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pulse. A full elucidation of this subject would require a treatise rather than a lecture; but these few observations may serve to give a philosophical and consistent character to your investigations in this interesting department of diagnosis.

Let me repeat that the strength of the heart itself, however important, is not the only element concerned in modifying the pulse; the condition of the elastic and of the muscular coat of the arteries will exert great influence, and alterations of the quantity, and perhaps also of the quality of the blood are not inoperative. It may be difficult to determine to what extent these circumstances suffer change in phthisis; but there cannot be a doubt that the disease, when established, is commonly marked by a considerable deviation from the natural condition of the pulse. The quality of pulse which has always attracted most attention is frequency. In a healthy adult male the average number is from 70 to 75 in a minute; in the adult woman from 75 to 80. Let us compare this average with the pulse of some of our patients. Of the men at present under my care in the hospital, the slowest pulses are those of W. G., 84; W. K., 80; P. D., 78; W. U., 72, and in all these cases the indications of phthisis are so slight as only just to warrant an opinion of the disease having commenced; prolonged expiratory murmur, and very slight inequality of movement in the two sides, being all you can detect in W. K., W. U., and P. D.; slight hæmoptysis being also present in W. K. In several cases, in the second or third stage, which I next introduce, you find the pulse respectively, 112, 104, 116, 112, 100. If a man comes to you for

medical advice with a pulse above 90, you may generally suspect phthisis from that symptom alone; for other diseases, when they quicken the pulse in so great a degree, generally disqualify for exertion. Recollect, however, that the pulse may be relatively, when not absolutely quick. Some persons have naturally a pulse remarkably slow. Thus the pulse of Napoleon was only 40 in a minute. Such a pulse, if raised to 60, would be relatively as quick as a pulse of 120 in an individual whose natural pulse is 80; and you should remember that persons of tubercular constitution often have a languid circulation. Among twenty patients in whom the disease has attained the second stage,—that of softening, and whose pulses are registered in the list before you, only one has a pulse below 90. It is Honora D., in whom the cracked-pipkin sound is observable; her pulse is 88. Even this is considerably above the healthy standard, and it may be safely asserted that we have not at present a patient in the second or third stage of phthisis, whose pulse is not considerably accelerated.

Bryan Robinson, and Falconer asserted that in healthy individuals the pulse is quicker in the evening than in the morning. This, as a general statement, is erroneous. When this circumstance occurs in those who seem to be healthy, you may suspect the peculiar cerebral excitability termed by the Germans abendfieber (evening fever). The valuable observations of Dr. Guy strongly confirm the conclusion of Dr. Knox, that in health, when any difference of frequency between these periods is marked, the morning frequency is greatest; or perhaps it would be more correct to say, that the degree of frequency, under circumstances of quietude, is the same; but that

diet, or other stimulants, produce more effect on the morning than on the evening pulse.

In the first of these respects, the pulse of the phthisical contrasts with that of the healthy individual. From the table before you, it appears that the pulse of our patients is usually quicker in the evening; but you perceive that, as in health, it is less easily accelerated in the evening than in the morning by changes of posture. The respiration is usually quickest, as might be expected, in cases where the amount of pulmonary disorganization is greatest. As yet I have not traced any remarkable difference between the frequency of the morning and evening respirations, nor any rule specially applicable to the phthisical, as respects the relative frequency of the respiration and the pulse.

One of the most interesting circumstances regarding the pulse, viewed as an aid to the diagnosis of phthisis, has reference to the effect of posture on its frequency. Here, again, I avail myself of the exact and laborious investigations of Dr. Guy, who has shown conclusively,* that, if the pulse of a healthy person be felt first as he rests with the back supported in an easy-chair, and then in the standing posture, a marked difference in frequency is observable, the difference increasing in proportion to the natural frequency of the individual's pulse. The healthy difference is shown in the following table of the rate of increase.

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*Cyclopædia of Anatomy and Physiology, Article Pulse.

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Stage.

Pulse in Morning.

WOMEN.

Pulse in Evening.

Respiration.

Sitting. Standing. Difference. Sitting. Standing. Difference. Sitting. Standing. Difference.

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In the table which I now present, recording the pulse of patients now in the hospital, you see that, with few exceptions, the difference produced by change of posture is comparatively trivial, and that in several instances, especially in the evening, no difference whatever is observed.

The greatest difference is in the morning pulse of M. A. F., in whose case the only indication of phthisis is wavy inspiration at the apex of the left lung. In S. J. D. the morning pulse also contrasts remarkably with the evening pulse.

There are three with a difference, as tested this afternoon, of 12, viz.-C. B., who has emphysema, but no phthisis; S. A. B., in whom the other symptoms are undecided. The third exception is E. H., with a pulse at 100. The healthy difference is about 19: in E. H. the difference is 12, which exceeds the difference in the other consumptive men. This patient's pulse is small and weak, the impulse of the heart imperfect, the first sound too much like the second, and the cardiac dulness on percussion too widely diffused. His heart is apparently thin and dilated, and the question arises whether this peculiarity may account for the fact that the influence of posture is more considerable in him than in consumptive patients generally. In cases of debility change of posture produces so much more effect on the pulse than in the healthy state, that Dr. Knox regarded this indication as a kind of asthenometer. The importance of this fact in connexion with our present subject is obvious; since the debility associated with phthisis might be expected to counteract rather than to produce the inaptitude of the pulse to be modified by changes of posture.

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