ORIGINAL COMMUNICATIONS

Short articles of practical help to the profession are solicited for this department. Articles to be accepted must be contributed to this jour nal only. The editors are not responsible for views exprest by contributors.

Copy must be received on or before the twelfth of the month for publication in the issue for the next month. We decline responsibility for the safety of unused manuscript. It can usually be returned if request and postage for return are received with manuscript; but we cannot agree to always do so. Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest pos sible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will cer tainly misunderstand them. Generally, also, a down right fact may be told in a plain way; and we want downright facts at present more than anything else.RUSKIN. RECORD

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A Cheap, Reliable and Efficient Sphygmomanometer, Which Any Physician Can Construct.*

EDITOR MEDICAL WORLD:-Since the use of the sphygmomanometer is becoming so universal and the necessity for careful physical examination growing greater every day, there is an increased demand for that instrument. A number of the larger life insurance companies are insisting upon this examination being made, especially in doubtful cases. It is resorted to routinely in many of the hospitals and clinics for diagnosis and during operations. This is as it should be, of course, but many general practicians could make and interpret the observations just as well in their office or at the bedside if they cared to.

Keeps Patients from Dispensaries.

It is likely also that so many patients would not drift into hospitals and dispensaries if the general practician would devote the same amount of time and use all possible means at his disposal to ascertain, as nearly as possible at least, existing conditions. The average man at the average dispensary or clinic is probably not so well qualified to diagnose disease as the general practician, one great reason being that the average years of experience are markedly in favor of the "everyday" practician. The hospital or dispensary may be better equipt in instruments and appliances, and they should be generally; but in the case of a blood-pressure apparatus there is no excuse for the everyday doctor not equipping himself and allowing the specialists, the hospital or dispensary a single vantage point so far as blood-pressure determination is concerned.

That more careful work and study are *Contribution from the laboratory of physiologic chemistry of Temple University, Philadelphia, Pa.

Figure 1.-The Wall Sphygmomanometer for Office Use: Not so Easily Transported as Figure 4. (Photo

graf by Dr. D. Bruce Richards.)

hospital abuse is concerned; for he can rest assured that there are many young physicians who are filled with enthusiasm, well qualified and ready to devote the time to this class of patients which he is willing to let drift, else they never would have drifted.

The Instrument in Detail.

While there is an ever-increasing necessity for the instruments, they do not seem to have followed very closely the general

law of supply and demand, so far at least as price is concerned. The instrument here described is one which any physician with even less than ordinary mechanical skill can construct for himself at less cost than a dollar-excepting the sleeve and bulb. Any rubber bulb which is used for atomizers, or ordinary office work, will do perfectly well to inflate the sleeve. If the bulb does not have an automatic cut-off, a rubber valve can easily be made as shown at V in Figure 2.†

The question frequently arises: Is the mercury instrument reliable, or as reliable as other instruments on the market? This is answered unqualifiedly in the affirmativ, since all other instruments have to be standardized either with a mercury or water column. Since mercury is the accepted standard, why not use the standard itself instead of any comparison instrument? The only objection which can be raised against the mercury column is that it is too bulky to carry in the pocket. That is true! But

Figure 2.-Rubber Valve for Use where an Automatic Cut-off is not Employed. (Photograf by Dr. D. Bruce Richards.)

we have yet to see a dependable instrument which is not."

Mercury at ordinary atmospheric conditions of temperature and pressure is a liquid, and a very evasive one; but all liquids must be kept in containers, the recognition of which fact prevents any and all objections to its use.

The instrument here shown has been repeatedly compared with standard instruments and gives readings perfectly reliable, which check as closely as any two readings by any instrument do (there always being a slight variation in two observations on the same patient with the same instrument); two or three millimeters' variation, however, are allowable.

This instrument is inclosed in a box which was picked up at the laboratory in which some apparatus was received. It was originally about twice this size, but cut down to the following outside dimensions:

A bulb with cut off can be secured from William V. Willis & Co., 134 S. 11th Street, Philadelphia, for $1.

Height, 151⁄2 inches by 41⁄2 inches by 32 inches deep.

The piece of board fastened to the inner side of door is 141⁄2 inches by 4 inches by 1⁄2 inch thick and is really all that is needed to support the instrument for office work. A screw eye can be placed in the top and the whole supported from a wall over a table or from a desk, as shown (Figure 1).

The glass tubing is 28 inches long; outer diameter, 6 millimeters; inner diameter, 3 millimeters. These diameters of the glass tubing do not have to be adhered to, however. Thicker wall, smaller or larger caliber, can be used. The long arm is 14 inches * over all; the short arm, 10 inches over all.

The glass tubing should be bent so that the two arms are parallel. The distance of the arms apart may vary, of course. In this case they are 15 millimeters apart. The near-side end, or the one attacht to the sleeve, can vary in length-here it is 11⁄2 inches, and after the two bends are made and the arms are found to be parallel and the bent tubing lies perfectly flat on a plane surface, the near side bend is again heated and the short end bent upward from the plane of the other two so as to facilitate connecting the sleeve to the glass tube by rubber tubing. The three clamps shown at A, B and C are ordinary paper clamps which are carried by stationers. Even these are not necessary; two wide rubber bands slipped over the board support and mercury tube will answer every purpose.

The mercury is put in the tube to a height of 61⁄2 inches, which leaves ample room in the long arm. This one contains 54 grams or 4 cubic centimeters (1 fluidram) of mer

cury.

The millimeter scale is carried by stationers and this one cost 10 cents. The clamps holding it were cut out of two pieces of brass (sheet iron or steel would do as well). The brass here used is 1⁄2 millimeter thick. They are arranged so the near ends are free and the scale can be slid up and down so the zero on the scale is adjusted to the top of the mercury column.

The rubber tubing is ordinary thick wall -8 millimeters, outer diameter; 4 millimeters inner diameter; 2 feet in length being sufficient, but 3 feet will be found more

convenient.

The lid or door to this case is hinged or

All directions, dimensions and details are given very fully, tho they may seem redundant, as it is the object of this paper to describe an instrument "which any physi cian can construct."

fastened to it by a strip of ordinary adhesiv plaster. The two clamps to hold it shut cost 5 cents each; those from cigar boxes would answer every purpose.

The handle here shown cost 25 cents, but a cheaper one would suffice.

To Make a Valve.

If a bulb with a cut-off valve is not at hand, one can be made very easily of rubber tubing on the principle of the washbottle valve, and indeed is superior to the one on ordinary bulbs for the systolic reading, but takes a little more time for the diastolic. This is made as shown at Vin Figure 2: a piece of pure rubber tubing 3 inches long is closed at its far end, or end nearer the mercury tube, by a few turns of string and tying. Into the end nearer the bulb is inserted a piece of glass tubing open

closed by a small sleeve of rubber tubing as shown at T, by slipping the rubber sleeve (plugged with a piece of glass rod) over it. With this sealed the instrument can be laid horizontally without the mercury running out. In order to take the reading the scale must be pusht up beyond the top of the case and if it is made a rule to plug either arm of the mercury tube before lowering the scale and subsequently closing the case, no loss of mercury can occur.

The case can be made as elaborate or artistic as any one desires, or to suit personal fancies in design, color, etc.

The Rubber Bag and Sleeve.

The rubber bags for the sleeve should be, when collapst or empty, 10 inches long by 5 inches wide. A number of experiments have been performed with bags of

The

at both ends 12 to 2 inches long. glass tubing must be made of such a diameter that, when it with the rubber tubing is inserted or placed within the outer tubing, the outer side of the smaller tube fits very snugly the inner diameter of the outer tube at the end holding the glass tube; the distal end, of course, fits loosely within the outer tube.

A longitudinal slit, 4 to 1⁄2 inch, is cut thru one wall (at S and S1) of the inner or smaller rubber tube. This is cut by a sharp knife, moistening it well with saliva before cutting. This allows air to pass. thru the glass tube out thru the slit into the larger tubing and to the sleeve, but prevents the air from coming back, as the edges of the slit are approximated by back pressure.

The long arm of the mercury column is

various forms, sizes and shapes, one of them, shown at G in Figure 3, being made from a rubber glove. This one gives readings which are too high, the bag not being long enuf and there is not a sufficient and properly distributed volume of air in contact with the arm. Erroneous but low results are obtained if the bag is long enuf to go around the arm tho too narrow, thus forming a constriction in a too limited length of the vessel. From the experiments all things seem to point to the fact that the bag should be not less than 10 inches by 5 inches in order to have a good air cushion

$R. Levick's Son & Co., 104 S. 13th Street, Philadelphia, Pa., rubber manufacturers, will make the rubber bag, II inches by 41⁄2 inches, with 2 rubber tubes attacht, incased in a sateen sleeve, to go around the arm, for $1.25. Those who have a sleeve or will make one can buy the rubber bag with tubes for $1. This is shown in Figure 3 (lower bag).

our readers the opportunity to get such an instrument at small cost. This one you can make easily yourself. Your druggist can probably get you the glass tubing, and perhaps will bend it for you. Glass tubing is bent by heating it red hot in a blue gas flame (the yellow flame is not as hot as the blue and deposits carbon or lampblack on the glass) and then bending it. The druggist also can supply the mercury. Dr. Attix will answer thru THE WORLD any questions that may arise in regard to the instrument. We suggest that our family reread our editorial on the subject of sphygmomanometers in March, 1912, WORLD, page 89. Next month we will present an article on the application of this instrument, with photografs showing how it is used.—ED.]

A Few Conclusions as to the Attitude of the
General Practician Relativ to Salvarsan
Therapy, Based on the Treatment
of 300 Cases.

EDITOR MEDICAL WORLD:-The practician has to consider the complexities of salvarsan therapy as of any other remedy intended to influence conditions induced by bacteria or protozoa, the host, the germ, the drug, the effect of the physical presence of the germ and of bacterial and protozoal toxins upon the host, the general nature and potentialities and the methods of administration of the drug.

In syphilis, the effect of the treponema pallida and its specific toxic substances on the human organism is, or should be, the common knowledge of every practician. The effect of our specific therapy upon neuronic, cardiac, renal and vascular ailments should also be an integral part of the mental equipment of everyone aiming to be a syphilologist or attempting to use that remedy in syphilis.

Any practician with sufficient knowledge and skill of minor surgery, and having the above specified qualifications, can conscientiously give intravenous injections. There is no mystery about it, all it requires is knowledge, skill, prudence, patience, courage and conscience. Occasionally, the size, location or condition of the vein may be such as to present some difficulty. These cases are so rare as to be practically a negligible factor. The technic is almost parallel with a hypodermic or intramuscular injection, with the added requirement of inserting the needle in the vein and retaining it there.

The cutaneous phenomena usually first directing attention to syphilis, the disease naturally addresses itself to the dermatologist.

Knowing the etiology and specific treatment and management of the disease, it is manifestly proper that by united effort the medical fraternity leave no opportunity escape in the attempt to eradicate syphilis as a disease entity. Therefore, it is the duty of the general practician as well as the syphilologist, dermatologist or neurologist to give intravenous injections of salvarsan or neosalvarsan and mercurial treatment in conjunction with this in primary and secondary lues, and these, with the iodids, in tertiary syphilis, whenever a clinical diagnosis has been made, not waiting for a Wassermann confirmation, altho it is advisable to have a Wassermann test made before instituting treatment, as a matter of scientific interest. Neither a positiv or a negativ Wassermann test corroborates the presence or absence of leutic taint if there be no clinical evidence of the disease. When there be obscure symptoms difficult of interpretation with a positive Wassermann, it is our duty to the patient to recommend a specific intravenous and mixt