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HAUGHTON said that if there was any doubt they shouldrepeat the photograph some time later. But a quicker andmore satisfactory way was to take a stereoscopic picture byMackenzie Davidson’s method. It was astonishing how tworather indifferent negatives would yield an excellent stereo-scopic result. The question of including the opposite kidneywas most important. He had come across patients in whichthe pain was referred to one side, and there were two largestones in the opposite kidney.-Dr. H. STOKES said they couldget the symptoms of stone from a hypernephroma. Most ofthese were not diagnosed until too late. Cases reportedshowed the surgeon practically certain of stone. If the radio-

grapher took two photographs and found no stone, were theyto sit down and let the patient die ?-Mr. PRIKGLB and Mr.HAYES also spoke.-Mr. GUNN, in reply, said he did not

attempt to deal with the differential diagnosis. What Dr.Stokes said was perfectly true. There were other conditionswhich made it difficult, but time would not permit theirdiscussion.-Dr. HARVEY also replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

-discussion on Blood Pressure.A MEETING of this society was held on Nov. 30th, Dr.

BYROM BRAMWELL, the President, being in the chair.Dr. GEORGE ALEXANDER GIBSON, in introducing a dis-

cussion on Blood Pressure, first gave a definition of theterms employed in studying arterial pressure. The maximal,or systolic presh’l1ll’e was gauged by that which would arrestthe flow in the vessel. The l1Ûnim,al or diastolia pressure wasestimated by the point of greatest lateral oscillation. Themean pressure was that half-way between maximal andminimal, and the pulse pressure was the amount of differencebetween maximal and minimal. But these pressures were

lateral-i.e., exerted on the walls of the vessels-andthe terminal pressure consisted in this pressure plusthe velocity. The lateral pressure in an artery was

usually held to be equal to the terminal of the next

pulse pressurebranch. The -- = co-efficient of pressure ;systolic pressure

thus, in a person in health if the systolic pressure were 120, thediastolic 90, the pulse pressure 30, and the pulse-rate 70, thenP.P. 30 1 1 co-efficient, and P.P. X P.-rate- velocityco- CIent and

= = , or the efficiency of the heart in health.In an instance of heart-block S.P. 270, D.P. 90, P.P. 180,

P.R. 30, . The factors which maintained

the arterial pressure were as follows-: 1. Energy of the heart.2. Access of blood. It had long been known that anyobstruction lessened the distal pressure and increased theproximal, and Dr. Gibson narrated an illustrative case ofobstruction to the subclavian. 3. Elasticity of the vessels.During the systole the vessels became dilated and the

potential energy thus stored up was given out later as kineticenergy in their contraction. 4. Resistance in arterioles ;resistance and pressure were reciprocal. Increased resist-ance was equal to higher pressure, and vice 1,ersd. Re.ist-ance was due to tonus of vessels which resulted fromthe antagonistic action of vaso-constrictor and vaso-

dilator nerves ; the former were always in action, thelatter only when required. 5. Character of the blood.Dr. Gibson had observed that density of blood and pressurewere in direct ratio, and viscosity of blood stood in the samerelation. Chemical impurities, for the most part, increasedpressure. 6. Quantity of blood. It might be expected thatincreased volume would cause increased pressure. This was,however, amply compensated for by vasomotor activity.With regard to the methods of estimating arterial pressure,Br. Gibson narrated the earliest observations made by ascer-taining the height of a column of blood from an artery, andlater by the use of a mercury manometer for the artery anda water manometer for the vein ; while still more recentlythe spring manometer had been introduced. The differentforms of kymograph were alluded to. He spoke of the earlystudies of the pulse and the importance of educating thesense of touch in this relation. He said that the only

accurate instruments were those based on estimation bymeans of a column of mercury. The systolic pressurewas gauged by the amount of external pressure necessaryto overcome arterial resistance ; while diastolic pressurewas estimated by the maximum waves of the columnof mercury. Dr. Gibson described the instruments of

Erlanger and the recording instrument suggested byhimself. As regarded the possible fallacies in the

methods, he alluded to: (1) the instrumental; (2) thepersonal equation ; and (3) the state of the walls-Herring-ham stated that the maximum pressure exerted by these was35 millimetres. Dr. William Russell held that increasedtonus could add to this, but the muscular coat of a largeartery was not so large relatively as a small artery. As tothe clinical results, the cardiac muscle and arterial pressurewere reciprocal, and arteriole contraction and arterial pres-sure were also reciprocal. With high arterial pressure therewas a loud aortic second sound, going on to hypertrophy ;with low pressure there were feeble sounds. Vascular crises(both high and low pressure) of Pal gave changes in theamount of secretion, renal and salivary. Nervous causeslead to high pressure, and worry to this and to sclerosis ;while, on the other hand, from high pressure nervous in-stability in varied forms resulted. Nervous causes could

give low pressure, and in the opposite sense low pressure ledto nerve depression. Abnormal extremes: In interstitialnephritis and arterial degeneration 260 D. ; 300 S. Addi-

sonism, 60 D., 90 S. Greatest pulse pressure in aortic

escape, 70 D., 150 S., and in heart-block 80 D., 270 S.In infective diseases there was an early rise and earlyfall ; this was very marked in typhoid fever. Inlead poisoning the pressure was high throughout until

recovery, and in gouty conditions it was also high. Itwas interesting to note that, apart from aortic disease,valvular lesions had little influence on pressure. In aortic

incompetence the pressure in the arteries of the legs wasmuch higher than in the arteries of the arms. Arterialsclerosis : There was a general consensus of opinion thatretained poisons as well as those from outside caused thisdisease. There might be arterial sclerosis without highpressure, as of 500 cases examined by Groedel in 35 per cent.there was none; Rudolf with Ellis and Robertson found50 per cent. of cases with none : and D. Elliot Dickson foundthick vessels with only moderate pressure in miners. Therelation of high pressure to angina pectoris was discussed.Respiratory diseases : The pressure was high in asthma andlow in phthisis. Glandular diseases : In myxoedema thepressure was high ; in exophthalmic goitre it was usuallylow, but was very variable. In Addisonism, low if the

medullary portion of the gland were affected. Renaldisease : The pressure was usually high from retention ofpoisons, but much depended on previous conditions. Inchronic Bright’s disease it was always high; in amyloidchanges, usually low ; in urasmio poisoning, high. In con-clusion, Dr. Gibson discussed the value of arterial pressurein prognosis and as a guide in therapeutics.

Dr. WILLIAM RUSSELL said that in the time at his dis-posal he could not debate the question before the society.He could only try to define what he considered to be the

essential phenomena in the subject under consideration. Hewould begin at the extreme end and take as an example ofit a patient admitted to hospital with a brachial pressure of295 mm. Hg. Under rest and treatment it fell to 165. Ibrose and kept about 190 to 210, but it would suddenly rise70 to 80 mm. more with symptoms which there was no timeto describe. This patient had thickened vessels, and alongwith the rise in pressure the vessels, including the brachials,underwent hypertonic contraction. 1 Nine years ago he hadmade a communication to the society on arterial hypertonus,in which he pointed out that hypertonus cccurred in normaland in sclerosed radial arteries ; with the advent of themodifications of the Riva Rocci instrument he had carriedhis observations to the brachial artery and found thatit became greatly thickened, and that it could infavourable cases be both felt and seen to diminish

greatly in size and increase greatly in the thicknessof its wall during such hypertonic contraction. When thiscontraction took place the pressure in the aorta was raised-how much there was no means of determining, for there wasa great power

of restoring the balance and relieving the

1 THE LANCET, Dec. 3rd, 1910, p. 1602.

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heart. The essential phenomenon was the arterial hypertoniccontraction and that it embraced such vessels as the brachials.His contention was that the hypertonically contracted andsclerosed arterial wall was a large factor in the productionof the brachial reading. A source of fallacy occurred fromthe fact that in some cases a brachial artery, althoughthickened, was dilated and atonic, and such a vessel gave arelativeiy lower reading. A man had died in his ward lastweek who came in with a failing big heart-failing on bothsides; the lungs were congested and he began pouringout fluid into both pleurae, the heart sounds could not

be heard, the pulse was a mere flicker at the wrist,the radial arteries were calcareous, the brachials were

large, sclerosed, and tortuous, and the brachial pressureduring this state of affairs was 140 mm. Hg. In one setof observations he found the pressure in the forearm was30 millimetres higher than that in the upper arm. At the

post-mortem examination the myocardium of the leftventricle was soft and fragmented, and that of the rightconsiderably replaced by fat. Yet eminent clinicians writeon blood pressure and heart power, estimated by the hæmo-manometer, without a reference to the arterial wall. To himthat position was beyond comprehension, and he left it tothem as to whether they were prepared to accept it. Hewould now ask their attention to the other extreme, andcould illustrate this by reference to two patients : the oneconvalescing slowly after an acute pericarditis was quitecomfortable with a brachial pressure of 120 millimetres.When from constipation, an error in diet, or emotion thepressure rose 15 or 20 millimetres he got cerebral breathingand the pulse intermitted. When this rise took place theradial and the brachial arteries could be felt to have becomesmaller from hypertonic contraction-that was not an

opinion, that was a clinical fact-the contraction threwan increased pressure into the aorta, and the feeblemyocardium was embarrassed. The symptoms couldbe promptly relieved by giving a vaso-dilator. Thesecond case was a medical friend, aged 80 years,who was having recurring attacks of angina pectorisminor. During these attacks the radials became small andthe brachials also became contracted with a very poor wavein them ; the pressure showed 140-150 mm. Prompt reliefcould be obtained by a vaso-dilator, and the pressure fell to120-125. He found that they entirely overcame this vesselsensitiveness and removed the symptoms by the administra-tion of a very small quantity of iodide of potassium. In both these cases the essential and fundamental clinical

phenomenon was the arterial hypertonus, just as it was whenthe vessels were sclerosed. The constriction might or mightnot embarrass the heart. No one knew what the pressurewas in the aorta ; and with the armlet of the hæmomano-meter they measured the changes in the arterial wall as wellas the pressure inside it.

Dr. HARRY RAINY discussed the physics of the problem.When the pressure was applied by a band to the upper armthe tissues were assumed to be compressed as if they were afluid, and therefore the constriction was transferred directlyto the vessel. This was a point subject to discussion, and itwas known that if there was much oedema the facts were

admittedly erroneous. There was also the question of therigidity or relaxation of the muscles. The question of thevascular walls was purely a physical one; a blood-vessellived for long and experiments could be carried on with itafter excision from the body. By perfusing certain fluidsthrough it hypertonus could be set up. The condition of thevessel wall would cause change in pressure. The brachial pressure was a central one, and not far off that observed inthe heart, while the pressure became enormously greater thesmaller the blood-vessels became. The pressure was reallyperipheral to those which were investigated-viz., thebrachials.

Dr. D. ELLIOT DiCKSON (Lochgelly) said that he badinvestigated this problem in 500 healthy miners of all ages.In 456 there were thickened, easily palpated accessiblearteries. In 116 youths under 20 years of age the radialartery was easily palpated, and only 44 miners had sucharteries which could not be palpated. Only 31 showed asystolic pressure of over 140 mm., or 6 per cent.; there wasno albuminuria. 469, or 94 per cent., had brachial pulsereadings within normal limits, and nearly all had thickenedarteries. The vessels were equally thickened from the

periphery right up to the axilla. They felt like lead pencils

and were almost incompressible. He thought that the causeof this thickening might be due to toxic conditions of theirwork underground. He had observed this thickening ofvessels to occur within one year of their commencing uoder-ground work. He had determined that in the air of well-ventilated coal mines there was an enormous excess ofcarbonic acid gas ; it might amount to 0.7 per cent., in com-parison with the normal 0 03 or 0’04 per cent.

Dr. H. OLIPHANT NICHOLSON spoke of the blood pressure inpregnancy. He said that all the conditions present duringthe later stages of pregnancy might be thought to favour in-creased blood pressure, but his observations showed thatthere was no definite rise of blood pressure until the com-mencement of labour pains. The uterine contractions raisedthe pressure, and this rise increased during the expulsion ofthe child. Operative procedures still further raised the

pressure, even though the patient were anaesthetised. Afterthe third stage of labour there was a distinct fall in pressure,but after the third day of the puerperium there was a definiterise. If there were a continuous rise above 130 mm. one

might suspect eclampsia. The blood pressure was usuallyhigher in primiparæ than in multipart. As a result of

pregnancy a vaso-constricting substance was retained in thesystem and accumulated to a dangerous amount in eclampsia.It caused the albuminuria and suppression of urine byaltering the circulation through the kidneys. This sub-stance was probably elaborated from the placenta. Owingto this widespread constriction of the arteriole field muchextra work was thrown upon the heart.

Dr. THEODORE SHENNAN said that in thickened arterieswhich were calcareous a constant feature was present-viz.,the absence of this calcareous change at the flexures. AtMunich the greatly dilated heart and arterio-sclerosis ofvessels so often met with at post-mortem examinations wereattributed to the excessive amount of beer drunk. Theviscosity of the blood seen in cases of polycythæmia wherethe heart was not hypertrophied might be due to greatlysclerosed conditions of the coronary arteries.

Dr. EDWIN MATTHEW referred to drugs employed to reducearterial blood pressure, and said that with the exception ofthe nitrites and iodides they were useless. It was said thatiodides acted by reducing viscosity or that they affected thenutrition of the vessel wall, or that they stimulated thyroidsecretion. Iodides were useful in cases of high bloodpressure with no arterio-sclerosis, and this was where theyfound their true action. Iodides were pure vaso-dilators justas nitrites, and acted in no other way. Iodide should be givenin minimum doses of 10 grains thrice daily, rapidly increasedfor some days, and then decreased. It had to be rememberedthat many organic preparations of iodine contained only2 grains in each dose.

Dr. HENRY M. CHURCH had found the test for high bloodpressure a most useful one as regards therapeutics. Thetime at which the pressure was taken was important ; beforebreakfast the pressure might be 15 to 20 mm. lower thanafter, and the same occurred before and after smoking,taking a hot bath, &c.The PRESIDENT said that he never could understand how

it was said that the condition of the vessel wall had no effecton the blood pressure. One might have thickened arterialvessels without any obvious rise in the blood pressure owingto parts of the vessel being left elastic. He had greatdifficulty in accepting Dr. Russell’s view that the brachialand radial arteries from a condition of spasm could give riseto such high readings.

SCOTTISH OTOLOGICAL AND LARYNGO-LOGICAL SOCIETY.

Exhibition ()f Cases.—Double Frontal Sinus Disease.—Purulent Labyrinthitis.

THE first meeting of this new society was held on

Nov. llth at the Royal Infirmary, Edinburgh, under thechairmanship of Dr. A. LOGAN TURNER.

Dr. W. G. PORTER showed a patient two and a half yearsafter Operation on the Right Labyrinth. Granulations wereremoved from the region of the horizontal canal, but theremaining canals and the cochlea were not interfered with.The vertigo had disappeared and the patient could follow hisemployment, but complained of severe tinnitus. It was a