[No. 126. [Jan 28, 1826.]

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XI.

Gentlemen,IT appears to me so indispensably ne-

cessary to admit the active or muscularpower of the blood-vessels, in order tounderstand the nature of the most im-portant diseases, that I must claim yourindulgence for dwelling somewhat longeron the subject, and for even recapitulat-ing some of the most important points.

In the two preceding lectures, I haveendeavoured to prove, that the heart isnot the sole propelling power of theblood : on the contrary, that it con-

tributes but a small share, towards theperformance of this function. I men.tioned to you, that upon the suppositionof the heart being the sole cause of mo -tion in the blood, it is impossible to ex-plain the varying force of the circulation,and the unequal distribution of bloodto various parts of the system. If theblood-vessels were merely passive tubesof conveyance, or were possessed only ofelasticity, the effect of every change inthe action of the heart, must be feltequally throughought the whole vascularsystem, in proportion to the size of thevessels, their direction, and distance fromthe heart. But this is not at all the case.A great degree of inequality in the dis-tribution of the blood, is often observed,when the heart is acting with eitheraugmented or diminished force. Andwhat is of still more weight, in proving*he influence of the vessels themselves,and their independence on the heart, is,that violent action of vessels, and, itsnecessary consequence, increased circu-

lation, are often observed, where theheart itself remains undisturbed.The most powerful argument on the

subject, however, is derived from thefact, that many animals exist without aheart, but have vessels in which theirblood is nevertheless kept in motion,which must necessarily be effected bythe action of the vessels themselves.Thus, in the leech, the sanguiferous sys-tem consists of four blood-vessels, reach-ing longitudinally, from one extremity ofthe animal’to the other. Two of thesevessels are placed laterally, and furnishanastomosing communications; these ap-pear to be arteries, and have an observa-ble systole and diastole, a sort of undu-latory motion. The other two are dorsaland ventral, and appear to be veins.But there is no heart. Thus a heartappears to be a less necessary part, thanblood-vessels.I If it is probable, then, that the heartis insufficient to effect the motion of theblood through the innumerable branchesof the arterial and venous systems ; andif, in many animals, and in certain partsof others, the circulation is found to becarried on independent of the heart’saction; it remains to inquire whetherany other power exists (except that ofthe vessels themselves,) by which themotion of the blood can be effected.An idea has been entertained by some,

that the heart and lungs possess a degreeof elasticity, which tends to expand them,and thus to create a vacuum ; and thatby this means, the blood is drawn fromthe venous trunks into the heart, andnext from the arteries into the veins attheir extremities ; by suction, as it were,This notion was first promulgated, I be-lieve, about fifty years ago; by Dr.Andrew Wilson, a physician practisingat Newcastle, and has been of late adop-ted by others.Such an hypothesis, however, appears

to be quite untenable; since nothingexists in the structure of the heart, thatcan be supposed capable of forcibly in-creasing the capacity of the ventriclesor auricles; whilst this organ is tod

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loose in its attachments, to be affectedin this way by the neighbonring parts.No conceivable arrangement of muscularfibres, could have the effect of produc-ing expansion bf the sides of the ventriclesor auricles ; and there is no elasticstructure, as in arteries, to produce theeffect. No power of suction, therefore,with regard to the veins, can be reasona’bly attributed to the heart. -

Bnt even allowing the heart to be sofar constructed like a pump, as to beable to form a vacuum in its cavities, stillthe effect would not follow, unless theveins were rigid 1nbes; without this, theinstant a vacuum began to be created inthe heart, the pressure of the atmospherewould compress the sides of the veins

together, so as to render them impervious.This is too obvious to need being dweltupon. Indeed it seems inconsistent to

suppose, that the same organ, by anymechanism, should be capable of two suchopposite effec , as forcible expansionand contraction ; as must be the case, ifit acted both as a forcing and suckingpump, as has been fancied.

It has been suggested, that the veins,by a kind of absorption, facilitate thepassage of the blood from the arteries.The opinion that the veins have a powerof absorption, appears indeed very pro-bable. There are parts of the body,(for instance the brain,) in which nolymphatic vessels have been hithertosatisfactorily traced; and yet where itseems impossible to donbt, that absorp-tion takes place. But, if so, to whatother structure can this be attributed,than the veins? There are so manypoints of analogy between veins and

lymphatics, that we may well ascribe tothem a community of function. The icourse of the flnids through both ordersof vessels is the same; that is, from

capillary extremities, to larger andlarger trnnks ; the streams constantlyuniting and enlarging as they proceed.They bring back equally their fluids tothe right side of the heart, in order totheir being transmitted to the lungs; andlastly, both orders of vessels, are val-vular in their structure, where valvescould answer any nseful purpose. Thereis no difficulty, therefore, a priori, in supposing veins to absorb; and if so, themovement of the blood through thearterial extremities into the veins, maybe in part effected in this way, andwould be afterwards continued onwardsto the heart, partly by the vis a ters-othus created at, the extremities of theveins, and partly by the muscular or con-tractile power of the veins themselves.There ia still another opinion that has

been maintained upon this subject, whichI may mention, but which, though it can-not perhaps be absolutely denied, is yetso remote from our usual manner of

thinking, and rests upod such slight evi.dence, that one feels natyally reluctantto admit it; this is, as life is but anothername for self-activity, and conseqnpntlythe very essence of lite lies in that acn-vity, it is impossible but that the fluids, inwhich that life resides, as much as in thesolids, must enjoy activity as a principleof their constitution, and not yield tomotion by mechanical impulse merelylike inert matter. It is this principleof life contained in the blood, that dis,poses it to move with the facility whichis observed in the circulation, and with-out which, it is alleged, not allthein.jections and mechanical contrivances innature, could open the recesses of thevascular system, so as to render thempervious to so viscid a fluid as the blood.This opinion wu. maintained by the in-

genious author named above, Dr. AndrewWilson, in an Inquiry into the movingpowers employed in the circulation of theblood ; and which I have given in nearlyhis own words. I must own that I seenothing extravagantin the notion, thoughit is at the same time difficult to admitit.Some other modes by which the circu.

lation of the fluids is carried on, havebeen suggested, bnt which are scarcelydeserving notice ; since they wiH not

bear a moment’s inquiry. One of theseis capillary attraction. But fluids rise bycapillary attraction only in tubes that areempty; when these are once filled, thefluids cease to rise, and become stagnant.Capillary attraction, therefore, is totallyinadequate to account for the continuedprogressive motion of fluids. The pres.sure of neighbouring parts has, likewise,been enumerated, amongst the’ causesof the ’circulatory motion of the blood.This, however, is inadmissible; a thegreater number of vessels are not mb’jected to any cause of this kind.

But I have before mentioned, that thepower upon which the movement of theblood principally depends, is the action ofthe vessels themselves, which, if they besupposed to possess muscular power,may, without difficulty, be conceived tobe fully adequate to the purpose.

Various circumstances concnr, in sllow-ing the’influence of the bfood-vessels onthe circulation of the blood,’ Mepeod-entry of the heart, as, first, the great de-termination of this fluid that take1!placèto particular parts, without any eorre’spondiag increase of action in the heartitself; and which indeed, could not be

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accounted for from any sach increase ofaction in the heart, if it actually tookplace. Again, the action of the heart

may be violently augmented, without anygeneral increase of the circulation ; as isseen in diseases of the heart, where, atthe time that this organ is actingwith greatviolence, the action of the general vas-cular system is often much diminished,and the extreme parts of the body cold.This could not be the case, if the blood.vessels were passive, or merely elastictubes..

I need notmention again, all the proofsof the muscularity of the arteries. Hav-

ing already fully discussed it in the fore-

going lectures, I shall consider the factas sufficiently proved.

I have told you, that two kinds of con-traction of blood- vessels riight be dis-tinguished, namely the tonic and theoscillatory action ; and that it is by thelatter of these, that the progressive mo-tion of the blood is effected. Havingpointed out the causes that either in-crease or diminish the tonic contraction,I have now to speak of those which in-nupnce the oscillatory or propulsive ac-tion.The propulsive action of blood vessels

may be increased in any part, by variouscauses ; as by Iteat externally applied,and other stimulants. By these, the cir.cnlatory motion. of the blood! is accelerat-ed ; more blood is brought ta the part;and all the attending phenomena, of in-creased circulation appear ; namely, .in-crease of temperature, greater redaessin many cases,, and a more active per-formarice of functions. An increased

propulsive action of the arteries of onepart of the body may influence remoteparts of the system, so as to occasiondiminished action of vessels in these, bykind of reverse sympathy, as Mr. Hnritertermed it. Thus, it is common to observein head-aches, that, the arteries of thehead are acting with great violence, pro.tlticing increased circulation of blood,with throbbing, heat, pain, &e. whilst, atthe same time, the arterial action through.out the rest of the system, is much dimi-aished. the pulse at the wrist being smalland feeble the extremities cold ; andthe circulation there nearly suspended.Now, in such cases, our object is to eqna-lise the circulation. This is to be at.

tempted, by increasing the propulsive ac-tion where it is deficient, and diminish-iagt it where it is in excess. it is in this

way, that head-aches are often relievedby general stimulants, as wine, &c.; or

by the warm bath ; or the pedilnvinm,.which increases the arterial action in the

lower extremities , and thereby diminishesit in the head.

Distention is another very powerfulcause exciting propulsive action of thearteries. When the external vessels aresuddenly constricted, as by cold, or anyother cause, the blood is repelled backinto the large vessels about the heart ;and, of course, distends them. This dis.tention excites both them and the heart,into increased action. At first, they actirregularly, but with increased -force;they make efforts to restore the balanceof circulation; and this brings on, whatis called, reaction, or the hotfit.

This increased action at first is naturalor healthy in kind; but sometimes its na.ture is changed, and it degenerates intoinflammation. In this way, carditis, or

inflammation of the heart may be broughton, by any causes which tend to throwthe blood suddenly back upon the heart;as, for example, cold ; or increased mus-cular exertion. I have thus, more than

once, seen this disease induced, and thatin a dangerous degree, by running. up-bill.

Certain emotions of mind, also, havethe power of increasing the propulsiveaction of the heart and arteries. We arenot to imagine, that they produce their

effect upon the heart only ; in manycases, the whole arterial system is affect-ed. Anger, for instance, produces thiseffect. The milder passions, hope andjo*. have an influence, of the same.kind,but in a less degree. We see the im-

.fluence of emotions of mind upon theblood vessels, in the act of blushing;where, in an instant, the arteries of the

cheeks, and, in many instances, those ofthe whole neck and breast, fall into astate of increased propulsive action.

Muscular motion, also, produces an in-creased propulsive action in the vessels ;as may be seen. by putting a number ofmuscles into action. This produces itseffect, inpart, by throwing the blood (asremarked above) back upon the heart,faster than usual. When, for instance,a number of muscles are put into action,the veins become compressed. Now, thevalves, prevent a retrograde motion ofthe blood ; and therefore, the effect is,,to accelerate its motion towards the

heart; and thus the heart is stimulated.But the effect in this case, is produced’partly also, through the mind; becausethe will, wnieh puts the voluntary musclesinto action, is the result of an exertioir:of brain, that is accompanied with, or:soon followed by, increased action of its’vessels; and this excitement of the brainoccasions a general increase of actionthroughout the vascular system. -

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The propulsive action of the blood ves-sels, may, likewise, be increased, by in-flammation. This disease, althongh oflimited extent, may after a time producethis effect upon the whole system ; andit is in this way, that general febrile ac-tion is produced. Nothing is more com-mon than to find the whole vascular sys-tem in a state of præternatural excite-ment, as a consequence of inflammation.A variety both of internal and external

stimulants, will also have the effect of

increasing this propulsive action of thearteries. Ammonia, or other stimulants,applied to the stomach ; and the hot bath,have all this effect: but more especiallythe hot bath, which first increases theaction of vessels in the skin, and this in-creased action is soon extended, by sym-pathy, over the whole system.On the other hand, the propulsive ac.

tion of arteries, may be diminished by avariety of causes, most of them the re-verse of those that have been just men-tioned as increasing it.Thus cold dimishes the propulsive action

of the arteries, and sometimes appearsto induce a kind of spasmodic contractionof their capillary extremities ; as in whatis called, the cutis anse7-ina, or goose-skin,where the passage of the blood throughthe extreme vessels is much diminished, ifnot wholly -interrupted. In weak per-sons, a very moderate degree of cold willoften have this effect in particular parts,which then turn cold and livid, as if de-prived of life ; as in cases where thefingers are, vulgarly, said, to die.

Astringents, both vegetable and mine-ral, and also diluted acids, appear to havean effect of this kind; and upon this,their sedative power seems to depend.Accordingly, we apply them to inflamedparts, in order to diminish the propulsiveaction, as well as use them internally.The taking away blood, is another cause

that tends to diminish the propulsive ac-tion of the heart and vessels. There canbe no doubt, but that, when blood isdrawn largely, general weakness will beinduced. The frequency with which theheart acts, indeed, is not necessarily di.minished in this case; but, in proportionas blood is drawn, the impetus of circu-lation is lessened. This may, in somedegree, be ascribed to the diminisheddistention of the blood vessels, renderinga greater degree of tonic contraction ne.cessary ; by which a greater expenditureof the vital power takes place.As certain emotions of mind have the

effect of increasing the propulsive actionuf the sanguiferolls system, so there areothers which diminish it. Fear, Terror,and Despondency, are of this kind, and

produce a feeble circulation. In the cold

stage of fever, the tonic contraction ofthe extreme vessels appears to be in-creased, while, at the same time, thepro.pulsive action is diminished. These effectsare prohably to he ascribed to a changein the condition of the brain, as theircause.

There are certain general effects pro-duced, (though of different kinds,) bothby increased and diminished propulsiveaction. If the propulsive action of thevessels be universally increased, the forceand velocity with which the blood circa.lates, will be likewise increased; and theconsequences will be in proportion; theheat of the body will be augmented, andthe functions altogether performed withgreater energy. On the other hand, ilthe propulsive action be much diminished,the general circulation will be propor-tionally diminished, the animal heat re-

duced, and the functions in general im-perfectly carried on.

If the propulsive action be partiallyincreased, the effect then will be, in.creased circulation in the part particu.larly affected, and a more energetic per.formance of its function, whatever thatmay be. Thus, (to quote any examplethat occurs,) if the action of the vesselsof the uterus be excited in a moderatedegree, menstruation will be increasedin consequence. While, on the contrary,a diminished vascular action in this or-

gan, will have the opposite effect, andprevent that function from being pro.perly performed.

In like manner, if the action of thevessels of the brain be increased, that

organ will be rortsed to a more active ex.ercise of its functions. Thus when sen.sorial stimulants, such as wine, are takeninto the stomach in a moderate quantity,the cerebral functions are all observedto be performed with greater energy. If,however, the bounds of, moderation areexceeded, the functions, mental as wellas corporeal, are not simply excited, butat the same time disordered; and thestate called intoxication is the result.This applies equally to other organs, aswell as the brain : moderate excitementincreases energy ; excessive excitementoccasions disorder of functions.The propulsive action may be either

increased or diminished in a considerabledegree, and yet be within the limits ofhealth. Thus the general circulation maybe greatly increased by exercise, withoutany attendant disorder of functions. And,on the other hand, it may be diminished,as by loss of blood, the application ofcold, or other sedatives, withont being fol-lowed by disease.

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1 If, however, the propulsive action is

urged beyond a certain point, disease

may arise, as inflammation. And, on thebther hand, any considerable diminutionof the propulsive action, or, in other

words, diminished arterial action, thoughnot in itself a disease, yet gives a predis-position to certain forms of disease, buto( course of a different kind from theformer.As an example of the ill effect of long

continued, or too frequent, excitementof an organ, I may mention the habitualuse of intoxicating drinks, exciting thearterial action of the brain. This prac-tice may be continued with impunity fora length of time; but it gradually laysthe foundation of apoplexy, palsy, or

other brain-affections, which, thus in-

duced, generally prove incurable.From all that has been hitherto stated,

I think, Gentlemen, you may safely con-sider the following propositions as esta-

blished ; and they are well worthy of yourparticular notice.

1st. The blood-vessels altogether are

full, during life ; whereas, after deaththey are found in great part empty. Thisproves that they are more contractedduring life, than after death. This can-not be referred to elasticity merely, aselasticity is a mechanical property, notinfluenced by life. It is a proof, there-fore, of vital contractility, which mustbe taken as analogous with muscular

power. This vital contractility is furtherproved, by their being under the influenceof stimuli; and also by their being snp-plied with nerves, the irritation of whichinfluences the state of contraction in thevessels. In both these respects, blood.vessels resemble muscular structures.2ndly. The blood after death is foundalmost entirely in the veins, the arteriesbeing empty of blood. Hence it is in.ferred, that the contractile power of ar.teries is greater than that of veins, andcontinues for a longer time after death.In conformity with this, the ventricles ofthe heart are generally found empty afterdeath, while the auricles contain blood.

3dly. Two kinds of contraction may bedistinguished in blood-vessels, both ofthem muscular, but different. One beingcontinued, (the tonic contraction,) andwhich serves merely to keep the sides ofthe vessels in contact with the blood, butwhich may be exerted differently at dif-ferent times and in different parts, thusdetermining the balance of circulation--the other, the oscillatory, pulsatory, orpropulsive, action, corresponding withthat of the heart, and upon which theprogressive motion of the blood depends.This propulsive action begins at the heart,

and is continued successively to the ex-tremities of the arterial system, and pro-bably exists in the veins also.

4thly. The tonic and the propulsive ac-tion do not necessarily correspond. Thepropulsive may be increased, while thetonic is diminished. Hence, the motionof the blood in any vessel may be in-creased, although the diameter of thevessel be enlarged.

5thly. In proportion as the oscillatoryaction of arteries is increased in any part,the greater will be the quantity of bloodcontained in them, and the greater themomentum with which it circulatesthrough the part. In snch cases, theveins will be found preternaturally dis-tended after death. So that the fulnessof veins in any part after death, is to betaken as a proof of the greater action ofthe arteries of such part during life. Andthus we may understand, in what lightvenous congestion is to be viewed ; thatis to say, not as a proof of diminishedarterial action, (as has been alleged,) butthe reverse. It is, indeed, altogether er-roneous to suppose, that the state of theveins observed after death, is that whichexists during life. All modes of treat-ment founded on such a supposition, musttherefore be wrong.

6thly. In the greater number of dis-eases of any importance, the propulsiveaction of the blood vessels is in excess.Consequently, our practice is mostly di-rected to the diminution of the propulsiveaction by some or other of the means

which have been pointed out to you. Thisis the case with regard to all inflamma-tions, haemorrhages, the greater numberof dropsies, and many other diseases.While the diseases that arise out of di-minished propulsive action are very fewand unimportant,

LECTURE XII.

Gentlemen,IT will now be proper for me to advert

to the state of the pulse in health, and’the changes which it undergoes in disease.This will be necessary, as I shall have torefer to it on so many occasions in the

consideration of disease ; and also fromits being one of the conditions of the san-guiferous system.

Definition of the Pulse.

The pulse is the stroke we feel upouapplying the finger over any considerablebranch of an artery, so as to compress it.It is derived from the force with whichthe blood is impelled onwards in the

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tery, and which is produced by the jointaction of the heart and arteries behind. Weare apt to imagine, upon feeling the pulse,that the artery is greatly distended everytime the heart beats, and that it con-

tracts, or is again emptied, when theheart ceases to act. This, however, is farfrom being the case, at least in any con-ssiderable degree. In a quiet state of thecirculation, the diameter of the artery,even at the wrist, undergoes but little,change, such in fact, as is often imper-ceptible ; yet when the sides of the arte-ry are pressed together with the finger,a considerable stroke is felt. In old peo-ple, the temporal arteries are often of alarge size, and run very superficially. Ihave often looked at these very atten-tively, without being able to perceive theleast dilatation or contraction in them,although they pulsated strongly whencompressed. Elasticity in arteries can-not explain this circumstance ; it can onlybe accounted for, on the admission of amuscular power in the artery, as well as

in the heart. This power it is, which en-ables them to resist distention, so as topreserve their calibre, when the blood is

propelled into them by the heart, and bythe exertion of which a fresh impulse is

given to the blood. The vis a tergo, there-fore, instead of producing an enlargementof the calibre of the artery, is expendedin propelling the fluid onwards ; and thiseffect is promoted further, by the muscu-lar exertion of the portion of artery im-mediately concerned.The examination of the pulse is a thing of

some importance, and must not be hastilymade ; otherwise we shall acquire a veryimperfect notion of it. If our objectwere merely to count the number of put-sations, it might easily be effected. Butthere are other qualities, besides that offrequency, which are not quite so easilyascertained. In order to make a satis-

factory examination of the pulse, muchattention is necessary. Two or threefingers should be applied upon the artery,in order to judge of the different qualitiesof the pulse; and it requires a minute ormore to satisfy ourselves on this head.The finger should be withdrawn and thenre-apptied. The artery likewise shouldbe examined higher and lower iu thelimb.We in general choose the radial artery

for examining the pulse, and that for suf-ficient reasoir. The artery here, is ofconsiderable size. It is superficially co-vered, and lies upon a flat surface of bone,which enables us to form an accurate

judgment of its various qualities. Theinformation we derive from the pulse,even in health, is of no small importance.

It enables us to judge of the generalstrength of the system, and its degteeof irritability. And in diseases, it for-nishes us with a great variety of usefulknowledge, both in regard to their existence, diagnosis, prognosis, and trel!i.ment ; as you will presently understand.

Of tlae various qualities of the Pulse inHealth.

More attention has been paid to thefrequency of the pulse, than to any otherquality. This, however, is only one o.many, that require to be attended to ;and it is also one of the least important:for very considerable differences exist inregard to the frequency of the pulse,which are yet compatible with health.The healthy qualities of the pulse re.

quiring to be noticed, are principally thefollowing:

1. Frequency.2. Fxtness, or volume.3. Strength.4. Regularity.

These, as well as the morbid condi.tions of the pulse, depend partly uponthe heart, partly upon the arteries them.selves.

1. Frequency of pulse is estimated bythe number of pulsations that take placein a minnte. There is great latitude inthis respect, in different individuals, andat different times, even in health; the

pulse being liable to vary from 60, or evenless, to 130 or 140, in a minute. The cir-cumstances which appear to determinethe frequency of the pulse in health, areage, sex, and individual constitution butthere is much latitude with respect toeach of these.

In men of from 30 to, 40 years of age,and of middling stature, the ordinaryrange of the pulse is from 65 to 85. Inold men, it is usually about 60. In in-

fants, immediately after birth, it is as

high as 130 ; and, for the first five years,generally above 100.

In females, cceteris paribus, it is com-monly from 5 to 10 strokes more in t4eminute, than in males.

Individuals, also, differ much, one fromanother, in regard to the number of thepulse. In some, it is at all times below60, in others, above 100, and this con-sistently with good general health.have known it, in one individual, m slowas 30 in a minute; and instances are re-corded, of its being sti,ll, slower.The frequency of the puise is, in gene-

ral, from 5 to 10 strokes less iu the re-cumbent, than in the erect posture; and

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111 the sleeping, than in the waking state.The pulse is commonly less frequent inthe morning, than in the latter part of theday.Muscular exertion, of all kinds, even

that which is required to keep the bodyerect, renders the pulse more frequent,by accelerating the return of blood to thelieart. Many emotions of the mind havea similar effect. The taking food, also,renders the pulse more frequent.. Generally, speaking, we have no powerotinnnencing the pulse voluntarily: butsome have acquired this power in a con-siderable degree. I have known a me-dical man, who, by merely willing it,could, after a little while, increase thefrequency of his pulse to double the for-mer rate.

As the frequency of the pulse is deter-mined by the action of the heart, it servesto show the state of this organ, in respectto its irritability, or disposition to con-tract. This, again, may depend upon itsotin innate disposition ; or upon occa-

sional changes in the supply of nervouspower, which it receives from the brain,as the chief source of nervous energy.The condition of the pulse as to fre-

qnency, appears to have an influence :onthe disposition to certain diseases, andlikewise on their tendency, and result.Thus persons, having naturally a very fre-quent pulse, are more liable to fall intodisease of most kinds, but especially in-flammation. And when disease actuallyarises in such, it proceeds more rapidlyin its course, than in the opposite cir-cumstances. Phthisis pulmonalis, for ex-ample, is more likely to take place in per-sons of naturally frequent pulse; and

proves fatal in such, in a shorter spaceof time. Hence we can judge, in somedegree, of the probable duration of thedisease, from the degree of frequency ofthe pulse.

2. Fulness of pulse, denotes the size ofthe artery, and of course the quantity ofblood contained in it, at the time of exa-mination. It shows, at the same time,the degree in which the artery is tonicallycontracted. To understand this, youmust advert to the double muscular ac-tion, of which I have told you arteriesare capable.

Fulness of pulse is increased by ex-fernàl heat, by internal stimulants, andby exercise. Opium also, and other nar-cotics, have the same effect. Thesecauses act probably in different ways ;the former, viz. heat, stimulants, andexercise, by increasing the propulsive ac-tion of the arteries ; the latter (narcotzcs"

by diminishing the tonic contraction ofthem.

Fulness of pulse is diminished by coldexternally applied, by acids, and the othermedicines termed sedatives; and likewiseby fear, and terror. These causes of di-minished fulness of pulse appear to act,by increasing the tonic contraction of thevessels. The fulness may be diminishedalso, by lessening the general quantity ofblood in a considerable degree. This acts,partly by an increase of the tonic con-traction, which is necessary in order to

bring the sides of the vessels in contactwith the blood,

Fulness of pulse does not in generalshow the quantity of blood in the systemaltogether; it merely indicates the qnan-tity circulating in the limb or part underexamination. Hence, it is not a sign ofgeneral plethora; nor, on the other hand,is smallness of pulse a proof of- a defi-ciency of blood in the general system; asis proved by the circumstance, that the’pulse often becomes much fuller afterblood-letting, than it was before.

Fulness, therefore, rather indicates thedetermination of blood to a particular-part ; and this is necessarily attendedwith a proportionate deficiency in otherparts..

If it could be ascertained, that there.was a corresponding fulness in every;part of the vascular system at the sametime, it would show a plethoric state ;but this cannot be done. A sense of ful-ness and oppression, however, may exist-about the heart and lungs; and if thiswere accompanied with continued fulnessof pulse, it might serve in some degree toindicate plethora. On the other hand, a

general diminution in the size of the ar-teries throughout the body, if it could beascertained, would show a deficiency ofthe vital fluid. -

3. Strength of pulse is denoted by the,force required to compress the sides ofthe artery together, so as to stop thecurrent of the blood through the vessel.It is occasioned partly by the force with,which the heart is acting, and partly bythe force of action in the artery belaind?or nearer to the heart.

. It is a tolerably certain criterion of thegeneral strength of the system. Never-theless, a weak system may have thepulse made to beat strongly for a short-time, as by the exhibition of powerfulstimulants; but it-will be unable to con-tinue it for any length of time. A strongpulse, therefore, is only a criterion of ge-neral strength, when it is permanent. -

: The strength of the pulse is increased,for the most partr by the. same causes.a

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increase its frequency and fulness ; whileit is diminished by loss of blood, absti-nence, and all prèternatmal evacuationsto any great extent.A weak pulse in disease, while it shows

a feeble action of the heart and vessels,is very generally accompanied with gene-ral weakness of system ; this circumstancerenders it necessary, in such cases, to becautious in the use of bloodletting, andother debilitating means.

4. Regularity of pulse consists in thestrokes following one another at nearlyeqnal interval and with an equal degreeof force.

Regularity is the natural state of thepulse in health; but now and then it is

irregular, in one or both the respectsmentioned above; and that without anydisease appearing to exist at the time. Inthese cases, it sometimes happens, thatthe pulse becomes regular when diseasetakes place, and returns to its irregularstate as the disease ceases.

Regularity of pulse generally shows aregular action of the heart. But theheart sometimes beats very irregularly,without producing irregular pulse ; as

occurs in palpitation. This serves toshow the influence of the arteries on themovement of the blood.

I shall now speak of the changes whichthe pulse undergoes in disease, and en-deavour to explain to you the causes ofsuch changes, with the indications theyenggest.

In the writings attributed to Hippo-crates, little notice is taken of the pulse,as a sign in diseases. The physiology ofthe arteries was then little if at all under-stood. They were not even known to beblood vessels, but were considered na- Iturally to contain air, as their name in-deed implies. Galen, on the contrary,paid great attention to the pulse ; andfrom his time, it has been much studied,and relied upon. On this subject, I amdesirous of recommending to your parti-cular notice, the late Dr. Parry’s « ob-servations on the arterial pulse," who hastreated it in a very luminous manner ;a character which applies indeed to allhis pathological writings.There are various morbid states of pulse

which require to be noticed, and ex.

plained ; as they throw much light uponthe nature, and, in some cases, even theseats of diseases ; while they enable usoften to form an opinion as to the event,and also materially assist us in the treat-ment of them. This, however, is not al- ways the case ; as diseases may be dan-gerous without materially disordering the

pulse ; and in stich cases, it, of course,,cannot be our guide in practice.

As the various morbid alterations ofthe pulse, are merely deviations from thenatural or healthy state of it, and only tobe known by comparison with this, it is

plain that a knowledge of the pulse inhealth should be first attained. For thispurpose, you should accustom yourselvesto examine the pulse in different indivi-duals, and under all circumstances; inor.der to have a standard for comparison inyour minds, when you come to examineit in disease.

The morbid conditions of the pulse thatrequire to be particularly noticed are thefollowing:-

1.-Excessive frequency.2.-Quickness.3.-Fulness. ,’

4.-Strength..5.—Hardness.

’ 6.-Regularity.

! And their opposites-1.-Slowness.

! 2.-Sluggishness.3.-Smallness.’ 4.-Weakness.

5.-Softness.

6.—Irregularity.

1.—Frequency, (pulsus frequens.) Too,great frequency of the pulse dependsupon too frequent an action of the heart,and shows the irritability of this organ tobe in excess.The excess of irritability may be owing

to disease in the heart itself, as inflam-mation, or its consequences ; or it mayarise from an excessive supply of nervouspower derived from the brain, as oftenhappens in inflammatory states of this

organ : as fevers, hydrocephalns, andother forms of inflammation in the brainin the early stage of the disease, before oppression has taken place.

Inflammation, wherever seated, hasoften the effect of rendering the pulse

præternaturally frequent. Hence, fre-queney of pulse always excites a suspicion,that inflammation may be going on some-where, as its cause. But this is not tobe implicitly relied upon; because greatfrequency of pulse may be owing merelyto general irritability.Some have said, that the pulse maybe

of different degrees of frequency, in dif-ferent parts of the body ; as in the twowrists. But this is neither sufficientlyproved, nor is it probable. The frequen-cy of the pulse being derived from the

heart, must of necessity correspond with

601

this in point of frequency-with the ex-ception, however, of palpitation, which Ijust now alluded to ; where the heartbeats more frequently, than can be feltat the wrist.. Slowness, (pulsus 2-atws,) is the counter-part of frequency of pulse, and indicatesdeficient irritability of the heart, andoften of the whole system. Slowness of

pulse seldom arises from disease in theheart itself; because, with few excep-tions, originally-diseased parts have theirirritability increased, rather than di-minished.Morbid slowness of pulse is almost al-

ways the result of an oppressed state ofbrain; which it therefore generallyserves to indicate. Spasmodic pain,however, as that produced by the passageof gatl-stones, sometimes renders the ipulse slower than natural. And thus we Iare occasionally able to distinguish spas- Imodic, from inflammatory pain, a pointof great importance in practice.

It is necessary to bear in mind, thatthe pulse may be rendered slow by7tarcotics, as opium; but more especially,by the digitalis, the use of which, there-fore, ought to be inquired into, where thepulse is found to be praeternaturallyslow.Both frequency and slowness of pulse,

depend upon the heart, and not uponthe arteries.

2. Quickness of pulse (pulsus celer, asharp pulse,) is not to be confoundedwith frequency. Frequency is measuredby the number of pulsations in a minute.Quickness, alludes to the suddenness ofthe strokes, leaving a longer interval be-tween them. A pulse may,be-frequent,without being quick; or quick withoutbeing frequent; or both together.Mere frequency of pulse often exists in

health ; but quickness is always indica-tive of disease. It seems to arise fromtoo great irritability of the arteries,rather than from the heart. It is generallyproduced by inflammation, which it serves Ito show the existence of.

Sluggishness of pulse, (pulsus iners,vel tardus;) is the reverse of quickness.The stroke is longer in being made, andthere is consequently little interval be.tween the strokes. It seems to be thatwhich some have termed a labouringpulse."

This state of pulse, generally, is pro-duced by an oppressed state of brain.Slowness and sluggishness are not pre-cisely the same, nor do they necessarilyexist together. This state of pulseshows an indisposition in the arteries too,ontract, a want of irritability in them;

while slowness is rather an affection of theheart itself.

3. Fulness of pulse in a morbid degree,is the result of a strong action of theheart and arteries in general, with a disposition to relaxation in the particularpart where the fulness exists. Inother words, thepropulsive action is goingon strongly, while the tonic contraction issmall.

This disposition to relax, or to receivemore blood, in the artery, constitutingfulness of pulse, is not at all inconsistentwith an increase in the oscillatory or pro-pulsive action of the vessel : for wherethe circulation is the strongest, thearteries of the part are usually the mostdilated.There is probably no universal state of

morbid fulness, or plethora, so as to

endanger rupture. If the arteries arepartially distended in some parts, theywill be less so in others. Fulness of pulse,therefore, merely shows an increased de-termination of blood to the part wherean examination is made; and this againis the consequence of increased propulsiveaction, combined with a disposition torelax in the arteries of the part: that is,a diminution of the tonic contraction.Such a state of pulse may at any time

be produced by the hot-bath, even inweak subjects. But in these, it soonends in syncope.

LECTURESON SOME

PRACTICAL POINTS OF SURGERY,DELIVERED TO THE

Students of the late Borough Dispensary,BY MR. ALCOCK.

LECTURE IX.

. Of Fractures.Gentlemen,Few subjects are more important to

the welfare of the patient or to the repu-tation of the snrgeon, than the tratmentof various fractures to which the bonesare liable.

If, instead of perfect recovery, lame-ness or deformity should result, the pa-tient becomes a walking memorial of thesurgeon’s want of skill; not to mention