at different times, record ob-servations absolutely contradictory. What makes the casemore interesting is the fact, discovered accidentally whilethe experiment was being made with another object, thatpressure on the carotids, or on one only, almost immediatelyinduced an epileptoid attack; the face flushed (even whenthe pressure was applied to the common carotid, whichwas remarkable), and the features were drawn into a pecu.liar smile; the patient looked confused, lost consciousness,staggered, and fell back upon his bed with slight generalconvulsive movements. A few moments later he lookedround with a puzzled expression, wondering what had hap.pened. There was no marked change in the size of th<pupils at any period. He slowly improved while takingiodide of potassium and tincture of nux vomica ; the leadline disappeared, the flushing and vertigo in stooping wertless marked, and the epileptoid attacks were less easily induced. Naturally, we did not repeat this experiment oftenThe combination in this case of fluctuation in the arteriatension, weakness of the vessels of the head and face permitting of the flushing described on stooping, with liabilityto artificial epilepsy, is peculiarly interesting as a paralleto the combination associated with true epilepsy. Takinglead to have been the cause of the condition, its action wano doubt primarily on the (sympathetic ?) nervous systemand to the state of the nervous system was due the instability of the vascular system. But it is, in my owtmind, an open question whether the liability to epileptoi(attacks was not in turn an effect of the vascular instabilityand want of tone.To make the account of arterial relaxation complete, ]

ought to consider exophthalmic goitre and aortic pulsation,

of which diseases it constitutes a feature, but I must passthem over with a simple mention.My observations on low arterial tension have been dis-

couraging, and I have as yet had little success to reportfrom treatment, but it sometimes affords an indicationwhich is of service. Many weak nervous women sufferingfrom leucorrhoaa or menorrhagia, or worn out by repeatedpregnancies or prolonged suckling, or overwhelmed bydomestic duties and responsibilities, have with ansemia anddebility the pulse of arterial relaxation, and in these casesthe addition of digitalis to the iron and other tonics oftenmakes a great difference in the effect. My friend Dr.Fothergill gives these patients bromide of potassium anddigitalis, and later quinine and iron with bromhydric acid.I saw them by scores in the out-patient department, butthey are almost excluded from the wards by more urgentcases, and I have not yet tried his plan of treatment,

I must bring this lecture to a close. I have been, I fear,diffuse and sketchy, but I have been tempted to take upthe subject, perhaps prematurely, by the interest some ofyou have manifested in it. I have seen you with extremepleasure acquire thoroughly the art of discriminatingbetween the different kinds of pulse and recognise the indi-cations they afford, and I wish to put you in possession ofwhatever knowledge I have which may make your skilluseful to yourselves and your patients.

ON GELSEMINUM SEMPERVIRENS.

BY SYDNEY RINGER, M.D.,PROFESSOR OF THERAPEUTICS AT UNIVERSITY COLLEGE ;

AND

WILLIAM MURRELL, L.R.C.P., M.R.C.S.,DEMONSTRATOR Of PHYSIOLOGY AT UNIVERSITY COLLEGE.

- S

THis powerful drug has long been employed in America,and a few years ago was introduced into this country as aremedy for neuralgia by Dr. Wickham Legg. His state-ments have been amply verified by Dr. Sawyer, Dr. Mackey,Dr. Spencer Thompson, and others. It is said to be espe-cially useful in non-inflammatory toothache and in neuralgiain the nerves supplying the teeth and the alveolar processesof the jaw. In large doses it produces general paralysis.Several cases of poisoning are recorded, some ending fatally.We extract from the Proceedings of the American Phar-

maceutical Association (vol. xxi., 1873) the following accountof the effects resulting from a toxic dose:&mdash;" The symptomsby which its effects manifest themselves in the animal eco-nomy seem to indicate that its energy is primarily exertedon the cerebro-spinal centres, and secondarily on the respi-ratory apparatus and the heart, the functions of the formerceasing before those of the latter. The motor nerves of the

eye are attacked first; objects cannot be fixed, dodgingtheir position; the eyelids become paralysed, drop down,and cannot be raised voluntarily ; the pupils largely dilate;there is a feeling of lightness in the tongue; it ascendsgradually to the roof of the mouth; pronunciation becomesslurred; then the extremities refuse to support the body,and erect motion without support becomes impossible; thepulse gradually becomes more frequent, rises to 120 to 130and more beats per minute, is small but regular ; respira-tion then becomes laboured, the mind remaining clear, how-ever. This state will set in about an hour and a half afterthe ingestion of an overdose of the drug....... All thesymptoms will disappear after about two hours, leaving nounpleasant effect or derangement of the organism." Inmany cases of poisoning the patients have complained ofdouble vision, and dimness, even loss, of sight, and thebreathing is slow and sometimes irregular and shallow.In the Practitioner for October, 1870, Dr. Roberts Bar-

tholow published an account of some experiments made onfrogs, pigeons, and cats. He concludes that gelseminum(a) acts chiefly on the motor portion of the cord; (b) itsparalysing effect is due to its action on the motor centre,and not to an action on the peripheral nerve-fibres ; (c) itacts also on the sensory portion of the cord, producing atlast complete anaesthesia, but this effect in warm-blooded