artery and is always considerably lower than the systolic. When a blood pressure is reported it is usually understood to be systolic unless otherwise stated.

quently several days later we make another observation with only our memory to serve us as a comparison of the degree of alteration. The feeling of many pulses in the interim has doubtless distorted our accuracy of judgment.

In making blood pressure records I have frequently found my previous opinion of the character of the pulse altered by its expression in millimeters of mercury. The hard full pulse with an up stroke that strikes the finger with quick force is never misinterpreted. It is always one that goes with high tension. Shading differences of such a pulse are difficult to recognize. For the most of us. some instrumental means of recognizing small as well as great changes is most satisfactory. Instruments which eliminate as far as possible the personal equation should be chosen. The study of a pulse tracing made with the sphygmograph gives an idea of the pressure at a glance. does not however unless in conjunction with a mercury manometer, give any trustworthy record of changes that can be expressed. The chief use of the sphygmograph is for recording and interpreting the movements of the heart and the blood coursing through the blood channels.

It

The mercury manometer is the only instrument of precision we have at our command for clinical records. It is now well agreed that the best form of apparatus is one after the idea of the Riva Rocci machine with wide armlet, 12 cm's. These instruments register the systolic pressure and may be connected with a tambor and chymograph for the registration of the diastolic pressure. The systolic pressure is obtained by taking the reading after the first return of the pulse. The diastolic registers the maximum pulsation of the

The force of the heart, the resistance against which it acts, nervous, and psychic influences are the factors which sustain and alter blood pressure. All of these factors must be considered when we endeavor to interpret the estimated blood pressure in a given case. Under normal conditions the pressure is higher after exertion, higher after sitting than after lying. There is always a tendency for the pressure to assume a level. This is well illustrated in the case of the athlete. At the beginning of a forced run there is an enormous rise in the pressure due to the enforced heart strain. This gradually sinks and assumes a new level when the runner gets his so-called second wind, and returns to normal after the run. The same is true, but to a less extent, of the patient who comes to the office for observation. When he enters, particularly if he has come up a flight of stairs, his pressure is often ten or fifteen millimeters higher than after he has remained quiet for a few minutes. The effort of taking off the coat and rolling up the sleeve gives a record on the manometer several points in advance of the record obtained during rest. In making permanent records it is therefore necessary to record a pressure level. The pressures I will report are all pressure levels. My plan is to take the pressure immediately after taking off the coat and twice after having remained quiet for five or ten minutes, the last two records must harmonize closely.

Suggestion has a powerful effect on arterial pressure. A man is sitting quietly reading a book, something he reads

causes a quick uncontrollable flush to come into his face, something has momentarily lowered his pressure. The effect of mental emotion on blood pressure has been well illustrated by the classical case of John Hunter, the victim of angina pectoris who said "My life is in the hands of any rascal who chooses to annoy and tease me." Unconsciously in susceptible individuals momentary changes may be produced by the attitude we assume toward them. The increased blood in the splanchnic system during the digestion of a meal causes lowering of the peripheral blood pressure. Normally there is always a balance maintained; but in those individuals who complain of chilliness and clammy hands after meals there is an over balance on the splanchnic side amounting to stagnation. On the other hand anything producing constriction of the splanchnic vessels causes a rise in pressure. A few days ago I was called to see a patient with subinvolution of the uterus. I had a book bound very tightly above the uterus. In an hour's time the patient's face became red and she complained of severe headache. Loosening the bandage stopped the headache. This can be explained on the same grounds as Oliver's test for the differentiation of undue splanchnic congestion. Oliver observed that when a weight is placed over the abdomen of a patient with subnormal pressure due to hypotonia an elevation of blood pressure results from the dislodgement of stagnated blood in the abdomen.

Curschmann has shown that pain produces a rise in blood pressure. When he applied the Faradic current over the upper part of the thigh in normal persons and malingerers a distinct rise in pressure occurs, whereas in hysteria and spinal

An

disease the pressure is unchanged. attack of angina pectoris occurred in a patient while Norris was taking his blood pressure. He noted a rapid rise of fifty mm., followed by gradual fall coincident with the disappearance of the pain. It has also been demonstrated by Beyer, Rhomberg, and Miller that pleasurable emotions, agreeable odors and tastes produce marked peripheral vaso-dilation, while excitement, worry, unpleasant odors, tastes, noises, and other sensations bring about vaso-constriction. Stimulation of the sciatic nerve by the Faradic current increases blood pressure. Mental pain such as that present during an attack of melancholia induces hypertension which disappears with relief from the state of anxiety. It is also quite well known that the motor excitement of mania causes hypotonia, the reverse of the condition found in melancholia.

EFFECT OF PROSTATIC MASSAGE ON BLOOD

PRESSURE.

A short time since I examined a patient who complained of some urinary symptoms. I found that he had a slightly enlarged prostate which I massaged for one or two minutes. I had previously taken his blood pressure and decided to take it again. I was interested to note a distinct lowering in the pressure. The prostatic massage experiments which I report this afternoon were planned in the beginning to control my first observation which I thought might be due to some instrumental defect. It will be seen from the illustrations that similar and definite changes occur in the three cases cited.

Charts 1, 2 and 3 are from records of the same individual. This patient, male, aged 62, had a distinct hypertonia, subject to considerable variation under nervous

, 1910

Series, Vol. V.,

, 1910

Series, Vol. V.,

a pressure record was taken and a fall of over ten millimeters recorded. The patient then sat up, after ten minutes the pressure resumed the normal point.

Exp. 2. The second observation was made a week later. This time the massage was continued only 12 minutes. An observation was made one minute later and the same reading was obtained, in four minutes a fall of 15 millimeters was recorded and in ten minutes the pressure was back to the previous lying pressure. One minute after sitting up the pressure assumed the sitting pressure previously obtained. No fall in pressure immediately following the massage suggested further observation on the time period of the reaction.

Exp. 3. The manipulations produced a little pain. One minute after the pressure had risen 25 millimeters, then gradually fell as is shown in the chart until five minutes when it reached a point 16 millimeters below the lying pressure.

CASE II, chart 4 shows very little effect from prostatic massage, there is however a tendency to an initial rise and a subsequent fall in the pressure. Prostate negative.

CASE III. Prostate slightly enlarged, groove not obliterated, lobes distinct. Cen