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They seem quite peculiar, and remarkably similar; are the only ataxic traces I have, and are unlike anything else in my collection. Both patients have been under observation for months, and the peculiarities of the traces are constart.
Fig. 3 is introduced to show the value of the graphic methoil in illustrating circulatory phenomena. It tells the story of a heart undoubtedly of great power, slowly breaking down under the work of driving the blood through thickened arteries and asthmatic lungs. He had asthmatic cough for ten or fifteen years; had been confineil to the house for nine mouths with dyspnea and anasarea of the feet and legs. The heart's action was without rhythm, the area of cardiac dulness was increased, but no murmurs could be heard. The effect of an intermission upon the systole is well shown. He died about a month after the trace was taken, and an autopsy could not be obtained.
Fig. 1 is of the greatest interest, from its pronounced characteristics, and the unmistakable nature of the disease. Ile had been a man of marked intemperate habits. An associate said of him," he had not been to bed sober in twenty years.” Ile was under my observation for five weeks, and the peculiarity of the pulse persisted to within six hours of his death. During this time his suffering from dyspnea, or rather breathlessness, was intense; he had slight dropsy, and a small per cent. of albumen in his urine. He was slightly emaciated when I first saw him, and his pulse was a revelation. The artery could be seen pulsating and vermiculating well up the wrist, and its impulse was simply prodigious. He had an increased apex impulse, an increased area of cardiac dulness, an accentuated second sound, marked episternal pulsation, and no murmur. His kidneys were found to be small, red, granular, hard-cutting organs, as was also the liver. The left heart was hypertrophied and thickened; the right was neariy normal. The aorta was largely dilated and generally atheromatous; its valves held water. When split open, the following measurements were taken from the inner surface: At the origin of the innominate artery, nine inches; at the subclavian, six inches; two inches beyond this point, four inches; at the celiac axis, three and three-quarter inches. The innominate, one inch above its origin, measured two and oneeighth inches.
This trace is extremely interesting from its relation to the question of what is the peculiarity of the trace of high arterial
tension. Certainly here was a case in which the conditions known to produce high tension were present in a marked degree. Evidence that high tension had existed for a considerable time was furnished by the dilated aorta. The obvious qualities of the pulse were those of high tension, and the peculiar characteristics of the trace appear in every specimen, of which I have more than twenty. I think there can be no doubt but that this trace is characteristic of the pulse from which it was taken, and is probably characteristic of extreme high tension in arteries somewhat advanced in fibroid degeneration. The high and regular rise tells of a powerful heart, and the extreme disproportion between the tidal and dicrotic waves is a perfect demonstration of the correctness of the authorities who claim that low pressure favors the development of dicrotism. Again, the trace is suggestive from the fact that the tidal wave is quite peculiar, while the aorta, which is supposed to cause that wave, had the most marked abnormal characteristic. I have in my collection several traces from persons with more or less advanced aortic disease, and one cannot but see a tendency of the class to resemble this trace. Fig. 5 was from a young man in the last stage of Bright's dis
He died three days after I saw him. The autopsy showed granular kidneys, cirrhosed liver, hypertrophied left heart, with healthy vessels. Here, again, is seen the disproportionately small dicrotic wave, the sure sign of high arterial ten. sion, which in this case exists in young and elastic arteries.
Fig. 6 was from a patient in the General Hospital, who had been suffering from Bright's disease, of something more than a year's standing. The trace was taken early in January of this year, at which time the patient was not particularly distressed by his condition, and after a month's stay in the hospital, he thought he was able to go to work, and, at his request, was discharged. He was soon back again, and ran down pretty fast, and died April 14th.
At the time this trace was taken, the pulse was one of moderately high tension. During the later weeks of his life the tension rose decidedly, and became very marked, and persisted to within forty-eight hours of his death. I submit this as a trace of moderately high tension in a slightly thickened artery, one that should warn the observer to suspect the existence of renal disease, even in the absence of other symptoms.
The autopsy was held twenty-six hours after death. The kidneys were extremely atrophied, pale, and granular; the right weighed one, and the left two ounces. The pelvis of the right contained eight small calculi; that of the left about the same weight of sand. The heart weighed twenty ounces, the enlargement being mainly of the left side. The aorta was normal in shape, its valves were noticeably perfect and healthy, while its coats showed now and then a spot of beginning atheroma. The liver weighed three and a half pounds, was slightly granular and firm. The spleen weighed three and a half ounces, and was also more firm than usual.
Fig. 7 was taken from a prominent lawyer of Buffalo, who had been out of health for more than a year, with symptoms of loss of strength and flesh, and bad digestion. He bad had several attacks of fainting, was about thirty pounds below his usual weight, and was thought to be breaking down. From the re. semblance of this trace to Fig. 6, I suspected that he had incipient Bright's disease, but the urine was neither copious nor albuminous. Soon after I saw him, he was down with a bad fainting, and after being in the house a couple of weeks, died from hemorrhage of the bowels.
The autopsy showed the heart to be fairly healthy, perhaps a little soft, and fatty; the left kidney to be small, puckered, and firm, but not sufficiently so to be called granular; the right kiilney to be enveloped in fat, and nearly as large again as the left, soft, and light colored, and contained a sac bolding forty to fifty grams of Huid, thought to be urine. The ureter was open, and the pelvis empty. The aorta was generally atheromatous, but not deformed. While to an extent the result of this examination was disappointing, upon reflection it was encouraging. I had expected to find decided renal disease, in spite of the failure to demonstrate the presence of albumen in the urine. The trace was surely one of high tension, and very like that produced by Bright's disease, but the kidneys could not be so classed. On the other hand, there was positive evidence of an abnormal circulation in both kidneys. The left was puckered and firm from capsulitis, and the right was distended with a sac of fluid of fifty grams. Plainly here was cause for decided obstruction of the renal circulation, and the consequent high arterial tension.
Fig. 8 is introduced, in order to call the attention of workers with the sphygmograph to what I consider a perfectly taken trace.
If this instrument is to be of any service to the profession, it must be made to perform more perfectly than the most of those do whose works have fallen under my observation. Traces can have no value, unless they bear with themselves the evidence that they are individual, and probably characteristic of the pulses from which they were taken. Undeveloped, half-taken traces can only be misleading and discouraging, and I would submit, for the criticism of the profession, this rule-Mistrust the sensitiveness of your instrument, or your skill in applying it, when, in a pulse of average strength, you fail to show the tidal wave as terminating in an acute angle, and remember that you have not perfectly taken such a pulse, until the trace shows the first and second elements clear and distinct, the dicrotic wave beginning and ending in an acute angle, and most important of all the diastolic line shown in oscillations.
Fig. 8 was taken from a member of the profession, an athlete of six feet high, weighing one hundred and seventy-five pounds, and who was remarkable for strength and endurance.