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A CONTRIBUTION 
TO PHYSIOLOGICAL MEDICINE 



BEING 



An address delivered before the British Balneological and Climatological 

Society on May 21st, 1903 



AM) 



A Preliminary Communication on the measurement of tissue-lymph in man 
read before the Royal Society, June nth, 1903, with additions 

and illustrations 



BY 



G/ 

GEORGE OLIVER, M.D.Lond., F.R.C.P. 




Pontoon 
JOHN BALE, SONS & DANIELSSON, Ltd. 

OXFORD HOUSE 

83-89, GREAT TITCHFIELD STREET, OXFORD STREET, W. 




MY67 mL M 





JUN-d 1931 



4iBRASX 




Hn Hbbress 



ON 



BLOOD-PRESSURE 



Mr. President and Gentlemen, — Two years ago it was 
intimated to me that this Society wished to do me the honour 
of calling me to its presidential chair. Inasmuch as circum- 
stances prevented me from accepting that honour, I have 
since been haunted by a desire to indicate in some way my 
appreciation of your goodness to me ; consequently, I have 
been casting about for some suitable avenue in which to 
express it. Therefore, I gladly embrace the present oppor- 
tunity of addressing you — an opportunity for which I am 
indebted to you, Mr. President, and to the Council of the 
Society. 

The physician practising at a health resort may be re- 
garded as a specialist in chronic ailments ; for by far the 
larger number of his patients have been out of health for 
periods of varying length. Now chronic ailments are gen- 
erally the outcome of some long operating cause or causes — 
hereditary or individual — and the material which they furnish 
for his daily thought and work induces the physician to culti- 
vate a trustful study of, and reliance on, physiology as the 
guiding star of his practice. He endeavours to make his 
knowledge of physiology a living power in his daily work ; 
he therefore adopts as far as possible methods of physiological 



observation in gauging and treating pathological deviations 
from the normal. He is alert to turn to practical ends the 
results of laboratory work which are apt to remain sterile ; and 
thus he endeavours to enrich the practice of his art. In a 
word, his aim is to become a practical physiologist, and some- 
thing more. But we all know how difficult it is to attain to 
such a high ideal as this ; for the exigencies of professional life 
tend rather to disintegrate the scientific spirit and to afford 
a somewhat insecure footing to the exact methods of science. 
As, however, medicine is moving forwards, she is happily 
adopting a closer walk with physiology ; and her votaries 
are growing keen to appropriate any bit of physiological 
lore that may first be tested as a working fact, and which, 
when proved to be a truth, will in due time be deftly fitted 
into the future edifice of physiological medicine. One of 
the far-reaching branches of physiology which has of late 
years been pressed into the service of medicine is the study 
of blood-pressure and of the distribution of the blood. I 
propose to glance at a few sections of this interesting chap- 
ter of physiological medicine which have more particularly 
engaged my attention during the past year or two, and which 
may be of interest to some of you as practitioners in balne- 
ology and climatology. But in submitting my jottings to 
your consideration, I must crave your indulgence in allowing 
me to draw exclusively on the data which I have myself 
collected ; and if I refer but sparingly to the work of others, 
it is not because I do not duly appreciate it. We are all 
fellow-workers in the good cause of endeavouring to advance 
our efficiency as practitioners of the healing art, and it is 
the duty of each one to contribute his mite to the common 
store. 

Normal Blood-pressure. 

The first requisite for the clinical study of blood-pressure 
is a knowledge of the normal blood-pressure ; for that is, of 
course, the standard to which clinical deviations should be 
referred. It is well recognised that in healthy subjects it is 



liable to very appreciable variations above and below a certain 
mean, and these extremes of normal fluctuation should be 
familiar to the practitioner. They are due to such physio- 
logical conditions as the ingestion of food, exercise and tem- 
perature. I have taken the opportunity afforded by the 
past winter's rest from clinical work, to study afresh these 
normal fluctuations of the circulation ; and I will now sketch 
an outline of the results. It may appear to you to be some- 
what of a reversion now-a-days to re-examine some of the 
elementary facts in our studies of blood-pressure ; but I 
think you will agree with me that the best possible assurance 
we can have of our advancing securely in a somewhat un- 
trodden field like this, is to retrace our steps occasionally and 
to re- test the safety and soundness of the track. In so doing 
we may verify or correct our position, and we may perchance 
pick up a few fragments of truth which before we passed by 
unheeded. 

For the most part, the observations on the arterial pressure 
were made with the haemodynamometer ; but Hill and Bar- 
nard's sphygmometer and Gartner's tonometer were likewise 
occasionally used. 

I have elsewhere* shown how delicate readings of the 
arterial pressure may be read for physiological purposes by 
the blood-pressure gauge. A small artery (like the super- 
ficial voire) is selected, and the pulsation of the indicator 
is gradually developed — by gently increasing the pressure 
on the water pad — to its maximum degree, when the reading 
should be made, it will then be found that beyond this point 
the motion at once diminishes. With a little practice differ- 
ences of even i or 2 mm. Hg. may be reliably read. I have 
found it useful to use rubber covers,f which can be placed 
over the pad so that the motion of the radial pulsation can 
be limited to a similar minimum range. This arrangement 
makes the reading of the arterial pressure taken from the 

* See " Blood and Blood-pressure," 1901. 

f Made by Mr. Hawksley, 357, Oxford Street, London, W. 



radial artery more precise, and prevents a secondary rebound 
of the indicator, apt to be produced in some cases when a 
high pressure is applied to the pad, which may lead an 
observer to infer that the arterial pressure is higher than it is. 

The Influence of Digestion on the Circulation. 
Daring the past winter I have been much interested in 
the effects which the ingestion of food produces on the cir- 
culation. I had previously worked on this subject, and the 
results of the observations then made, and published in iqoi, 
were confirmed ; but this more thorough and more critical 
inquiry has revealed an extension of these results. It has 
shown that the ingestion of food initiates a most interesting 



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Fig. i.— Hourly Observations of Mean Arterial Pressure. 

series of circulatory events which recur with perfect regu- 
larity after every meal. The observations have proved that 
the influence exerted by the act of digestion on the circula- 
tion is not a mere transitory one, which may pass away, for 
example, within half an hour or so after a meal— it is a much 
more prolonged physiological disturbance, which can be traced 
for fully three or four hours. 

I will first describe the effect of digestion on the arterial 
pressure, then on the capillary and venous pressures. 

In fig. i are recorded hourly observations on the mean 
arterial pressure throughout the day from 8.30 a.m. to 10.30 
p.m., in a subject leading an ordinary quiescent life with com- 



parative rest of the muscles. You observe that the pressure 
follows a rhythmical course, that there is a marked rise imme- 
diately after each meal, which attains its maximum develop- 
ment in an hour, and then the pressure slowly subsides. This 
wave- like rise and fall of the arterial pressure produced by 
each meal lasts from two and a half to four hours. I have 
observed that the amplitude and length of the curve, are, 
as a rule, proportionate to the size of the meal. The 
observations show that the average maximum rise of the 
mean arterial pressure attained in an hour after a meal 
amounts to 15 mm. Hg., though it may reach 20 mm. Hg. ; 
for example, a typically normal blood-pressure wave should 
rise from 100 to 115, and then gradually return to 100 mm. Hg. 

Now, you will naturally ask, why should we have a rise 
in the arterial pressure after meals, when dilatation of the 
splanchnic arterioles should make for a lowering of that 
pressure ? Observation with the arteriometer shows that the 
arterial calibre is slightly lessened when the splanchnic diver- 
sion takes place. There is, therefore, apparently a compen- 
satory reduction of the systemic area of the circulation ; 
and the increased tonus of L the arteries is one factor in 
raising the arterial blood-pressure, the other being cardiac 
— an increase in the output of the ventricle and stimulation 
of ventricular contraction. 

These digestive waves are also present when the arterial 
pressure is above the normal range. In determining the 
arterial pressure in clinical work, a correction for the influence 
of digestion on the mean arterial pressure may be usefully 
made by applying the following rule : To deduct from a pref- 
sure observed in the first hour after a meal 15 mm. Hg., 
in the second hour 10 mm. Hg., and in the third hour 
5 mm. Hg. 

The best time to make a reliable observation of the mean 
arterial pressure is within an hour before a meal. 

The study^of the capillary and venous blood-pressures 
during the digestive circulatory wave has likewise afforded 
some interesting results. The venous blood-pressure is 



8 

easily determined by a method of using the haemodynamo- 
meter elsewhere described * ; but so far no reliable method 
for gauging the capillary blood-pressure has been suggested. 
I have, however, employed a method which is simple and 
practical ; but as I hope to improve it I will not describe 
it. This method has so far shown that the capillary blood- 
pressure is considerably raised at the acme of the digestive 
circulatory wave, and that it then gradually falls during the 
decline of the disturbance. The rise and fall of the capillary 
blood-pressure, therefore, coincide with those of the arterial 
blood-pressure. The venous blood-pressure, on the other 
hand, falls during the full development of the digestive cir- 
culatory wave ; sometimes, however, it falls immediately 
after the meal (A, fig. 2), but more generally it rises a little 
at first, concurrently with the increase of the arterial and 
capillary pressures, and then it falls (B, fig. 2), or it merely 
remains stationary, failing to rise with the other pressures 
(C, fig. 2). But in all cases the venous pressure rises rather 
suddenly after the acme of the circulatory disturbance is 
attained, and then it reads much higher than before the meal, 
and again concurs with the capillary pressure. Fig. 2 illus- 
trates the behaviour of the three blood- pressures after a 
meal. Now were the capillary pressure to subside with the 
venous pressure, we should infer that this concurrent fall 
of these blood-pressures was caused by contraction of the 
arterioles ; and in clinical observation equally low readings 
of them, along with an increase of the arterial pressure, fur- 
nish good evidence of the predominance of arteriolar resis- 
tance. But the rise in the capillary pressure excludes this 
cause, and this rise together with the diminished venous 
pressure suggest an increase of resistance beyond the capil- 
laries. We know that the venules and veins are endowed 
with muscular fibres, so that these vessels can offer a varying 
resistance to the onflow of blood from the capillaries. It is 



* See Journal of Physiology , Cambridge and London, 1898, and 
" Blood and Blood-pressure," 190 1. 



true that these fibres are somewhat less abundant than in 
the arterioles and in the small arteries ; but inasmuch as the 
capillary pressure is normally low, it is not necessary that 
the venules should be provided with so large an amount of 
muscular tissue as the arterioles, which have to resist the 
arterial blood-pressure, and have thus to shield the capil- 
laries from that high pressure. These muscular fibres of the 



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FlG. 2. — Diagram illustrating Concurrent Observations of the Mean Arterial 
Pressure, the Capillary and Venous Pressures every Fifteen Minutes after a Meal. 

venules must surely serve some purpose in the economy of 
the circulation ; but regarding it physiology has hitherto 
remained silent. The foregoing observations, however, suggest 
that during the digestive disturbance of the circulation, the 
venules play an important part in regulating the capillary 
blood-pressure ; at one time, as at the acme of the disturb- 
ance, contracting and so increasing that pressure, and then 
relaxing and letting it down. I have, however, observed 
that contraction of the venules only comes into play when 



IO 

the body is at rest, for it is overcome during exercise, which 
raises both the venous and capillary pressures together, 
though it may reassert itself when the exercise ceases. I 
have just lately discovered that my friend Sir Lauder 
Brunton, so long ago as in 1879, when writing on the contrac- 
tility of the veins, anticipated this function of the venules. 
' It is obvious that, if venous radicles contract, they may 
oppose a resistance to the flow of blood in the capillaries, 
and by thus increasing the pressure within them, may cause 
more fluid to exude from them into the tissues."* 

Why should the capillary pressure be raised during the 
digestive disturbance of the circulation ? As suggested by 
Sir Lauder Brunton, a rise in capillary blood-pressure may 

cause an increased exudation of tissue fluid. The experi- 

# 

mental work of Ludwig and Noll,f of Starling, J of Lazarus 
Barlow, § and others, undoubtedly supports this view ; and 
following a new method of observation by which the tissue- 
lymph may be measured, I have been fortunate enough to 
obtain confirmatory evidence of it in man. May not these 
periodically recurring variations of the capillary blood-pres- 
sure which accompany the act of digestion be of supreme 
importance in nutrition ? Moreover, do they not afford us 
a glimpse of a much broader fact than is signified by the mere 
act of digestion ? For when food is taken there is, it would 
seem, not only the internal flow of the digestive secretions, 
but there is likewise a concurrent exudation into every tissue- 
of nourishing fluid expressed from the blood into the inter- 
stitial spaces. Should further inquiry substantiate this view, 
the physiological significance of the prolonged rhythmical 
movement in the circulation produced by the ingestion of 
food will be apparent. 

In reading quite lately Professor Paulow's lectures on the 

* " Collected Papers on the Circulation and Respiration,' by 
Sir Lauder Brunton, F.R.S., 1903, p. 537. 

f Zeitschrift f. rat. Med., 1850, Bd. ix., S. 52. 

% Journal of Physiology , Cambridge and London, vol. xvii. 

§ Journal of Physiology, Cambridge and London, vol. xvi 



II 

work of the digestive glands,* I could not avoid observing the 
similarity of the form and duration of his curve of the secre- 
tion of gastric juice in the dog after a meal, with the curves 
of arterial blood pressure incited by digestion in man — as 
if both were concurrent events, which proceeded from the 
same physiological movement in the system ; the maximum 
secretion, like the acme of the digestive wave, being attained 
in an hour ; and then the gradual subsidence of both occu- 
pying some three or four hours. For the purpose of com- 
parison I have reproduced one of Paulow's gastric juice curves 
in fig. 3. 



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Fig. 3. — Curve of Secretion of Gastric Juice after a Meal of Flesh. After Paulow. 

I have observed that the beverages, tea and coffee, pro- 
duce a similar rhythmical disturbance of the circulation to 
that which follows the ordinary meals ; it is, however, less 
pronounced and shorter (see fig. 1). 

The Influence of Exercise on Blood-pressure. 
It is now well known that the primary effect of exercise 
is to raise the arterial pressure, but I do not think it is as 
generally recognised as it should be, that this immediate 
rise of pressure is but temporary, and is soon succeeded by 
a marked fall, which fall persists during the further con- 
tinuance of the exercise and for some time after the cessation 
of it. The peripheral tubing very soon widens, and the rise 
is thus converted into a fall. Fig. 4 illustrates how quickly 
and how effectually the mean arterial pressure may be lowered 



* " The Work of the Digestive Glands." Lectures by Professor 
J. P. Paulow. Translated into English by W. H. Thompson, M.D. 
&c., 1902. 



12 

by merely throwing the muscles of the limbs and trunk into 
a state of contraction for short intervals. You observe two 
deep indentations in the curve of the digestive wave ; they 
are the impressions made on the normal course of that curve, 
produced by throwing the muscles into a state of sustained 
tension for two minutes. In spite of these interruptions the 
digestive wave of blood-pressure continues its course, and 
ultimately subsides in a normal manner. The effect is there- 
fore only temporary ; but it is instructive in showing how 



126 

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Fig. 4. — The effect of two minutes' Static Contraction of the Muscles (a and b) 
on the Digestive Curve of the Mean Arterial Pressure. 



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great is the power of muscular contraction in lowering the arte- 
rial blood-pressure. This is the fundamental fact in resistance 
exercises. But this fall in the arterial pressure is but a portion 
of the physiological fact we are now studying ; it is simply 
the result of the widening of the arterioles produced by the 
muscular contraction — a fact which is proved by the rapid, 
though transitory, concurrent rise in the capillary and venous 
blood-pressures. It therefore follows that mere static mus- 
cular contraction lets down, as it were, a large volume of 
arterial blood into the capillaries, and in this way brings 
more oxygen within reach of the tissues, and thus raises the 
metabolic processes. But it may do more than this ; for, 
by raising the capillary pressure, it may greatly accelerate 



, 3 vx JUN-8 193! r 

and increase the flow of interstitial fluia^terg^rfrpmYth 
blood into the vacuoles of the tissues, and ma3^tfms~^ush 

i 

these spaces and favour the clearing away of residua from 
them. From the clinical standpoint such effects as these 
produced by mere muscular contraction should prove useful 
in the treatment of diseases of the suboxidation type, in which 
the removal of waste products is imperfect, as in chronic 
goutiness. Static contraction of the muscles produces all 
the physiological effects of exercises on the periphery of the 
circulation, thereby easing the unloading of the ventricle, 
without increasing the work of the heart, as ordinary 
exercise does. 

A large group of our cases at a health resort have as a 
prominent feature of their circulatory disturbances a hyper- 
tonic* state of their arteries and arterioles, and in a large 
majority of these cases the mean arterial pressure is consider- 
ably raised. In some such cases both the capillary and 
venous pressures are lowered together — showing the pre- 
ponderance of arteriolar contraction ; while in others the 
capillary pressure is raised along with the arterial, while the 
venous pressure is lessened — indicating the predominance of 
venular contraction. Now in such cases the pulse is generally 
felt to be small, and is often reported as feeble, and the hands 
and fingers are apt to be clammy and cold, and sometimes 
they may even afford a cold, fish-like impression to the 
touch. The unguarded physician is apt to regard these 
signs as indicating a feeble heart and a weak circulation, 
and when he places his hand over the apex and finds it 
displaced outwardly he is confirmed in that view. In many 
such cases the heart muscle remains unaffected ; but in nearly 
all, the second aortic sound is markedly accentuated. In nine 
out of ten such cases the trouble originates in the periphery 
of the circulation. The physiological tonus of the arteries, 
arterioles and venules have passed the normal bounds and 



* The appropriate term " arterial hypertonus " was first employed 
by Dr. Wm. Russell (Lancet, June I, 1901, p. 1519)- 



become pathological. There is, in fact, a persistent hyper- 
tonic condition which often threatens to overmaster the 
ventricle. The embarrassment is peripheral, and the bravely 
acting heart muscle is apt in time to yield, and, indeed, does 
very frequently yield, and then there is established a new 
centre from which a fresh series of pathological deviations 
emanate. In a large majority of such cases the physiological 
measures applied at a well-equipped balneological resort will 
rectify the disordered peripheral mechanism, and then the 
blood-pressures (arterial, capillary and venous) either approxi- 
mate to their normal relationship to one another, or they 
become normal. After the course of treatment, it is a 
matter of some importance to suggest such simple methods 
of preventive management as may be easily followed up at 
home, so that the benefit acquired from the visit may be 
maintained. Among other measures designed to this end, 
I have found static or tension exercises of considerable value. 
At first the duration of the sustained tension of the muscles 
should be brief — so as not to be irksome — and as time goes 
on it should be lengthened. The exercises should be prac- 
tised perseveringly at all odd times and seasons, but espe- 
cially during the hour before every meal — this being the time 
when Nature herself produces a normal fall in the arterial 
blood-pressure. It is interesting to find how such exercises 
will frequently warm the extremities. One patient (a doctor) 
volunteered the remark that in his case the effect resembled 
that of a dose of nitro-glycerine ; and that reminds me that 
Brunton and Tunnicliffe suggested in a recent article that 
muscular contraction may produce some product which 
possesses the property of dilating blood-vessels.* 

It is apparent that the ultimate physiological effect of 
muscular contraction on the circulation is much the same 
as that induced by warmth, namely, a widening of the peri- 
pheral channels and a consequent easing of the work of 
the heart and a proportionate lowering of the arterial pres- 

* See British Med. Journal, October i6, 1897. 



15 

sure. But beyond this result, common to both, there is a 
difference between the therapeutic effect of warmth and that 
of exercise ; for heat merely relaxes muscular fibre, while 
exercise — even though tiring at the time — is followed by 
improved tone and vigour. It seems to me that physiology 
has a promising suggestion to offer to account for this dif- 
ference ; for Ranke showed that whenever muscles contract 
they absorb water from the blood : now, that water is proteid- 
containing water, which, after serving the immediate needs 
demanded by the contraction, may provide for repair and 
construction. So that we may say that exercise, like heat, 
expands the contracted peripheral mechanism, and thus 
reduces the consequent increased arterial blood-pressure, but 
does more than heat in providing for repair. 

It is an easy matter for you to test this lowering effect 
of muscular tension on the blood-pressure during the course 
of your examination of a case. I have frequently done so. 
Of course you must see that the patient preserves quiet and 
regular breathing when he throws the muscles into static 
contraction. You will not uncommonly observe, when the 
arterial pressure is raised, while the venous pressure is lowered, 
that after a minute's, or even after half a minute's, muscular 
tension the former will fall 20 or even 30 mm. Hg., and the 
latter will be doubled. 

The Influence of Temperature on Blood-Pressure. 

We now come to the third leading cause of variation in 
the blood-pressure, namely, temperature. We are all familiar 
with the contracting influence of a fall of temperature on 
the walls of the blood-vessels with rise in blood-pressure, 
and the relaxing effect of warmth with lowering of that 
pressure ; but few of us, I think, quite realise how powerful is 
the influence of changing temperature, not only on the 
systemic blood-pressure, but on all the physiological processes 
governed by that pressure. With the view of obtaining some 
evidence bearing on this point, I registered daily at 8.30 every 
morning for over three months during last winter, the mean 



i6 



arterial pressure, and some other physiological data, as well as 
the temperature as recorded in Stevenson's screen and in the 
room. Though these observations on the circulation were 
made in the house and before experiencing the influence of the 
outside air, the record obtained was certainly instructive ; for 
it showed that the circulatory mechanism is very sensitive to 
thermic variations in the weather. The record is, of course, 
too long to quote in detail. Suffice it to say, that the average 
reading of the mean arterial pressure was 120 mm. Hg. for 
all the screen temperatures below 36 F., and 107 mm. Hg. 
for all those above that temperature. 



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Fig. 5. — The Effect of a Warm Bath on the Digestive Curve of Mean 
Arterial Pressure. 



Such striking effects being traceable in a normal subject, 
we gain some notion of the disturbing influence of thermic 
changes of the weather on many of our sensitive patients. 
Thus it may be that " cold snaps " (as they are popularly 
called) may throw as much additional strain on a yielding 
ventricle — even though the patient be quiescent — as might 
result from an uphill walk. Surely our patients suffering from 
arterial hypertonus need quite as much the protecting influence 
of an equable winter and spring as do our bronchitic invalids. 

Fig. 5 shows the effect of a warm bath (temp. ioo° F.) 
on the mean arterial pressure taken a little over an hour 
after a meal. You observe how deeply it indents the normal 



17 

course of the digestive wave of blood-pressure. The influence 
of warmth quickly passes off, as in this example. It is, never- 
theless, a great power when judiciously directed in balneo- 
logical practice. It acquires its force as a curative agent by 
repetition, as in a course of baths. My physiological obser- 
vations have suggested that in certain cases the beneficial 
influence of warm immersion bathing may be enhanced by 
directing the patient to throw the muscles into a state of 
tension for short intervals during the immersion. In this way 
the dilating effect on the periphery of the circulation is in- 
creased, and the warm bathing becomes less relaxing. I have 
also found it useful to direct those patients who suffer unduly 
from the exhausting effects of warm immersion baths to con- 
tract the abdominal muscles frequently, so as to reduce the 
abdominal stasis which warmth encourages. Massage, and 
especially abdominal massage, is also a valuable addition to 
the warm immersion bath. 

To return from this slight digression. Cold may raise the 
line of the digestive curve on the blood-pressure scale so that 
the commencement and the finish may read from 5 to 10 mm. 
higher than the strict normal (100), and warmth may lower 
these points 2 or 3 mm. These figures furnish somewhat of 
a guide to the clinical correction for the effects of temperature 
on the arterial pressure. 

It will be recognised from this sketch of the respective 
parts taken by these three leading causes of variation in 
the arterial pressure — digestion, exercise, and temperature — 
that the influence of digestion is paramount and constant ; 
for the long curves of rise and fall produced by the meals 
recur with perfect regularity, and persist beyond the tem- 
porary variations of the blood-pressure produced by muscular 
action and by temperature, which, therefore, modify the line 
of these curves in a mere transitory way. 

The Influence of Altitude on the Blood-pressure. 

In the winter of 1899-1900 I made some observations at 
Arosa (5,900 ft.) in Switzerland on the mean arterial pressure 



i8 

with the view of ascertaining the effect of altitude upon it. 
These observations led me to conclude that in the winter 
months the blood-pressure is raised in high altitudes. Inas- 
much as intensely cold weather prevailed during the visit, 
I could not on that account regard my observations as alto- 
gether conclusive ; especially, too, as other observers were 
led to believe that altitude lowered the blood-pressure. 
Summer is undoubtedly a more suitable period of the year 
for observations of this kind than winter ; for then there is 
less liability to encounter the disturbing influence of a low 
temperature. Unfortunately for myself, I can only make 
any such observations in the winter : still, even then 
they may prove instructive ; for, if it be a fact that altitude 
does lower the blood pressure, and if that lowering influence 
is apparent in the cold months, it should on this account be 
all the more readily accepted. 

Having, last January and February, five or six weeks at 
my disposal, I spent them in Switzerland, where I made a 
large number of observations at different altitudes, and at 
some (Chateaux d'Oex, St. Moritz, Zurich, Klosters, and Siis) 
the blood-pressure was taken at different times. At Chateau 
d'Oex (3,498 ft.) and at St. Moritz (6,100 ft.) serial observa- 
tions were made at 8.30 every morning in a warm room, and 
a number of digestive waves were recorded, and the effects 
of exercise on the blood -pressures at these altitudes were 
also determined. Having previous to the visit made a large 
number of observations of the blood-pressure under the same 
conditions at home, I had the advantage of having a well- 
worked-out standard for comparison. Besides these observa- 
tions on myself I made others on another subject, on many 
visitors, and on some residents. 

1 Now what is the teaching afforded by the three groups of 
the observations, namely (1) those made apart from the 
influence of digestion and exercise ; (2) those afforded by the 
digestive waves and (3) those furnished by exercise ? 

In fig. 6 are plotted out the mean arterial pressures deter- 
mined at 8.30 a.m. or an hour before a meal, in a state of 



19 

rest in London, and at fourteen different altitudes, advancing 
progressively from 1,128 to 7,835 ft. You will observe that 
at about 1,000 ft. there is no appreciable change ; that a 
marked fall is apparent when a little over 2,000 ft. is reached ; 
that at 3,500 ft. (Chateau d'Oex) the blood-pressure, though 
somewhat higher than at the lowest point reached, is much 
lower than at home ; and that above that altitude (3,500 ft.) 
there is a rise progressive with the altitude until we reach 
the highest point, the Fluela Pass (7,835 ft.). 



MM.Hg. 




Fig. 6. — Mean arterial pressure taken at 8.30 a.m., or an hour before a meal, 
at various altitudes in Switzerland in January and February, 1903. 



In fig. 7 are recorded the consecutive morning observa- 
tions at Chateau d'Oex and St. Moritz (8.30). You observe 
the relative position of the two records on the scale : the 
spurts of pressure above the lowest readings were due to falls 
of temperature, as shown in the lower curves. Guided by 
my previous observations on the effects of variations in the 
temperature on the blood-pressure at home, I am quite sure 
that such decided falls in the thermometer as occurred at 



20 

Chateau d'Oex and at St. Moritz would in our own climate 
have produced much greater impressions on the blood-pressure 
than are here recorded. 

In fig. 8 are shown two digestive waves of blood-pressure 
(both after lunch without alcohol), one (a) taken at Chateau 



w) 



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JAN. 








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Fig. 7. — Consecutive morning (8.30) observations of the mean arterial pressure 
and temperature at Chateau d'Oex and St. Moritz. 



d'Oex and the other (b) at St. Moritz. These waves are 
typical of others. You observe that the wave at Chateau 
d'Oex begins at and falls to a lower point on the blood-pres- 
sure scale, namely, 98 instead of no mm. Hg., as at St. Moritz. 
The effects of exercise on the arterial pressure also show 
that the pressure is lower at Chateau d'Oex than at home 
or at St. Moritz, and that it is higher at St. Moritz than at 



21 



home. At home the usual effect of active exercise is to cause 
a fall of my arterial pressure to 97 mm. Hg. (observed just 
after the exercise is over) ; at Chateau d'Oex a similar 
amount of exercise reduced the pressure to 92 ; but at St. 
Moritz I could not diminish it below 105. 

After completing the foregoing observations I made some 
interesting readings of the arterial pressure at Zurich, where 
there is a railway which ascends from 1,345 ft. (Zurich) to 
2,865 ft. (Uetliberg), with a midway halt. 2,040 ft. (Waldegg). 



txo 



2. 

ZE 


TIME 






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Fig. 8. — Digestive waves of arterial pressure at Chateau d'Oex and St. Moritz. 



The uniform temperature and rest of the railway carriage 
afforded the most favourable conditions for comparable 
observations of the blood-pressure. The results furnished 
by the up and down journeys, which corroborate each other, 
appear in fig. 6, and confirm in a general way the previous 
observations made at similar altitudes. 

The concurrent testimony of all these observations made 
in winter, points, I think, to the conclusion that altitude 
does lower the blood-pressure within certain limits — and 
especially so between 2,000 and 3,500 ft. — above which the 
pressure rises. 



22 

When one thinks of it, it is surely improbable that alti- 
tude should either lower or raise the blood-pressure pro- 
gressively throughout all gradations ; for in either case 
life would soon be threatened or would cease. We know 
that Nature when dealing with organic life does not, as a 
rule, work in straight lines ; it is but the limitations of our 
view that give us that impression. She is ever deviating by 
her corrections to her beneficent ends. We should not, there- 
fore, be surprised at this contrary effect of altitude on the 
blood-pressure, as it is apparently but an example of this 
universal law ; for the observations suggest that at a certain 
point the lowering influence of the reduced atmospheric 
pressure is met by an adjustment on the part of the organism. 
How is this adjustment brought about ? The observations 
show that in the higher altitudes (6,000 ft. as at St. Moritz) 
the heart's action is more frequent, and the calibre of the 
arteries is somewhat smaller than in the lower elevations 
(3,000 ft., or so at Chateau d'Oex). The morning observa- 
tions give an average pulse rate of 76 at St. Moritz and of 
71 at Chateau d'Oex ; and an average radial calibre 0*4 mm. 
less at the former than at the latter place. 

I think we may therefore conclude that the progressive 
rise in the mean arterial pressure observed in the higher 
elevations is the result of an increase of the output of the 
heart and of the normal tonus of the arteries. 

Observations at St. Moritz on several visitors — even 
on those who had been sojourning there for two and three 
months — and on one whom I had observed at Chateau d'Oex, 
were exactly similar to those on myself ; but those made on 
a few natives showed that the mean arterial pressure in them 
was lower — in fact, it was much the same as in England. 
From this it may be inferred that acclimatisation in a high 
altitude is not a question of a few months only. 

I am sorry I could not prolong my visit so as to extend 
these observations to other altitudes and to verify or to correct 
those already made by repetition ; and I regret this the more 
because at the highest point reached — namely, on the Fluela 



23 

Pass, 7,835 ft. — it seemed to me as if a second compensation, 
having for its object a reduction of the blood-pressure, were 
coming into play — namely, a vagus effect. I hesitate to 
mention this single observation, as there may be nothing in 
it. I was, however, struck with the fall of ten beats per 
minute below the average pulse-rate which I had observed 
at St. Moritz, as a slow pulse at the highest altitude reached 
seemed to be somewhat noteworthy. Should a vagus effect 
develop in still higher elevations it would, of course, counter- 
act the rise of blood-pressure maintained by a further increase 
of the arterial tonus, and might afford a suggestion as to the 
cause of that mysterious ailment " mountain sickness." 

I merely give you my limited observations, which without 
further extension you should regard as but tentative, 
though they were made with care so as to exclude fallacies 
as much as possible. I trust that other observers may be 
induced to take up this work and report their results. Cli- 
matology is sorely in need of exact physiological data ; and 
we cannot have too many good observers. I think it is highly 
probable that in the warm months the lowering influence of 
altitude on the blood-pressure may extend to a much higher 
limit than my observations made in winter indicate, for 
warmth reduces the arterial tonus. But so far as these 
observations go I am inclined to think they have a sugges- 
tive bearing on practical climatology. I am not aware of 
a climatic condition that will lower the mean arterial pres- 
sure to the same extent as the medium altitudes. Why 
should we not think of this when deciding where to send 
some of our patients with plus arterial pressure in the winter 
months ? Then, again, our colleagues at Aix-les-Bains, and 
other foreign bathing resorts for the gouty, wisely advise 
their patients after the " course " to resort to a moderate alti- 
tude for theii " after cure " ; now, according to these observa- 
tions this advice means that the effect of the baths in 
lowering the arterial pressure will be maintained, even though 
the course of treatment has terminated. Can we not utilise 
some of our own moderate altitudes in a similar way after 



H 

a course at one of our bathing resorts ? Perhaps, however, 
I am looking too far ahead, as the question of accommodation 
on our mountain sides is doubtful. Then there is a thought 
that will occur to you in connection with the raised blood- 
pressure maintained in the winter by the higher altitudes. 
These should be well adapted to the climatic treatment of 
cases which require construction and repair, such, for example, 
as the phthisical ; and should be contra-indicated in cases in 
which the removal of waste products should be the keynote 
of treatment, such as in gout and chronic Bright's disease ; 
and should be further contra-indicated when we cannot be 
sure that the heart muscle will safely bear the additional 
strain of a high altitude. 

The Balance between the Visceral Blood Supply and 
the Systemic Blood Supply. 

There is another branch of our subject which, having an 
important bearing on practical medicine, I will briefly refer 
to. For many years I have been studying the evidence 
bearing on the relation which exists in health, and which is 
so often perverted in disease, between the quantum of blood 
in the abdominal area and that in the systemic area. This 
is a large subject which cannot be adequately handled, were 
a lengthened address devoted to it — much less in the few 
minutes that remain to me ; I will, however, endeavour to 
outline it sufficiently, I hope, to enable you to see some of 
its possibilities and bearings on practice. 

In the earlier observations of ten years ago, I inferred 
that the volume of the blood in the abdomen was increased 
when the radial calibre (determined by the arteriometer) 
became considerably enlarged on the patient assuming the 
recumbent posture — a reduction of the calibre in that posi- 
tion being the normal variation in persons of good vaso- 
motor tone. The explanation of this reversed reading that 
suggested itself was, that the diminution or loss of gravitation 
control in the splanchnic area led to a loading of the capa- 
cious abdominal veins in the erect position of the body, and 



25 

that when the circulation was freed from the influence of 
gravity in the horizontal position, the surplus blood was 
liberated, and merged itself into the general circulation, and 
thus the systemic arteries became fuller and larger in that 
position. Though this was but an indirect way of clinically 
testing whether the gravity control of the splanchnic was 
impaired or lost, I found it to be a most useful clinical guide, 
and one on which I placed — and still place — much reliance. 
But during the past few years I have been fortunate enough 
to find a supplementary method, which provides direct cor- 
roboration of the inference drawn from the reversed postural 
variation of the radial calibre ; it is based on the displace- 
ment of the surplus abdominal blood by means of a weight, 
and on the measurement of the effect which this displacement 
produces on the systemic blood-pressure. The patient having 
assumed the recumbent position, the mean arterial pressure 
is taken from the radial or ulnar artery — the arm being 
extended in a line with the body ; then a bag holding 14 lb. 
of shot is placed on the abdomen, and the arterial pressure 
is again read. The result of observation has shown that in 
persons of healthy tone, the arterial pressure is not altered, 
or is not very appreciably altered by the weight — except 
for a short time after a meal, when it is raised about 
10 mm. Hg. In the course of clinical work, however, a 
large number of cases are met with which afford a marked 
rise (of from 10 to 20 or even 30 or 35 mm. Hg.) at all times. 
It is this fact which is a matter of interest, because it is ab- 
normal ; and this interest is increased when it is found that, 
after suitable treatment, in a large proportion of these cases 
the weight will fail to produce a rise in the blood-pressures, 
when it is presumed the abdominal stasis has passed away. 

This clinical sign (for such I take it to be) characterises 
a large group of cases. What does it signify ? The only 
satisfactory explanation of it which I can discover, consistent 
with all the observations made, is, that in the cases referred 
to, the weight displaces at all times some considerable volume 
of blood from the abdomen, just as it does in health shortly 



26 

after a meal only, and for the same reason : namely, because 
the volume of the splanchnic blood is increased. There is, 
therefore, a continuous increase of the splanchnic area instead 
of an intermittent and transitory one as in health. The 
condition may be described as one of splanchnic stasis. How 
is it brought about ? Broadly, there appear to me to be 
four types of cases presenting this clinical sign. 

Firstly, there is the group of cases due to cardiac failure, 
in which a certain volume of the blood falls away from 
the control of the circulatory forces, and passively collects 
in the deep abdominal veins. 

Secondly, blood often collects unduly in these veins, 
when the muscles of the abdominal wall become flabby and 
toneless, as after pregnancy, the removal of abdominal 
tumours, &c, Nature's abdominal belt having become 
weakened. 

Thirdly, there is a group of cases which may be termed 
auto-toxaemic, in which the arteries are hypertonic (the con- 
traction being shown by the arteriometer), a condition which 
may result from the irritating presence in the blood of auto- 
generated products and residua, as in chronic goutiness and 
in various abdominal disorders. In such cases it would 
seem as if a certain portion of the blood is simply drifted, as 
it were, into the abdominal area from contraction of the 
systemic area. 

Fourthly, there is a very large group of cases depending 
on diminished tone of the splanchnic arterioles, so that at 
all times in the erect postures a considerable volume of blood 
simply drains, uncontrolled by these vessels, into the capacious 
abdominal veins. This class of case includes patients suffer- 
ing from all forms and degrees of exhaustion and lowering 
of tone, however produced ; but the most prominent mem- 
bers are neurasthenics. In every case of neurasthenia I have 
so far met with — and I have seen not a few — the shot bag 
test has invariably afforded decisive evidence of pronounced 
splanchnic stasis. I need scarcely point out the usefulness 
of an objective sign, which the observer can himself fully 



27 

appreciate, in an ailment like neurasthenia, with its inter- 
minable catalogue of subjective symptoms. 

In all these classes of cases the shot bag and the blood- 
pressure gauge indicate that there is a considerable volume 
of blood constantly present in excess in the wrong place — 
in the abdomen. The blood thus withdrawn from circulation 
(for such it is) will doubtless limit and cripple the nutrition 
of the whole organism, and especially that of the master 
centres. 

Now, though splanchnic stasis is always caused by some- 
thing — such as cardiac weakness, auto-toxaemia, exhaustion 
of nerve centre — it is itself a cause of endless derangements 
of function, so long as it remains uncorrected. It is, indeed, 
the centre of an ever- widening vicious circle. To follow its 
effects in all their clinical ramifications would lead me too 
far afield. Suffice it to say that beyond the incapacitating 
influence which it produces on the brain and the muscles — 
in limiting the power of thought and exercise — splanchnic 
stasis favours the production of various abdominal ailments 
and derangements of the cerebral circulation. In the abdo- 
men it predisposes to catarrhal inflammations of the various 
hollow viscera, to gastrectasis, enterectasis, and their sequelae, 
fermentation and the generation of toxins, to hepatic derange- 
ments, to menorrhagia, &c. I have also frequently found 
splanchnic stasis associated with marked and persistent 
forms of vertigo, and also with insomnia. 

Draining of blood into the splanchnic veins frequently 
produces a pale quasi-anaemic appearance, especially in young 
subjects. The pallor in some such cases may, of course, be 
due in part to actual anaemia ; it is not so, however, as 
a rule, but is entirely caused by the reduced volume of 
blood in the vessels of the skin, lips, conjunctivae, &c* In 
a word, it suggests haemorrhage ; and in the sense of blood 
diverted from circulation, there is virtual haemorrhage, only 



* Unless the blood is examined it is not easy to determine 
whether the anaemic appearance is due to actual anaemia or to 
splanchnic drain. 



28 

the blood withdrawn is temporarily resting, as it were, in 
the splanchnic veins. In most cases there is a slight loss of 
colour and a faded look, which appeal to the practised eye 
as suggestive of splanchnic stasis. In fact there is a lowered 
capillary pressure in the systemic area. 

There is, I think, some ground for suspecting that 
splanchnic stasis may be occasionally set up for the purpose 
of relieving the heart and the circulation ; the volume of the 
blood in some cases being, perhaps, in excess, or if normal, it 
may nevertheless be too much for a failing ventricle, and 
so a portion of the blood drops out of circulation and gathers 
in the capacious splanchnic veins, which form a convenient 
over-flow chamber. This view probably affords one expla- 
nation of the discomfort produced in certain cases by the 
application of the shot bag to the abdomen, the breathing 
becoming hurried and oppressed and the heart's action becom- 
ing disturbed. I have sometimes observed that when the 
ventricle is yielding under increased peripheral resistance and 
the apex is felt well out to the left in the sitting position, 
on the patient assuming the recumbent posture the arterial 
pressure will fall and the apex will come distinctly within 
the nipple line ; then the application of the shot bag will 
cause the apex to move outwards again, and the arterial 
pressure will rise as in the sitting posture. In such cases of 
diminished tone in the ventricular wall, it is not desirable 
to attempt to bring the excess of splanchnic blood into cir- 
culation, for by doing so we add to the load, which is already 
too much for the ventricle. Our aim should be first of all 
to tone the ventricle. In fact, splanchnic stasis of this type 
is frequently rectified by a course of cardiac tonics alone. 

In those cases in which the abdominal muscles are soft 
and atrophied, and especially when the abdomen is pendulous, 
the practitioner is often tempted to order abdominal belts ; 
but, inasmuch as mechanical supports of this kind rest the 
muscles, and in this way perpetuate the atonic condition 
of the abdominal wall, though they may afford temporary 
relief and comfort, they should, if possible, be avoided. Per- 



29 

sistent attempts should be made by electrical treatment and 
by specially devised exercises to strengthen the muscles of 
the abdominal wall. 

In all cases in which splanchnic strain is the result of 
asthenia the treatment should be concentrated on the cause 
of the stasis, namely, on the toneless state of the splanchnic 
arterioles. General tonic treatment alone will sometimes 
suffice to tone up these vessels ; but it is always aided by the 
adoption of suitable measures addressed to the splanchnic area 
itself. Your knowledge of physiology will now afford valuable 
clinical guidance. I have referred to the fact that in healthy 
subjects the shot bag may afford a rise in the arterial 
pressure for a short time after a meal. Should the splanchnic 
arterioles be more open than they usually are, they will be 
specially so during the first hour of digestion, when the erect 
position of the body will aggravate the splanchnic stasis. 
Hence the importance of absolute recumbency for an hour 
after the meals, and especially after lunch and dinner. Then 
before the patient rises it is desirable if possible to incite 
some contraction of the arterioles ; and for this purpose I 
have found it useful to advise him to apply a shot bag 
(weighing from 7 to 11 lb.) to the abdomen for ten minutes, 
through which he may massage the abdomen. Deep and 
thorough massage of the abdomen should also be syste- 
matically practised for ten minutes some time during the 
hour before each meal ; and for this purpose the shot bag 
has been found valuable, as through it, as thorough an effect 
can be obtained by the patient himself as by the hand of a 
masseur. Direct abdominal douching is also of considerable 
value in the treatment of splanchnic inadequacy ; and occa- 
sionally I have seen the D'Arsonval current useful. 

In neurasthenia the existence of splanchnic stasis pro- 
vides the rationale of the rest cure, now regarded as an im- 
portant factor in the successful treatment of this ailment. 
In the less severe cases the recourse to absolute rest and isola- 
tion, however, becomes less necessary when sufficient promin- 
ence is given to the measures which favour the restoration of 



30 

tone to the splanchnic arterioles, and when such measures 
are perseveringly followed up. 

Conclusion. 

Though our knowledge of the physics of the circulation 
is now considerably advanced, there remains much yet to 
be learnt, especially in regard to the peripheral part of the 
circulation — that part which is so intimately associated with 
nutrition and its derangements, and with various pathological 
conditions, such as chronic gout ; and it is to be hoped that 
the further study of this portion of the circulatory mechanism 
will throw some light on what may be termed the physics 
of metabolism. We practitioners in balneology attach much 
importance to the powerful influence which the measures 
at our command exert on the distal parts of the circulation ; 
for the outlying area of the circulatory tubing, actuated as it 
is by delicately balanced forces, is specially prone to get out 
of gear, and observation teaches us that the physiological 
methods of treatment we employ are more potent than drugs 
in clearing away and rectifying peripheral obstructions and 
embarrassments. 



The Circulation of Tissue Fluid in Man. 

(PRELIMINARY COMMUNICATION.) 



In the course of some observations made with the view 
of eliminating tissue fluid as a cause of variability in the 
samples of blood obtained for examination, I found that the 
rolling of a tight rubber ring over the ringer from the tip 
to beyond the interphalangeal joints will, as a rule, consid- 
erably raise the percentages of the blood corpuscles and of 
the haemoglobin. I could not arrive at any other conclusion 
than that the ring not merely empties the vessels, but like- 
wise clears away any tissue fluid present in the skin, and 
subcutaneous tissues.* The needle in puncturing the capillaries 
liberates a certain portion of lymph from the areolar tissue 
which surrounds them, and this dilutes the blood. When, 
however, both fluids have been dispersed as much as possible 
by the compression of the firm rubber ring, a puncture made 
just before removing the ring yields blood per se ; for the 
blood instantly returns to the vessels, whereas an appre- 
ciable interval must elapse before the lymph reappears, or 
is exuded afresh (see p. 37). I am aware that some may 
regard it as an open question as to whether or not lymph 
can be dislodged from the skin and the tissues covering the 
phalangeal bones ; consequently I have exercised myself as 
to how all the facts observed can be otherwise accounted 
for. Having, however, failed to conceive of any other satis- 
factory explanation of them than this, and my friends, 
physiological and medical, being unable to suggest another 
view consistent with all the data observed, I cannot avoid 

* It may be that the lymph is dislodged from the skin only. 
Blood derived from punctures of varying depth has, however, 
afforded the same results, 



32 

the inference that the reading of the difference in the per- 
centage of the corpuscles or of the haemoglobin before and 
after the use of the ring provides a measure of the tissue 
lymph, and makes the study of the circulation of it in man 
possible. We know that slight oedema can be completely 
transferred by compression from one part of the cellular 
tissue to another, and that the tissue fluid present in the 
intercommunicating lacunae of that tissue is akin to it.* The 
finger is anatomically well adapted to this mode of observa- 
tion, for the phalangeal bones provide a firm and fairly 
uniform base on which the soft tissues may be effectually 
compressed. 

This simple method having furnished somewhat unex- 
pected results, I naturally accepted them at first with reserve, 
and for some time the data were allowed to accumulate, 
until at last it was quite apparent that they invariably fell 
into the same order. Inasmuch as the method did not provide 
results which were exceptional or erratic or contradictory 
and unaccountable, reliability on it became gradually estab- 
lished by the mere repetition of the observations. 

A number of observations have been made on normal 
subjects leading a quiescent life with comparative rest of the 
muscles, and on persons subjected to varying degrees of 
exercise and to different temperatures. In this communica- 
tion I limit myself, however, to a statement of results obtained 
in the former class of subjects only.f 

The numerous observations which this inquiry necessi- 

* The connection between tissue lymph and cedema has not yet 
been worked out. It will, however, be shown that the exudation and 
absorption of tissue lymph are controlled by the capillary blood 
pressure ; whereas it would seem that cedema is tissue lymph which 
has fallen away from that control, and, being amenable only to the 
force of gravity, may therefore be regarded as the pathological 
analogue of hypostatic congestion as compared with the normal 
capillary circulation. 

f Among other additions to this " Preliminary Note " now 
reprinted are one or two results of clinical observation on the tissue 
lymph circulation, which illustrate the bearing of the physiological 
data on practical medicine. 



33 



tated on the corpuscles and on the haemoglobin were made 
by the haemocytometer tubes and the haemoglobinometer, 
which were described by me before the Physiological Society 
some few years ago,* and the specific gravity of the blood 
was determined by Roy's method. The blood - pressures 
(arterial, capillary and venous) were read by the haemo- 
dynamometer.f Hill and Barnard's sphygmometer and 
Professor Gartner's tonometer were also occasionally used 
in determining the arterial pressure. 

The Mode of Observation. — A sample of blood is taken 
from the first easily flowing drop derived from near the root 
of the nail, the object being to obtain the actual proportion 
of lymph present in the tissues around the puncture. No 
difference, however, has been observed in the reading of the 
corpuscles when the first drop was wiped away and the pipette 
was filled from the second drop. Three stout rubber rings 
are rolled in succession slowly from the tip of the finger to 
beyond the interphalangeal joints, and these are then removed 
by placing over the finger a rigid tube on to which the rings 
are rolled ; in this way compression of the tissues in one 
direction only is secured, namely from the tip. The original 
puncture will generally suffice for supplying the second sample. 
The finger is held upwards until the blood is made to flow ; 
for observation shows that compression does not now alter 
the proportion of the corpuscles. The haemocytometer tubes 
are then read in the usual way,t and the difference between 
the readings indicates the percentage of tissue-lymph. 

The sample of blood obtained after the compression is 
invariably darker and more venous looking than that yielded 
before the use of the rings. This difference is not due to a 
higher concentration of the blood, for it is apparent when 
the samples read alike, but is probably a result of the 
suspended oxidation of the tissues. 

* See Journal of Physiology , Cambridge and London, vol. xix. 
f See Journal of Physiology, vols, xxii., xxiii. 
% See " Blood and Blood-pressure," 1901. 

3 



34 

The samples are then washed into the haemocytometer 
tubes by which the corpuscles are enumerated in the manner 
elsewhere described.* Two graduated tubes and two 
measuring pipettes are required — one for the sample of blood 
taken before, and the other for that obtained after the use 
of the rubber rings. The difference afforded by the readings 
of the tubes (before and after compression) will be referred 
to as " the lymph difference." Should the two samples of 
blood furnish the same readings, there is no " lymph differ- 
ence," and it is then inferred that no measurable lymph is 
present at the time of observation. This fact is referred to 
as " the zero point " of lymph. 



General Conclusions. 

Some of the general conclusions afforded by the observa- 
tions may be thus epitomised : — 

(i) The Amount of Tissue Lymph varies at different times 
in the course of the day, and each variation is of short 
duration. 

(2) The Ingestion of Food produces a rapid flow of Lymph 
into the Tissue Spaces, which in an hour after meals acquires 
its maximum development, and then slowly subsides, and 
only ceases to be apparent after the lapse of from three to 
four hours (fig. n, AAA a). 

(3) The Digestive Curve of Variation always follows the same 
General Type, the rise being rapid, the acme short and the 
subsidence somewhat gradual. The curve of variation is 
therefore rhythmical, recurring after each meal with perfect 
regularity (fig. n). 

The following are two examples : — 



* For a description of this method of enumeration the reader is 
referred to " Blood and Blood-pressure," H, K f Lewis, 1901. 



35 



Example I. 

Corpuscles. 



Difference. 



Before the meal 
(breakfast) 

One hour after 
Two hours after 
Three hours after 
Four hours after 



Per cent. 

99* 



103 

[ 9i 
{106 

94 
105 

f 96 
(104 
( 98 
i 101 



200,000 



Per c. mm. 
4,950,000 [ 

5,1 50,000 j 

4,550,000) 

r 750,000 
5, 300,000 J 

4,700,000) 

5,250,000! 

4,800,000) 

5,200,000) 

4,900,000 I 

5,050,000} 



550,000 
400,000 
150,000 



Percentage 
of Lymph. 



15 



I I 



Example II. 

Corpuscles. 



Difference. 



Before the meal 
(dinner) . . 

One hour after 
Two hours after 
Three hours after 



Per cent. 

I 99* 
I 99 
( 9i 

1 108 

( 94 
I106 

J 104 
(104 



None 



Per c. mm. 

4,950,000) 

4,950,000j 

4,550,000) „ 

DD * I 850,000 

5,400,000 1 D ' 



Percentage 
of Lymph. 



4,700,000 
5,300,000 
5,200,000 
5,200,000 



600,000 

None 



12 



o 



(4) As the Digestive Lymph Wave develops there is a rise in 
the percentages of the Corpuscles, of the Hcemoglobin and of 
the Specific Gravity of the Blood. — The differential readings of 
the haemocytometer tubes, of the haemoglobinometer, and of 
the specific gravity of the blood demonstrate the same fact, 
namely, that the blood becomes more and more concentrated 
as the effusion of lymph into the tissues progresses, and is 
most concentrated when the acme of the lymph wave is 
attained. The average rise of the corpuscles and of the 
haemoglobin is 15 per cent., and of the specific gravity is 
7*° (fig- 10). 

(5) As the Digestive Wave declines there is a fall in the per- 
centages of the Corpuscles, of the Hcemoglobin and of the Specific 



* The figure on the first line represents the percentage of corpus- 
cles before, and the figure on the second line that after compression 
of the finger by the rubber rings. 



36 

Gravity of the Blood. — In proportion as the water effused 
into the tissues is restored to the blood the percentages of 
the corpuscles and of the haemoglobin and the specific gravity 
of the blood fall. 

(6) The interchange of Fluid between the Blood and the Tissues 
may be measured. — The observations have shown that 15 per 
cent, of the volume of the plasma flows into the areolar spaces 
during the maximum development of each lymph wave. 
Now if we assume that the blood forms one-thirteenth of 
the body weight, a man weighing n st. should exude 
850 cc. (or 28 oz.) of lymph into the interstitial spaces of 
his tissues after each meal, during the short period occupied 
by the acme of the wave. This large interchange of fluid 
between the blood and the somatic tissues exceeds other 
fluid-transfers from the blood, consequently when the maxi- 
mum exudation takes place the volume of the blood will 
shrink considerably ; during absorption it will increase, and 
when absorption is completed it will acquire its fullest expan- 
sion. Therefore after each meal there is a rhythmical diminu- 
tion and increase in the volume of the blood, in keeping with 
the periods of transfer of fluid to and from the tissues. 

(7) The Exudation of Tissue Lymph. — Physiologists are 
divided as to whether tissue lymph is a pressure product 
(Ludwig, Starling and others) or a secretion (Heidenhain). 
Inasmuch as the amount of lymph in normal subjects is 
always proportionate to the rise in the blood-pressure (arterial 
and capillary), my observations seem to me to support Lud- 
wig's theory. It therefore follows that the prolonged rhyth- 
mical curves of rise in blood pressure elsewhere described 
(see p. 6) following the meals are identical with the curves 
of the digestive lymph waves. In fact, the agreement between 
the blood-pressure and the exudation of lymph is so complete, 
that the " lymph differences " provided by the hsemocy to- 
met er tubes and the readings of the mean arterial pressure 
by the haemodynamometer furnish interchangeable scales, 



37 

one point of lymph being equivalent to i mm. Hg. pressure ; 
so that from the blood-pressure it is possible in normal 
subjects to predicate the amount of lymph, and from the 
" lymph differences " may be inferred the degree of pressure 
which produces it. Moreover, in cases of splanchnic drain 
the limited exudation of lymph into the somatic tissues, which 
is in keeping with a feeble rise in the systemic capillary pres- 
sure, is markedly increased if that pressure be raised by 
mechanically dislodging the extra load of blood in the 
splanchnic veins (see p. 47). Furthermore, a supernormal 
or a subnormal blood-pressure determines a corresponding 
variation in the tissue-lymph circulation (see p. 42). The 
following example illustrates the agreement between the blood- 
pressures and the amount of lymph. 



Before the meal 
Half hour after 
One hour after 
One hour and a half 

after 
Two hours af ter 
Three hours after . . 



Percentage of 
Lymph. 

None 

IO 
16 



3 

None 



Blood-pressure in mm. Hg. 



Mean arterial 
IOO 

I IO 

Il6 

IO8 

I05 
IOO 



(8) The rate of the effusion of Lymph. — Fig 



Capillary. 
20-22 

27-30 

30-35 
27-3O 

25-27 
20-22 



9 gives some 
data which illustrate the rate of the exudation of lymph. 



corpuscles 



per c.mm. 

6,300.000 

6,200,000 

5,100,000 

6,000,000 

4,900,000 

4,800,000 



per cent 

106 
104 
102 
100 
98 
96 



(«) 



15' 



30' 



90' 



120" 



^. ................ .... ...... ...... .......1 1...... .... ... ... ...i... ..... -1 

t.... ...... ... ........... »...- .1. ,_1..^m ......... W .u a i^a^ 



Fig. 9. — Illustrating the rate of the exudation of tissue lymph. 

The " lymph difference " was found to be 10. A series of 
observations were made at short intervals, allowing succes- 
sively after each, 15, 30, 60, 90 and 120 seconds to elapse 
before the blood was drawn after compression — the finger the 



38 

while being held up to prevent gravitation of lymph. The 
aim of this observation was to ascertain how soon the " lymph 
difference " of 10 becomes reduced (showing how quickly a 
fresh exudation takes place) and the time required to replace 
the whole of that difference. The initial reading of 10 points 
was confirmed at (a) and (b) ; so that the tissue-lymph was 
thus proved to be uniform in amount throughout the observa- 
tions. The mean arterial pressure was also taken before each 
observation, and was found to remain at the same reading. 
In 15 seconds some fresh lymph was formed already ; in 30, 
60 and 90 seconds the new exudation progressively increased, 
and in 120 seconds the whole of the original amount was 
effused. That the exudation of lymph is rapid is also shown 
by the fact that in splanchnic stasis a low percentage of lymph 
(e.g„ 6) may be considerably raised (e.g., to 15) in five minutes 
by applying a shot bag (14 lbs.) to the abdomen (see p. 47). 

(9) The Absorption or Disposal of Tissue-lymph. — In the 
normal condition of the circulation, each exudation or lymph 
wave completely disappears before its successor is thrown 
out. Lymph can only be disposed of in two ways, namely, 
by (a) absorption into the capillaries and (b) by transmission 
along the lymphatics. Experimentation on animals has shown 
that muscular action of some kind is necessary to ensure a flow 
of lymph along the lymphatics.* That fact, as well as others 
brought out in this inquiry, suggests, that when the body 
is in a state of rest, the fluid exuded into the tissues is mainly 
absorbed directly into the blood ; and I am disposed to think 
that further inquiry will confirm this view. An essential 
condition required to effect this absorption is a falling capillary 
pressure ;f and the absorption becomes as a rule complete 
when that pressure settles down to a little over 20 mm. Hg. 

* " Text -Book of Physiology." E. A. Schafer. Vol. i., pp. 291 and 
301. 

t Starling regards the osmotic attraction of the proteids of the 
plasma as the force which determines the absorption of lymph from 
the interstitial spaces of the tissues, this force, which he estimates as 
equivalent to 30 mm. Hg., coming into play when the capillary blood- 
pressure falls* 



39 

Should the blood-pressure when higher than this cease to 
fall, absorption likewise ceases to go on, and at whatever 
point it halts in its descent, at that point the lymph flow 
from the tissues is arrested. Hence the continuous charge 
of lymph in the tissues of those in whom the blood-pressure 
is supernormal (see p. 42). 

(10) The Intermediary Circulation. — The to and fro trans- 
fers of fluid from the capillary to the tissue spaces constitute 
a circulation which appears to suffice for all the requirements 
of metabolism while the body is in a state of rest. This cir- 
culation, interposed as it is between the capillaries and the 
lymphatic vessels, may be appropriately termed the " inter- 
mediary circulation." It is merely an extra-vascular exten- 
sion of the capillary circulation controlled by the forces which 
actuate that circulation. 



CORPUSCLES 


nt 




„, , Specific gravity 

3 ±!l2^__ ^ of blood 


per c.mm. per ce 


5,400,000 108 


( 








































1068 


6,300,000 106 


c \ 
1 

3 

a j 





















■£* 


^ 
















1067 


6,200,000 104 








j 


& 


<.yS 




ll 

■6 ° 
E ° 

3 C 

E 

x n 

« •- 

«£ a) 

> 


E 
E 
6 

<u 
a 





0- 

d 

10 






r 2 ^ 


fo* 


^ 










1066 


6,100,000 102 






A< 


P\ 


















r^> 


^ 






1065 


6,000,000 100 


O 


A 


s 




a 




a 


> 


y, 




/ 


k 












1064 


4,900.000 98 


u 

it 

1 

if 








\ 


' 


\ 


f 




b 






b 


$ 










1063 


4,800,000 96 




% 


S535 
















*h 


^ 










1062 


4.700,000 94 








1 


^5 








^ 


W 














1061 


4,600,000 92 










Sv. 


























1060 



Fig. 10. — Diagram showing the average variation in the enumeration of the 
corpuscles and in the specific gravity of the blood before and after the compression of 
the finger during the flow and ebb of the lymph (digestive lymph wave) ; (a, a), 
exudation of lymph conveying proteids and salts to the tissues ; (b, b), absorption of 
tissue fluid containing soluble waste and salts. 

(11) The Physiological ends served by the Lymph Waves. 
— Inasmuch as proteids are diffused through membranes in 
proportion to the pressure which exudes them, it may be 
inferred that the physiological end served by the rise in the 
capillary blood-pressure which produces the digestive exuda- 
tions of lymph is to supply pabulum to the tissues. Proteids 
are therefore probably distributed to them in the exudation 
current which flows from the blood -(fig. 10, a). Inasmuch as 



4 o 

absorption does not commence until the blood-pressure begins 
to fall, the current from the tissue spaces to the capillaries 
will not set in until after the acme of the wave has been reached. 
This return stream (fig. 10, b) probably consists of a solution 
of salts and waste products only ; and any surplus of pro- 
teids not used up in construction and repair of the tissues 
may be restored to the blood by transmission along the lym- 
phatics, rather than by direct retransfer through the capillary 
wall — for there is a difficulty in explaining how proteids can 
be absorbed from the tissues by this direct route. 

If these views on the physiological purport of the lymph 
waves be correct, it may be inferred : — 

(a) That the intermediary circulation provides the mech- 
anism, as it were, for the supply of pabulum to the tissues 
and for the removal of soluble waste products from them. 

(b) That the lymph wave which follows a meal ensures 
the immediate supply of pabulum from the blood, which 
restores all the tissues of the body at once, and long before 
the food itself can be assimilated into the blood. Thus it is 
that the ingestion of food secures the speedy renewal of the 
energies, which is a matter of common experience ; and the 
exhausted tissues have not to remain unsupplied with fresh 
nourishment until the food taken becomes part of the common 
store of pabulum which the blood keeps ready for distribution. 

(c) That beverages (tea, coffee and alcohol) probably 
invigorate the body by inciting a flow of lymph into the tissues 
(fig. n ). Beverages, however, viewed from this standpoint, 
differ from food-stuffs, in that they fail to restore to the blood 
the outflow of pabulum which they create. They are there- 
fore but temporary expedients of nutrition. 

(12) The Zero Point of Tissue-lymph. — It was a surprise 
to me to find that at certain times of the day in normal sub- 
jects, the differential readings of the haemocytometer tubes 
indicate the apparent withdrawal of tissue fluid ; for though 
nothing hitherto has been ascertained as to variations in the 
volume of that fluid, the presence of a certain portion of it 
at all times seemed to be more probable than the temporary 



41 

absence of it. It is not improbable of course that when the 
tubes afford a negative reading, some minimum quantity of 
tissue-lymph is actually present, though too small to be measur- 
able by that mode of observation. But whether this be so 
or not, it is a well-assured fact (the observations, made with 
exceptional care, being now so numerous as to exclude doubt) 
that in normal subjects the tissue-lymph is at certain times 
apparently absent — the two haemocytometer tubes then read- 
ing exactly alike. This zero point is invariably met with 
after the lapse of three or four hours following a meal and as 
a rule, just before the next meal — when in fact the lymph 
wave has ceased ; and is not found at any other time during 
the day. 

In adults it is as a rule apparent when the mean arterial 
pressure is ioo mm. Hg. and the capillary and venous pressures 
are 20 or 22 mm. Hg. From the few observations which 
have been made so far on growing subjects it would seem as 
if the blcod-pressure must fall still lower in them before the 
zero point of tissue-lymph is reached. Inasmuch as in young 
subjects tissue-lymph is exuded under a lower capillary pres- 
sure than in adults it is probable that in them the capillary 
wall is more permeable. Exceptional cases have been met 
with in adults in which the arterial pressure follows a sub- 
normal range {e.g., from 90 to 105 mm. Hg.). But in such 
cases the capillary blood-pressure was relatively higher and 
the lymph wave was found to be normal. 

(13) Types of Digestive Lymph Waves. — The agreement 
between the readings of the tissue-lymph and of the blood- 
pressure is also well illustrated by the effect produced on the 
lymph waves by a blood-pressure above or below the normal. 
In fig. 11 are represented a day's series of three typical forms 
of digestive lymph waves. The continuous line (a) shows the 
curves which are observed in subjects in whom the blood- 
pressure follows a normal course ; and the interrupted lines 
(b and c) indicate variations of the normal waves produced 
by a rise in the blood-pressure (b) and by a fall of that 
pressure (c). 



42 

The typical physiological wave is that which rises out of an 
apparently lymph-free condition of the tissues and completely 
subsides to the same zero point. When such is the case, in 
the majority of adults the arterial blood-pressure rises from 
ioo mm. Hg. before to 115 or 120 mm. Hg. after a meal, and 
then falls to 100 mm. Hg. before the following meal ; and 
the capillary blood-pressure rises from 20 to 35 mm. Hg. and 
again subsides to 20 mm. Hg. (see pp. 7, 8 and 9). But when 
the blood-pressure follows a higher course than normal, there 
is invariably a large percentage of lymph in the tissues before 
every meal ; then the lymph wave rises out of and subsides 
into a certain quantum of lymph permanently present (fig. 11, 





8 3C 




9 3C 


• 


30 


11 3C 




2 30 


1 3C 




2.30 


3 30 




4 3C 




6 3C 




6 30 


7 30 


8 3C 


1 


9 3C 


10.30 


rn 








B 


















B 
























• « 1 








24 








f. 


















» % 
























' 










?? 










\ 














t 


1 


\ 








B 
















*, 








20 






/ 
/ 






\ 
















\ 








f, 












/ 


A 




'. 






18 














\ 
















y 






I" 


1 










t 






% 






in 




1 

1 
1 




A 






* 








/ 




A 




% 


, 














/ 










', 




14 




1 

1 












*^ 


, 














\ 


1 




1 








/ 

/ 




A 






\ 




12 


/ 






A 










\ 


t 






,« 






1 












1 




J , 


'0 


\ 








10 


4 




/ / 


c 


\ 










4 






fc" 


1 






', 1 

4 






V- 


... 


-4 




' ; 




\ 






*» 


8 






/ 




* 


















I 




















/ 




\ 








8 





1, 


















/, 






', 






c 












If 
It 






■ 








4 


a 
1 










\ 






\ 




1 ' 






1 






" I 


:c\ 








V 

c 


/,' 








» 






2 


CD> 












» 


' \H 


' 


• 




k/, 




1 






c 




t i l\ 1 
















D 


W- 


.— h -Ar 


w J.-.-,-V 




\_ 




J 


', n! Vj_ 


-• 





















' 


1 






u 












" 







Fig. II. — Typical digestive waves of tissue-lymph, (a) Blood-pressure normal; 
(b), blood-pressure super-normal ; (c), blood- pressure sub-normal; (d), zero points of 
lymph. 



bbb). This form of the wave was observed in high altitudes 
where the haemodynamometer indicated a rise in the blood- 
pressure (see p. 19) ; this rise was therefore demonstrated 
by two totally different modes of observation, namely, directly 
from the arteries and indirectly from the differential readings 
of the blood. 

When the arterial blood-pressure is subnormal, the lymph 
waves become somewhat reduced in amplitude and duration, 
and the lymph-free intervals before the meals are consequently 
lengthened (fig. 11, c d). This type of lymph wave was observed 



43 

in the medium altitudes (from t,ooo to 4,000 ft.) which lower 
the blood-pressure (see p. 19). 

(14) The density of the Blood in Circulation is largely 
controlled by the Capillary Blood-pressure. — According to my 
observation the specific gravity of normal blood is in close 
agreement with the number of the blood corpuscles per 
cmm. of blood ; one degree in specific gravity being nearly 
equivalent to 100,000 corpuscles, or to 2 per cent, on the 
scale of the haemocytometer tube. I will therefore refer to 
the density of the blood as expressive of the percentage of 
the corpuscles as well as of the specific gravity. This 
inquiry has shown that the density of the blood in circula- 
tion cannot be accurately ascertained from a sample yielded 
by the finger in the ordinary way ; it can only be learnt 
after the tissues have been compressed as by the rubber 
rings. This procedure has demonstrated that the density of 
the blood increases pari passu with the rise in the capillary 
blood-pressure and in the consequent exudation of lymph, 
and decreases with the fall in that pressure and the gradual 
withdrawal of lymph from the tissues. Furthermore it has 
likewise shown that when the blood-pressure becomes super- 
normal, as in high altitudes, in chronic goutiness (see p. 45) 
and in kindred ailments,, the density of the blood rises in 
proportion to the increased and persistent exudation of 
tissue-lymph ; and when the pressure falls below the normal 
range (see p. 47), the fluid exchange between the blood and 
the tissues diminishes and the density of the blood tends 
to be low. 

(15) The bearing of Lymph Observation on the Clinical 
Determination of Blood-pressure. — It has been conclusively 
shown by my clinical work, that the haemocytometer tubes 
afford useful information, not only in regard to the inter- 
mediary circulation in various ailments, but in definitely 
settling the question of blood-pressure — whether it be 
normal, supernormal, or subnormal. I have found this mode 



44 

of observing the blood-pressure through the blood a most 
reliable one. As a clinical method, it possesses one great 
advantage over the ordinary modes of directly determining 
the blood-pressure. The data it furnishes are not affected 
by a temporary nervous perturbation of the patient. 

As previously stated (see p. 36), the scales of the 
haemocytometer tubes and of the haemodynamometer are 
interchangeable within the normal range of variation (from 
100 to 115 mm. Hg.) but for arterial pressures above 115 
or 120 mm., the percentage of lymph rises in a decreasing 
ratio ; for example, there may be no more than 25 per 
cent, or so, though the arterial pressure may be 135 
or 140 mm. Within the normal range of variation of 
the blood - pressure, there appears to be a fairly constant 
relation between the rise and fall of the arterial and 
capillary blood-pressure ; but beyond that range the rise of 
the capillary pressure may be modified by arteriolar con- 
traction, or if it is not so modified, the filtering capacity 
of the capillary wall may be relatively lessened for the 
higher capillary pressures.* 

(16) Clinical Observation of the Intermediary Circulation. — 
The types of digestive waves just described (fig. 11 b and c) 

* It has been shown by experiments on nitration through animal 
membranes that " the quantity of nitrate rises with the pressure, but 
in lower ratio " (" Schafer's Text-book of Physiology," vol. i., p. 281), 
Increasing viscosity of the blood, produced by increasing capillary 
blood-pressure, may likewise retard nitration. Experiments have 
also demonstrated that a period of rest between two filtration experi- 
ments increases the permeability of the membrane (op. cit.). This 
fact may suggest that the rhythmical falls of the capillary blood- 
pressure, observed during the ebb of the lymph waves, and when 
digestion is at an end, will restore the capillary wall as a filtering 
membrane ; and that the alternating rise and fall of the capillary 
blood -pressure is the best possible arrangement for affecting filtration 
and for the recovery of the filter. 

Observation has shown that a comparatively limited rise of the 
blood-pressure, if persistent (e.g., 5 or 10 mm. Hg.), is of clinical 
importance in profoundly modifying the fluid exchange between the 
blood and the tissues. 



45 

are frequently met with in the clinical field. The waves which 
rise out of, and which subside into, a varying quantity of lymph 
are met with when the blood-pressure (arterial and capillary) 
is supernormal, as in chronic goutiness, &c. In this class 
of case the prominent features of the peripheral circulation 
are (a) a low venous pressure and (b) a raised capillary 
pressure. A persistent increase of resistance in the venules 
would account for these alterations in the circulation in 
chronic gout ; and this increased resistance may arise either 
from contraction of the muscular fibres of the venous radicles 
(see p. 8), or from obstruction to the flow of blood through 
them in consequence of an increase in tissue tension (tissue- 
lymph pressure.)* 

The volume of the lymph before a meal (a time when no 
lymph should be apparent), may be as large as it is at the 
acme of a normal lymph wave, or it may be even larger. 
The following typical example illustrates this fact and also 
shows the effect of treatment in restoring the zero point of 
lymph : — 





ist. obs. 


2nd. obs. 


3rd. obs. 


4th. obs. 






(6 days). 


(12 days). 


(18 days). 


Arterial press, mm. Hg. 


.. I45 . 


112 


IO4 


IOO 


Capillary press, mm. Hg. 


•• 35 • 


30-35 


25 . 


20-22 


Venous press, mm. Hg. 


15 . 


30 •• 


25 • 


20 


Percentage of lymph 


. . f27 • 


12 


4 • 


O 



All the observations in this case were of course made at 
a time of the day when in a normal state of the circulation 
the reading of lymph is nil. 

In all the cases of undoubted gout so far submitted to 
observation this obstructed form of the intermediary circula- 
tion has been found, but whether it will be invariably present 
in gout cannot at present be affirmed. It is conceivable that 



* Starling has found that ff a rise of tissue tension above the 
pressure of the veins causes collapse of these veins, a rise of capil- 
lary pressure, and a diminished flow of blood through the part." 
(Schafer's "Text-book of Physiology," vol. i., p. 307.) 

-j- The percentage of lymph was in this case exceptionally high, 
but in chronic goutiness readings of from 15 to 22 per cent, at the 
normal lymph-free periods of the day are not uncommon. 



46 

cases of gout may be met with in which tissue residua may 
lodge in the tissue-vacuoles in consequence of an imperfect 
interchange of fluid between them and the capillaries — the 
capillary blood-pressure being too low for the development 
of the normal lymph waves. 

AH the remedial measures which counteract chronic 
goutiness liberate the embarrassed peripheral circulation by 
reducing the increased venular resistance, and thus they 
secure a rise in the venous pressure, a fall in the capillary 
pressure, and a reduction in the exudation of tissue-lymph. 

When the obstructed intermediary circulation in gouty 
subjects is thus relieved and the normal flow and ebb of 
tissue-lymph is restored the general health is improved and 
the local manifestations of the gouty state as a rule either 
disappear or are lessened. 

In acute gout the condition of the blood, of the circulation 
and of the tissue-lymph circulation, has appeared to me to 
differ from that in chronic goutiness. For some years I have 
recognised, that when gout becomes acute, the blood-pressure 
falls and the density of the blood diminishes ; and this change 
in the blood-pressure and in the blood takes place rapidly. 
Since employing the method of measuring the tissue fluid, 
which enables one to ascertain with accuracy the density of 
blood in circulation, I have obtained some confirmation of 
this position — though my opportunities for observing this 
transition have so far been few. It would seem as if, when 
gout becomes acute, the embarrassment of the peripheral 
circulation, which characterises the chronic form of the 
disease, suddenly vanishes, and the fall of the capillary blood- 
pressure which ensues, suffices to secure complete absorption 
of the pent-up tissue fluid ; and then once more the normal 
flow and ebb of the lymph tides are established. If this be 
so it follows that whatever quickly lowers the capillary blood- 
pressure may precipitate an attack of gout ; and that, in 
consequence of the normal fluid exchange between the blood 
and the tissues being thus restored, the patient becomes less 
gouty — at any rate for a time. 



47 

A reduction in the systemic capillary pressure and a corre- 
sponding lessening in the volume and duration of the lymph 
waves is well illustrated, as a rule, in those cases in which 
there is drainage of blood into the splanchnic veins from loss 
of tone in the splanchnic arterioles (see p. 26). It has been 
observed that when this failure of lymph exudation is apparent 
that the application of pressure to the abdomen, either by 
means of a shot bag or by tightening an abdominal belt, will 
not only raise the arterial and capillary pressure, but will in 
five minutes create an ample flow of lymph. The following 
is an example of the temporary restoration of the normal 
lymph wave by applying a shot bag (14 lbs.) to the abdomen. 

Percentage of Tissue-lymph and Mean Arterial and Capillary 
Blood-pressure One Hour after a Meal. 

Before application Five min. after applica- 

of shot bag. tion of shot bag. 

Percentage of lymph . . 6 . . . . 15 

Mean arterial pressure mm. Hg. 106 . . . . 115 

Capillary pressure mm. Hg. . . 25 . . . . 35 

When in this case the splanchnic inadequacy was corrected, 

the digestive exudation of lymph into the systemic area was 

restored. 

One Hour after a Meal. 

Percentage of lymph .. .. .. .. 15 

Mean arterial pressure mm. Hg. . . . . . . 115 

Capillary pressure mm. Hg. . . . . . . 35 

Then the application of the shot bag no longer altered the 
blood-pressure, and improved systemic nutrition was indicated 
by a rise in weight and a gain in strength and well-being. 

(17) The bearing of the foregoing data on our views upon 
Gout and kindred ailments. — This inquiry has afforded me a 
convincing demonstration of the correctness of the generally 
entertained opinion, that goutiness primarily depends on the 
retention of some waste product or products — whether the 
materies morbi be specified as uric acid, or whether it be 
regarded as a group of residua. There may be differ- 
ences of opinion as to how gout originates — though light is 
dawning on this obscure point — but as to how it is main- 



4« 

tained when established my observations leave no doubt 
in my mind. They have shown that it is essentially 
dependent on a derangement of the intermediary circulation, 
and that, therefore, the tissues themselves form the arena in 
which gouty disturbances manifest themselves. Residua may 
accumulate and be deposited in the interstitial spaces of 
the tissues, because their removal is thwarted, either by 
an excessive capillary blood-pressure limiting the absorption 
of fluid from these spaces, or by a diminution of that pres- 
sure reducing the fluid exchange between the blood and the 
tissues. Hence the two leading types of gout which are well 
recognised. According to my observation, the continuous 
presence of a large quantity of tissue-lymph provides an 
important condition for the development of the local mani- 
festations of gout, which were present in by far the majority 
of the cases observed, and those few cases, in which local 
signs of gout had not so far declared themselves, might 
fairly said to be gouty — in the sense of potential gout. 

This inquiry is still in progress ; and the results it has 
already yielded afford some assurance that further experience 
of the method of observation on which it is founded will 
extend still more our knowledge of the intermediary circula- 
tion. Over one thousand observations in various cases have 
not only confirmed the conclusions formed during the experi- 
mental stage of the inquiry, but have considerably enlarged 
these conclusions.