f THE \ c 'ry of * HEALTH SCIENCES LIBRARY HOW TO FEEL THE PULSE AND "WHAT TO FEEL IN IT Works by the same Author. Price 21s. THE BRONCHI AND PULMONARY BLOOD- VESSELS. Their Anatomy and Nomenclature; with a criticism of Professor Aeby's views on the Bronchial Tree of Mammalia and of Man. With 20 Illustrations. J. & A. Churchill, London. 1889. Price 5s. 6d. CARDIAC OUTLINES FOR CLINICAL CLERKS AND PBACTITIONERS; and firat principles in the Physical Examination of the Heart ior the beginner. With upwards of 60 Illustrations. Intended as a Pocket Companion at the bedside. The Outlines are designed to illustrate the methods and the results of the examination of the heart in health and in disease, and to assist the student in recording his clinical observations. A supply of Thoracic and Cardiac Outlines (4^ \>x 3-J inches), on gummed paper, will be included in each copy. Bailli£re, Tixdall & Cox, London. 1892. [In the Press. HOW TO FEEL THE PULSE AND WHAT TO FEEL IN IT / PRACTICAL II IN IS FOR BEGIXXERS BY WILLIAM EWART, M.D. Cantab., F.R.C.P. PHYSICIAN TO ST. GEORGE'S HOSPITAL; CLINICAL LECTURER AND TEACHER OF PRACTICAL MEDICINE IN THE MEDICAL SCHOOL ; PHYSICIAN TO THE BELGRAVE HOSPITAL FOR CHILDREN; ADDITIONAL EXAMINER IN 1S91 FOR THE 3RD M.B. OF THE UNIVERSITY OF CAMBRIDGE; LATE ASSISTANT PHYSICIAN AND PATHOLOGIST TO THE BROMPTON HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST WITH TWELVE ILLUSTRATIONS NEW YORK WILLIAM WOOD & COMPANY 1892 \AU rights reserved] 74 /8U 2> I ^ TO WILLI A M W A D H A M M.D., F.B.C.F. CONSULTING PHYSICIAN TO ST. GEORGE'S HOSPITAL AND FOB MANY TEARS DEAN OF THE MEDICAL SCHOOL AND THE STUDENTS* FRIEND THIS LITTLE BOOK FOR STUDENTS IS GRATEFULLY INSCRIBED BV HIS CLINICAL PUPIL THE AUTHOR Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/howtofeelpulsewhOOewar PREFACE. The old-fashioned arfc of feeling the pulse holds its own in medical practice, although very scant notics has been taken of it in modern medical literature. On the subject of the Sphygmograph, the student has at his disposal many and excellent books, and this volume would have had no purpose had it attempted to follow the same lines. It is specially devoted to matters which are scarcely touched upon in most books on the Pulse ; but which are deemed of practical importance. It has been my aim to treat these in an elementary fashion, reserving for later publication merely theoretical or personal opinions. In spite of their imperfections these pages may perhaps be of service in directing the young student's attention to the oldest and not the least important of our methods of clinical study. I am much indebted to the editor of Gray's Anatomy, Mr. T. Pickering Pick, and to the publishers, Messrs. Longmans and Green, for their leave to use two viii PREFACE. plates from that work, and to Dr. Douglas Towell for his kind permission to reproduce his valuable diagrams of the pulse ; also to my nephew, Mr. P. de Vaumas, and to Dr. H. B. Grimsdale for their assistance in the production of the other illustrations ; and lastly, to my friend Mr. Godfrey Thrupp for his valuable help in revising the proofs. WILLIAM EWART. S3 Curzon Street, Mayfair, March 1S92. TABLE OF CONTENTS. Preface vii Introductory Remarks 1 CHAPTER I. THE PULSE AND THE PRACTICAL METHODS FOR ITS STUDY. The Pulse ; Circumstances and Situations favourable for its Detection .3 The visible pulse and the tangible pulse — Circumstances favouring or hindering the detection of arterial pulsation — Situations in which pulsation may be seen in lean subjects — The influence of position — Situations in which the arterial pulse may be felt in most subjects — The common pulses. The Mode of Feeling the Various Pulses .... 8 The Seats of Election for a Study of the Pulse. The Radial Artery; its Advantages 9 Description of the Practical Methods for the Study of the Pulse 10 The Method for Counting the Pulse . . . .10 Various sites for counting the pulse— Counting the pulse at the Carotid and at the Heart — Duration of the observa- tion — Preliminary precautions — Rules to be followed in counting the pulse. x TABLE OF CONTEXTS. TAGK The Method of Feeling the Pulse 14 I. General Rules relating to the Attitude of Body and Limb Attitude of the body — The observer's attitude — The patient's attitude — Attitude of the arm — Steadiness essen- tial ; how secured — Patient's arm supported by the observer — Muscular relaxation essential, in the observer, in the patient — Management of the patient's wrist — The attitude of the hand — "Which pulse to hold ? — Which hand to use ? — The attitude of the observer's hand — The superior and the inferior position of hand — The arrangement of the fingers and their relation to the wrist — The distal position and the proximal position of the index finger — The exact spot where the finger should be placed — The inclination of the fingers. II. Exploration of the Pulse .25 The degrees of pressure to be applied — How to regulate the pressure — The behaviour of the pulse under varying pressure — The manipulation or fingering of the pulse. IIT. Methods for rapidly finding the Pulsation of some other Arteries 20 How to find the beat of the Facial Artery ; of the Temporal ; of the Carotid ; of the Brachial. CHAPTEE II. ELEMENTARY NOTIONS ON THE PHYSIOLOGY OF THE PULSE. The Structure of Arteries. • 34 The Cardiac Systole and the Pulse-Wave . ^ . .35 Velocity of the pulse wave — Velocity of the blood stream — Length of the pulse-wave— The pulse-wave and the sphyg- mogram. TABLE OF CONTENTS. xl I'ii.i: Intra-arteiual Blood Pressure, and Peripheral Resist- ance 38 The mean arterial pressure ; the pulse curves and the re- spiratory undulations — Amount of the intra-arterial and intra- ventricular pressures — Amount of the intra-capillary, and of the intra-venous blood pressure. Arterial Tension 40 The artery as an elastic and contractile tube— Influence of varying calibre on arterial tension — Softness and hard- ness of pulse— Influence of elasticity on arterial tension. Dicrotism 42 The arterial foot jerk as a type of the sphygmograph. CHAPTER III. THE CHIEF QUALITIES AND VARIETIES OF THE NORMAL PULSE. Systematic Description of the Qualities of the Pulse 46 Large and small size, or volume of pulse — So-called fulness and emptiness of pulse — Strength and weakness of pulse — The artery during the interval between beats — Soft- ness and hardness of pulse — Swiftness and slowness of pulse ; or short or long duration of the pulse-wave. Frequency and Inprequency of Pulse ; or Pulse-Rate 51 Accelerating and retarding influences. I. The normal rate in the two sexes. II. Influence of age. III. ,, stature. IV. „ the hour of day V. „ sleep, and of the waking state. VI. ,, meals, and of fasting. xii TABLE OF CONTEXTS. VI L Influence of the quantity, and of the quality of food — alcohol, tea and coffee. VIII. „ tobacco-smoking. IX. „ muscular exercise, and of rest. X. ., posture. XI. ,, emotion. XII. .. variations in barometric pressure. XIII. ., ,, the external temperature. XIV. .. ,, ,, temperature of the body. CHAPTER IV. THE CHIEF ABNORMALITIES OF THE PULSE. PAGE The Variations eh Size 59 Unevenness of pulse — Periodic unevenness — Abortive beats — Xon-periodic unevenness — Linked beats — Differ- ence between linked beats and pulsus trigeminus and trige- minus — Combined unevenness and irregularity. The Vabxatiohs in Rhythm 62 Irregularity of pulse — Intermittence — Allorhythmia and Arhythmia — Intermittence at the wrist — The varieties of Rhythm in intermittence — Absolute Arhythmia — Classical varieties of uneven and irregular pulse known under special names — Pulsus paradoxus. The Incompeessible Pulse, So-called . . . .67 Arterial sclerosis — Calcification of the arterial wall. The Recueeext Pulse 60 Circulation by Anastomosis — Refluent radial pulse. TABLE OF CONTENTS. xiii CHAPTER V. ON THE SIX CHIEF MORBID PULSE TYPES ; AND ON THE METHODS OF TESTING PULSES AS TO TENSION. PAGK Preliminary Description of the Methods for Gauging Arterial Tension with the Finger . .72 I. The obliterating pressure — II. The test for successful obliteration — The elementary or "bimanual" method of testing the nature of the distal pulse — The <; one hand" method — III. The estimation of the pressure needed for complete obliteration of the pulse. I. The Pulse of high Arterial Tension— II. The Pulse of low Arterial Tension— III. The Pulse in- Mitral Regurgitation (not complicated with Cardiac Failure)— IV. The Pulse in Mitral Stenosis (not complicated with Heart Failure) 76-79 V. The Pulse of Aortic Regurgitation — Corrigan's Pulse, or Water-hammer Pulse . . .79 The tactile characters of Corrigan's pulse — Why the patient's hand is to be elevated in testing for this pulse — The visible characters of Corrigan's pulse — The progress of the wave (according to theory) — The artery between the beats (as observed)— Arterial elongation and tortuosity; the locomotor pulse. VI. The Pulse of Aortic Valvular Obstruction . . 83 CHAPTER VI. ASYNCHRONISM AND INEQUALITY OF THE PULSES. The Methods of Testing for Equality of Pulse-Beats, and for Identity of Pulse-Time at the Two Wrists 85 xiv TABLE OF CONTENTS. PAGE How to Test foe Equality of the Two Radial Pulses 85 The two best positions for the patient's hands — The two methods which the observer may adopt. How to Test foe Synchronism in the Two Pulses . 87 Check Observations Essential 89 CHAPTER VII. Capillary Pulsation 90 Elasticity and contractility of capillaries — Capillary pulsation normally absent — Pathological occurrence of capillary pulsation — The methods for detecting capillary pulsation: I. The "Tache" method; how to examine the tache for pulsation— II. The "lip" method— III. The "nail "method — Backward or regurgitant capillary pulsa- tion — Mode of distinguishing the backward from the onward capillary pulsation — Local throbbing. CHAPTER Till. VENOUS PULSATION. I. Venous Pulsation in General 97 Venous pulsation a tergo, a fronte — Their respective districts — True or direct, and false or communicated venous pulsation — How to tell one from the other — The onward venous pulsation and its causes — King's method of demon- strating venous pulsation — The backward or regurgitant pulse ; its causes. II. Pulsation in Particular Veins — Pulsation in the Jugulars and their Tributaries . ' . 101 Its limits — Backward jugular pulsation, and backward jugular rlow (or regurgitation} — Methods for ascertaining TABLE OF CONTENTS. xv I- U.K. the presence of reflux into the jugular vein — The subcostal pressure method — The presystolic and the systolic jugular pulsations Varying degree of jugular distension as affect- ing the pulsation — Inspection of the episternal notch and of the supra-clavicular fossa?. Backward Pulsation into the Inferior Vena Cava — Hepatic Pulsation— Hepatic Arterial Pulsa- tion 105 HOW TO FEEL THE PULSE AXD WHAT TO FEEL IX IT. INTRODUCTORY. The vast importance of the various features of the pulse was guessed by physicians long before the dis- covery of the circulation, but it has only been fully demonstrated within the memory of living men. It would be unfair to suppose that all the labour which was devoted to the pulse by our early predecessors in their numerous treatises (Galen alone wrote seven) had been wasted and barren in practical results, but the amount of definite information to be extracted from them is remarkably small and buried in a mass of extravagant assumption. All empty surmises have now been cleared away, and the clinical uses of the pulse narrowed down to substantial facts connected with it, which might be recorded in a few pages. But the value of these clinical facts, few as they may be, is in advance of anything dreamt of before, and is the result of vastly improved anatomical and pathological knowledge. It is already capable of demonstration by the instrumental methods of physiology, and we are rapidly approaching a stage when some of the qualities of the pulse will find a mathematical expression. A 2 HOW TO FEEL THE PULSE. Meanwhile, the pulse has still to be felt. But it is an operation of far greater importance to students of medicine nowadays than it was to those of long ago. Having much more definite objects in view in examin- ing the pulse, we should not be inferior to them in the attention bestowed upon the examination. Moreover, since all experimental results are dependent upon the conditions of the experiment, we should take care that, even in apparently so trivial an operation as feeling the pulse, we use the best available method ; in seeking for which we must be prepared to consider matters in some detail. The following are the subjects dealt with in this book, and their order : CHAPTER I. The pulse and the practical methods for its study. II. Elementary notions on the physiology of the pulse. III. The chief qualities and varieties of the normal pulse. IV. The chief abnormalities of the pulse. V. The six chief morbid pulse types. How to test the pulse as to tension. VI. Asynchronism and inequality of the pulses. VII. Capillary pulsation. VIII. Venous pulsation. The matter having been arranged in short paragraphs with special headings, an index has not been deemed necessary ; but a short glossary of the terms used formerly, and at the present time, has been appended. CHAPTER I THE PULSE AXD THE PRACTICAL METHODS FOP ITS STUDY. THE PULSE : CIRCUMSTANCES AND SITUATIONS FAVOURABLE FOR ITS DETECTION. The Visible Pulse and the Tangible Pulse. In common language " pulse " is synonymous with the pulsation at the wrist. But accuracy demands the prefix of " radial " to this particular pulse as there are various situations in which arterial pulsation can be seen as well as felt ; while in others it can be felt, though not seen. When we speak of the pulsation being visible or palpable, we do not always mean that the pulse is easily seen or easily felt. Sometimes pulsa- tion is quite obvious and even obtrusive, but, as a rule, we have to look very closely for any evidence of move- ment in the situations where the pulse is stated to be visible ; and in the same manner we must feel and feel again before we may safely say that we are unable to discover pulsation where pulsation should be felt. Circumstances Favouring or Hindering the Detection of Arterial Pulsation. No device except position, a good light, and the me of a lens, can help the eye in perceiving the pulsation of 4 HOW TO FEEL THE PULSE an artery if feeble. Palpation, on the other hand, is much assisted by a little knowledge and previous practice. Independently, moreover, of personal experi- ence, there are definite conditions assisting, and others that hinder, success in the finger's search for the pulse. This is amply borne out by the experience of surgeous in various operations by which vessels are laid bare, and especially in those where an artery has to be found and tied. The operator, after exposing the vessel and whilst able to touch it, may be left in doubt as to its identity, or may even mistake it for some similar structure, ' ' because unable to feel in it any pulsation." Yet, before the operation, the vessel may have been felt to 'pulsate when pressed against lone or muscle. Similarly, if the various arteries which are easily accessible to the touch be explored, it will be found that some pulsate much more distinctly and others less so ; that those arteries which are supported by a firmer back-ground pulsate more powerfully than others ; and, lastly, that pulsation is most strongly felt in those which are in proximity with bone. On the other hand, we shall become acquainted with arteries so superficially placed between thin skin and hard bone immediately underlying the skin, that the finger almost inevitably obliterates them in the attempt to feel their pulsation. Arteries thus situated do not afford very good opportunities for palpation, in spite of their superficial position. In conclusion, the favourable conditions are : (1) fair size of the artery ; (2) superficial course ; (3) a covering of thin shin; (4) a supporting surface of muscle, cartilage, dense fascia, or bone (note exception which follows). AND WHAT TO FEEL IN IT. 5 The unfavourable conditions are : the reverse of the preceding ; and, in addition, — immediate contact of an artery with underlying bone, especially if the skin (as over the temple) be tightly stretched over the bone. Bony contact becomes then relatively a disadvantage. I. Situations in which Pulsation may be Seen in Lean Subjects. In the young, even when spare, and especially in children, the arterial pulses are hardly ever visible. At most, it may be possible to perceive the beat of the radial. In. old 'people, and especially in those of lean habit, several of the arteries will be seen to pulsate. This is due to the atrophy of muscles and of other tissues, or to the senile dilatation and elongation of the arteries, or to a combination of both. The subjects of aortic regurgitation afford specially favourable opportunities, their pulsations being of exaggerated type, and their arteries large, whilst the patients themselves are generally thin. Taking, then, the most favoitrablc sidy'cct, a lean man, advanced in years, and suffering from aortic valvular incompetence, the following arteries would probably be seen to beat : — The temporal artery. The anterior and the posterior temporals* The angular. The faded. Sometimes the transverse facial. Sometimes the superior and inferior ccronaries (at their origin). 6 HOW TO FEEL THE PULSE The occipital (in cases of baldness). The external carotid. Tin: common carotid, Sometimes the subclavian. , Sometimes the innominate. The long thoracic. The axillary. TJir brachial (especially near the lend of the elbov). The radial. The ulnar. The dorsalis indicis. Sometimes the abdominal aorta. The femoral (in the upper part of Scarpa } s triangle). Sometimes the inferior external articular. Sometimes the malleolar branches. Sometimes the anterior peroneal. The dorsalis pedis. In addition, pulsation may be seen in sundry small subcutaneous arteries, and, with the ophthalmoscope, (in cases of aortic reflux, of glaucoma, and sometimes in Graves 1 disease) in the retinal arteries. The Influence of Position. In the case of several of the arteries enumerated above, the ease with which pulsation may be per- ceived varies with the position of the patient or of the limb. As special instances should be mentioned, the radial at the wrist, whose beat is favoured by very slight flexion, or at least by the absence of extension ; the vlnar, whose pulsation may be visible, in slight extension only ; and especially the brachial, which becomes curved into a prominent loop above the fold of the elbow when the limb is flexed. AND WHAT TO FEEL IN IT. 7 II. Situations in which the Arterial Pulse may re Felt in most Surjects. With the exception of the smaller arteries, which are more easily seen than felt by the average observer, pulsation is perceptible to the finger in all arteries in which it is observed by the eye. It is unnecessary to repeat here the list previously given, which applies to the special combination of senility and of emaciation with cardiac disease. It was stated that during health, and in the young and sleek, the number of visibly pulsating arteries would be very small. This is not the case with the pulse as felt. In adults, even when presenting fairly thick integuments, the beat of the following arteries may usually be made out on palpation : — The temporal artery. The anterior and posterior temporals. The occipital. The facial. The superior and inferior coronaries. The external carotid. The common carotid. The subclavian. The innominate. The axillary. The brachicd (in its entire course). The radial. The ulnar {with difficulty). Sometimes the princeps pollicis and the digitals (as a general pulsation of the pidp). The abdominal aorta. 8 HOW TO FEEL THE PULSE The external iliac. The femoral (in the upper half the thigh). The popliteal {in the lower part of the popliteal space). The posterior tibial (at the ankle-joint). Sometimes the anterior peroneal. The anterior tibial (just above the ankle). The dor sails pedis In special cases, the thyroids (as a general pulsation). The Common Pulses. Of this long series of arterial pulses five only are utilised in every- day medical practice : — The temporal, The faded, TJie external carotid. The brachial, The radial. III. The Mode of Feeling the various Pulses. The mode of feeling the radial pulse will be pre- sently described at some length, and the best way of finding the other four will be thereafter briefly in- dicated. Among the remaining pulses that of the eoronaries may be felt from the outside, against the teeth as a background ; but better from the inside, by grasping the thickness of the lip between two lingers. The innominate and the subclavian beats will be felt by deeply plunging the finger into the cpisterncd notch and into the supra-clavicular fossa respectively. The beat of the subclavian is best felt where the AND WHAT TO FEEL IX IT. 9 vessel lies on the surface of the first rib. That of the innominate is not readily, except in special case?, dis- tinguishable from the strong impulse of the arch of the aorta communicated upwards. In order to perceive the axillary pulsation the arm must be raised. The vessel can then be felt beating between the finger and the head of the humerus. For the detection of the external iliac deep pres- sure must be made into the pelvis above Poupart's ligament. Rather strong pressure is also required in the case of the femoral, if the thigh be muscular or very fat. The femur forms the background. The popliteal pulse is more readily perceived when partial flexion has relaxed the tension of the powerful muscles among which the artery lies concealed. The easiest way to feel the posterior tibial heat is to place the flat of the finger (whole length) in a vertical direction just behind the inner malleolus. Soft pri ssure of the phalanx against the os calcis will suffice. The dorsalis pedis is readily felt pulsating when the finger is applied across the upper part of the arch of the foot. Here again the pressure should be soft, and the flat of the finger should be used. IV. The Seats of Election for a Study of the Pulse. The Radial Artery; its Advantages. In most of the situations enumerated above, although the pulse may be recognised, it lies too deep to be successfully studied. For this purpose the seats of election are the face for the temporal and the facial arteries, the arm for the brachial, and the wrist for ic HOW TO FEEL THE PULSE the radial. The first two vessels are almost too super- ficial. The radial, besides being much larger, possesses great advantages over them ; and over the brachial, it has that of personal convenience. (1) The radial presents to perfection those ana- tomical conditions which were described on page p. 4 as rendering pulsation easy to feel. It is superficial, and it is backed by a bony plane. But it is not in imme- diate contact with bone at that part where the pulse is felt : although, nearer the wrist-joint, it lies on the styloid process, in close contact with its surface. ( 2 ) Another great advantage of the radial is the considerable length (quite three inches) over which it is accessible to the touch. This enables the observer to feel the pulse with three or even four fingers. DESCRIPTION OF THE PRACTICAL METHODS FOR THE STUDY OF THE PULSE. I. The Method of Coubtdtg the Pulse. The pulsating artery having been found, the next thing (because the easiest) is to count its beat. This is quite distinct from the operation of " feeling the pulse." which is an active and rather difficult inquiry. Here the touch is almost entirely passive. The points requiring attention are : — (1) To keep touch with the pulse by a gentle pressure, so that none of the beats are lost to the finger ; AND WHAT TO FEEL IX IT, i r £>tiT!Tftfla2< fatmcA cf Vlnm The Radial and Ulnar Arteries at the Wrist and the Superficial Palmar Arch. [From Gray's "Anatomy," by permission.) 12 HOW TO FEEL THE PULSE (2) To moderate the pressure of the finger, so that none of the beats are suppressed by it ; (3) To avoid mistaking the pulse-beat of the finger for that of the patient's radial artery. It is chiefly owing to the reality of this source of confusion that counting the pulse with the thumb has been con- demned by authors ; the beat of the princeps pollieis arteries being larger than that of the digitals, and rather more liable to be felt during the operation. Various Sites for Counting the Pulse. For a simple determination of the pulse-rate we are not limited to the radial artery; any artery will serve which, being superficial, is of sufficient size to enable us to securely feel the beat. An opportunity often occurs of counting the pulse without awaking a sleeping patient, by lightly feeling the temporal artery where it crosses the zygomatic process. This method is espe- cially useful in children. It is indispensable in cases of great restlessness and of delirium, and in chorea, where the arms are violently thrown about. It is also indispensable to the anaesthetist. Counting the Pulse at the Carotid and at the Heart. In the foregoing remarks it has been assumed that each systolic wave reached the periphery ; but in ex- haustion and in cardiac disease this is not always the case, and our observation must be a direct' one — viz., by palpation or auscultation of the apex beat, after the method used in cases of apparent death for de- termining whether life is or is not extinct. Whenever AND WHAT TO FEEL IX IT. 13 the pulse has been taken at tit*: heart, let the fact be noted. It may sometimes be convenient to take the pulse of the carotid artery (see p. 33) if the wrists are not available or their pulse too weak, but especially during auscultation of the heart, when the first sound has to be timed from an artery as little distant from the heart as possible. In some diseases this beat is so prominent that the pulse may be counted hy sight and without touching the patient. The same facility is also presented by the heart itself when the apex-beat is visible. Duration of the Observation. Although the clinical unit of time is the minute, our observations are, in practice, limited to fractions of a minute. Hence the necessity for a watch beating the second. A pulse beating regularly may be safely •• taken " in fifteen seconds, less accurately in ten. An irregular, and especially an intermittent pulse, requires an observation lasting at least thirty seconds. In cases of unusual slowness or rapidity, it is well to make two separate observations of half a minute each, and to take the mean. The frequency of any inter- missions, linked beats, or small beats, should be ascer- tained by separate observations. Preliminary Precautions. Since the pulse-rate varies with movement, change of posture, emotion, thought, and speech, it is well that the patient should be at rest, supine, silent, and unexcited. If sitting or standing, or if asleep, the fact should be noted. It will often save time to count the pulse before the patient has moved or spoken ; but i 4 HOW TO FEEL THE PULSE with some, who are nervous, the physician's approach is enough to cause excitement, and with them a later count would probably be more reliable. Where the pulse is very rapid, weak, or irregular, considerable delicacy of touch — i.e., considerable atten- tion — may be required for its detection. Rules to be followed in Counting the Pulse. Rule I. — Determine the member of heats in fifteen seconds, and, multiplying that by four, record the rate per minute. Rule II. — If the pidse should be irregular in rhythm, count for thirty seconds, or else for two separate periods of fifteen seconds. Rule III. — If the pidse should be very small or very slow, or faltering, count at the heart and record the fact. It is usefid in these cases to record also the rate found at the wrist. Rule IV. — Whenever possible, let the patient be re- clining. If not in bed, let him be seated. Rule V. — The patient should be silent and still, a nd judgment must be used in selecting a moment when no excitement prevails. II. The Method of " Feeling the Pulse." I. General Eules relating to the Attitude of Body and Limb. The operation of " feeling" or "trying" the pulse must always be kept separate from the operation of "taking" the pulse. It claims the whole mind. Simple and purely mechanical in appearance, it is a AND WHAT TO FEEL IN IT. 15 combined effort of some of the higher functions, and requires skill in manipulation, keenness in observation, and other qualities which wait upon long practice and experience. Moreover, the data obtainable are mean- ingless apart from a knowledge of physiology and pathology. That which has previously been said in this con- nection under the heading of counting the pulse applies here also, and need not be stated afresh. In all things success is largely dependent upon attention to small matters ; and details such as the patient's attitude and that of the observer have their importance. The work of the draughtsman, of the musician, of the various artists and artisans is severally performed to greatest advantage in certain positions of the body, of the arm and of the hand. Of percussion the same is true and it is also true of feeling the pulse, where the touch has to be brought to bear with great delicacy. In most of the instances quoted movements of vaiying difficulties have to be performed. In this case it is the absence of movement that needs to be secured. Attitude of the Body. (l) The Observer's Attitude. Attitude is of importance, because it facilitates, on the part of the observer, the appreciation of the pulse ; and because in the case of the patient it influences the pulse itself. For the observer almost any attitude may be made to answer so long as freedom from effort, and firmness are ensured. Certain things are nevertheless to be avoided. Too great a distance from the patient will necessitate stretching the arm : this is unfavourable. Unsteadiness of muscle will be greater in proportion to any fatigue ; 16 HOW TO FEEL THE PULSE — therefore if in the least tired the observer should be seated ; the body no longer needing to support itself, muscular work and reflex nervous work are thereby spared. (2) The Patient's Attitude. Many patients are aware that their pulse is influenced by position. A fortiori should the observer not lose sight of the physiological variations. It is normal for the pulse to become more powerful and rapid when the reclining posture is exchanged for the sitting or espe- cially for the standing position ; in feeble invalids, and even in nervous and weak persons, this difference may become considerable. Moreover, putting aside the direct influence thus exerted on the pulse, the patient's atti- tude may have some bearing on the success of the operation of feeling the pulse. In the case of bedridden invalids the supine position is the most natural and the best because the most supported. When not bedridden, it is desirable to cause the patient to sit dovn if previously standing. This will afford the student an opportunity of verifying for himself the accuracy of the statements made as regards variations of the pulse in changing position. Bearing all this in mind, it is well to establish for oneself a rule to take pulse observations on patients either in the supine or in the sitting position. If this practice should be occasionally departed from, a special note should be made of the fact. Attitude of the Arm. Steadiness Essential ; how Secured. Adequate support is essential for the observer's arm as well as for the patient's arm. AND WHAT TO FEEL IX IT. 17 (!) 7" 'a arm is liable to oscillations arising from the heart's action. The less the support, so much the greater the instability from this cause. This is a first reason why the pulse should not be felt at arm's length. Again, for the same reason, accuracy of obser- vation is out of the question under the influence of car- diac excitement from whatever cause ; or during breath- lessness induced by a rapid ascent. In practice the observer's arm most frequently seeks support on the bed, or on the table ; but failing any mechanical sup- port the upper arm should be gently steadied against the chest, allowing free play to the movements of the elbow and of the wrist. (2) The patient's arm. Support in this case is yet more important, not only for the sake of steadiness, but because it often affords the simplest means fcr ensuring absolute relaxation of the muscles (see p. 19). The best plan, whenever manageable, is to cause the entire fore-arm and the hand to rest with their ulnar border 071 I tabic, the hand falling over in very slight pronation, so as to bear on the semiflexed joints of the 4th and 5th fingers. Patient's Arm supported by the Observer. Effectual support may be often afforded, according to another method, to the arm both of the patient and of the observer. The patient's left fore-arm is received on the observer's left hand and arm, so as to be sup- ported almost in its entire length, whilst the observer's left elbow is steadied against the side of the chest. O Again, when the pulse has to be felt under difficulties, for instance from a slight distance, or across the bed, as sometimes happens to the student in a crowded clinical B IS HOW TO FEEL THE PULSE class, the observer's grasp of the patient's wrist may both give and take a measure of support. In an attitude such as this the larger muscles come into play and much delicacy of touch cannot be expected. An observation taken under conditions so adverse cannot be a good one, though it may not be absolutely worthless. Muscular Relaxation Essential. (1) In the Observer. The first requisite for fine sensory appreciation is freedom from muscular strain. Any performance requiring skill is rendered difficult to beginners by misplaced energy. Their good intentions run into physical force. Yet of the latter very little is really needed. In this special case, as the words " feeling the pulse " imply, we are dealing with a sensory rather than a muscular function. Adequate support may be said to be the cure for the muscular anxiety of all beginners. This is one of the chief reasons why any delicate work, be it of the hands as in fine dissection, or of the eye as in micro- scopic work, or of the ear as in auscultation, demands a firm basis. An excellent instance in point is afforded by the patient's strain, to which we shall presently refer. (2) In the Patient — Management of the Patient's Wrist. The chief difficulty arises in many cases from the nimia diligentia of the too willing patient. Com- plete muscular relaxation is needed : fik'st, because muscular effort affects the pulse (a source of error which might be overlooked) ; secondly, because, under effort, the leaders will stand out at the wrist, AND WHAT TO FEEL IN IT. 19 placing the radial artery out of reach. Among hospital patients the student will recognise two types differing in the presence or in the absence of energy. The feeble and timid subjects usually allow the hand to lie on the bed ; this is generally the case with female patients. Even they, however, if nervous, will involuntarily raise the wrist in opposition to our purpose, though they may allow the elbow to rest supported on the bed. On the other hand, the rough working man almost always presents his wrist, that is, raises his arm and stiffens his powerful muscles in moderate supination. To such wrists the employment of any force is worse than useless ; it will only aggravate the tension. The quickest method is to seemingly give up our attempt, to drop the stiffened arm, and to refuse it again if it be raised from the bed. When the patient has at last allowed the hand to remain at rest, the wrist is to be clasped with great gentleness by the observer's hand, whose fingers are then applied to the pulse. At the same time the thumb glides softly from the back of the radius to the back of the carpus, where a gradual and light pressure will almost at once succeed in fully flexing the wrist. This being effected, the spasm of the whole limb relaxes and the pulse is under control. The Attitude of the Hand. Before proceeding further we have two questions to consider : (A) Which Pulse to hold? As a constant rule that of the opposite side to that of the hand which feels. This is the only method which the learner can conveniently practise on himself. It 20 HOW TO FEEL THE PULSE may, however, be desirable to check the results of one position by those of the reverse one ; and to feel the patient's left pulse with the left hand and his right pulse with the right hand, in addition to the previous experiment. (B) Which Hand to Use? It matters very little whether the right hand or the left hand be used. There is obvious advantage in training both if possible. Most observers however will fall into a one-sided habit, which probably will enable them to secure greater delicacy of touch at the expense of a little freedom. This may have the advantage that the untrained hand can be brought to bear in cases of doubt, and, like the consultant's opinion, add new light through its comparative strangeness to the case. The Attitude of the Observer's Hand. Here, also, as far as the hand is concerned, the best position is depicted in the illustration. As previously stated, the observer's right hand should hold the patient's left pulse and vice versd. It will be noticed that the observer's thumb is applied to the bach of the lower end of the radius : this arches his wrist and raises the second phalanx from the patient's wrist. A modification of the same method consists in pass* ing the thumb round the wrist in such a manner that its extremity faces that of the fingers ; or the thumb remaining unemployed over the back of the metacarpus, the ball of the thumb and of the little finger may be pressed against the back of the ulna. In both these methods the hand encircles the wrist, and the last AND WHAT TO FEEL IX IT. 21 phalanx bears, not with its tip. but with its entire length, on the region of the radial beat. Fig. 2. The " Superi ition of hand to be adopted in feeling the pulse. In this illustration the index finger alone is show the act of feeling. The median and annular fingers are engaged in compressing the artery. Although it is best to adopt the hand position first named, it is desirable for the beginner to try every 22 HOW TO FEEL THE PULSE variety of position ; and it is good at any time to test doubtful results by another method. The "Superior" and the "Inferior" Position of the Hand. When feeling his own pulse the student will observe that his finger tips may be made to approach it either Fig. 3. The "Inferior" Position of hand. — The right hand is, in this illustration, applied to the left wrist (as when the observer is taking his own pulse). If, however, the patient's right pulse be felt with the right hand, the index finger will then occupy the usual position, near the wrist. The fingers are shewn with the flat of the pulp applied to the artery, in the position most favourable for feeling the pulse. with the palm of the hand turned upwards — or with the palm turned downwards. The position which has been described (see Fig. 2) represents the first of these AND WHAT TO FEEL IX IT. 23 two methods. I am in the habit of terming this the u Superior " the other being the "Inferior" method (see Fig. 3). These names have reference to the rela- tion of the fingers to the outer border of the radius. The superior position is the one to be adopted in all rases by the student, except (for convenience) when trying his own pulse. The Arrangement of the Fingers, and their Relation to the Wrist. The simplest case, in which one finger only is applied to the pulse, requires no special description. Most observers prefer to use two or even three fingers. It is to this case that our remarks specially apply. The Distal Position and the Proximal Position of the Index Finger. (1) If we imagine that the observer's right hand is feeling the patient's left radial pulse from above, whilst his thumb rests on the back of the wrist, the employed fingers will be arranged in the following order: — The index nearest the patient's hand; the median, in an intermediate position; the annular nearest the heart. The same arrangement will prevail if the observer's left hand tries the patient's right pulse. ( 2 ) If, on the contrary, the right pulse be felt from above by the observer's right hand, the situation of the fingers will be reversed — viz., the index will be nearest the heart ; and the annular, nearest the hand. The second arrangement is preferred by some. But the first arrangement has the support of considerable antiquity and appears to be not less excellent. It is 24 HOW TO FEEL THE PULSE decidedly more convenient in controlling a stiff wrist, (see p. 19). Beyond this there is really no superiority, worth arguing here, of one over the other method. On the other hand, the advantage to be obtained from uniformity in the method will repay us for strictly adhering to one or the other plan. Let it be understood that the foregoing refers ex- clusively to the "superior method," which alone is recommended to the beginner for reasons which need not be set forth at length. The Exact Spot where the Finger should be Placed. The distal finger, whichever it be, should be placed on the artery immediately above the base of the styloid process of the radius. The other two fingers (if three be used) would be arranged in loose contact with each other. For the special purpose of estimating tension it is desirable to separate the two centrally placed lingers by an interval from that more distally placed (see Fig. 2), To this arrangement reference will be made later on. The Inclination of the Fingers. The direction of the distal phalanges as they rest on the pulse claims a moment's attention. According as the hand and fingers are more or less arched above the wrist, the last phalanx of each finger will be more or less vertically applied to the long axis of the radius and of the artery. The absolutely perpendicular position (see Figs. -1, 5, G) is not desirable unless it have for its object the occlusion of the artery by pressure. For the 'purpose of fine feeling a slight inclination {obliquity) of the phalanx is desirable. This brings a very sensi- AND WHAT TO FEEL IX IT. 25 tive portion of the pulp (not that nearest the nail) to bear on the artery, namely, that portion which generally meets the pulp of the thumb in the simple movement of opposition. This portion seems specially adapted for such tactile explorations as require to be combined with slight pressure ; whereas at the ex- treme tip of the pulp there exists, it is true, yet greater delicacy of surface-touch, but one easily blunted by the slightest pressure. II. The Exploration of the Pulse. The fingers having been securely placed over the beating artery the exploration of the pulse begins. This consists A. of the application of a varying amount ofpres to the artery ; B. of a careful notice of the behaviour of the pulse under each degree of pressure : C. of a manipulation (or "fingering") of the pulse. A. The Degrees of Pressure to be Applied. The amount of pressure may of course be varied almost indefinitely ; but there are three degrees which it is convenient to single out from the rest, namelv. 1. Tlie lightest possible touch of the finger; 2. The medium pressure. 3. The obliterating pressure. These three varieties are shown in the accompanying illustrations (taken from Dr. Douglas Powell's dia- gram), which do not however depict the proper attitude of the fingers, but simply the effect of their pressure on the artery. 26 HOW TO FEEL THE PULSE Fh.. 4. Shewing light pressure. In Fig. 4 there is bare contact between the finger and the artery. The latter is felt, but is not compressed. Very little pulsation is perceived. Fin. Shaving medium pressure. In Fig. 5 the finger is applied with moderate force, and the diameter of the artery at that spot is reduced by one-third, to one- half. It is this degree of pressure which yields the maximum sensation of arterial beat. Fig. 6 Shewing forcible pressure. In Fig. 6 the finger bearing upon the artery has flattened it. AND WHAT TO FEEL IN IT. 27 The deep pressure is made with the object of ascer- taining the atnovnt of force, or the weight, which will completely abolish pulsation. This is one of the most important parts of a systematic exploration of the pulse. The force required in order to extinguish the pulse will be found to vary within very wide limits in different individuals, and at different times. We shall see later on that a combination of deep and of medium pressure is to be employed whenever we desire to ascertain that the obliterating pressure exerted by one or by two fingers has effected its purpose. In this case the other finger is pressed moderately firmly at a point nearer the wrist, in search of any vestige of pulsation, as shown in Fig. 2. How to Regulate the Pressure. Of the three degrees of pressure the third alone represents a definite result ; it is a procedure requiring strength rather than skill. The other two degrees cannot be defined with precision (since they must vary with each individual strength of pulse), but must be left to personal judgment and experience. To those gifted with delicate touch, or trained to artistic pursuits, any suggestions are almost superfluous ; but some beginners will find assistance in the following hints : 1. On first applying the fingers exert rather firm pressure, so as thoroughly to feel the beat ; 2. Almost immediately relax the pressure, but let this be done gradually so that the finger is gently raised by the artery or would even seem to lift the artery with it ; 3. By degrees reduce the pressure to the utmost, so that bare contact remains with the skin covering the 28 HOW TO FEEL THE PULSE artery. This is the first degree. After observing the pulse at this stage, i. Proceed now to use active exploring pressure and determine the amount which gives the maximum pulsation. This is the second or medium degree ; 5. Lastly gauge the resistance of the pulse by using as much pressure as will obliterate the artery. X.B. — A quick and most practical way of gain nig an idea of the procedure to be followed) consists in getting in succession two or three senior fellow-students to fed one's own pulse. The different sensations conveyed to the wrist by different observers will be more suggestive than the most elaborate descriptions. B. The Behaviour of the Pulse under Varying Pressures. This is the tale which each artery under observa- tion must tell for itself. The special points which have to be appreciated and described are indicated in Chapter II. C. The Manipulation, or " Fingering," of the Pulse. Hitherto the fingers have been stationary, and the presence or absence, the degree or quality, of the arterial beats have been their object of study. The present heading refers to a separate inquiry, in con- ducting which, movements of the fingers must be combined with their tactile function. It is no longer the pulse- beat alone, but also the artery itself, during the interval between the beats, or whilst obliterated by pressure, which comes under observation. Arteries differ greatly in their shape, size, and other qualities, as will be seen hereafter (see p. 58). Some of their changes being of much importance, we should avail ourselves of the AND WHAT TO FEBL IX IT. 29 information concerning them which may be gained by the two simple movements of the fingers about to be described : A gliding or rubbing movement across the axis of the arti ry. A similar movement conducted along the course of the it I . By the first we learn whether the artery has much or little thickness, hardness and elasticity. By the second we are informed as to the degree of smoothness, of straight ness, or of tortuosity; and the elasticity of the vessel is further tested. In addition to this form of manipulation, which addresses itself to the arterial walls, there is a finer fingering of the pulse itself of which the systematic pressure applied to the artery is but the coarser mode. It can be more easily hinted at than described. It is a touch which tests the qualities of the pulse through and through, sometimes playing at the surface, some- times sounding as it were the depth of the arterial stream, sometimes bearing with full weight against the force of the pulse wave, sometimes pursuing it in its fall and floating up with its rise, a touch as soft and as keen as that of the blind, — in short a touch with a mind in it. METHODS FOR RAPIDLY FINDING THE PULSA- TIONS OF SOME OTHER ARTERIES. HOW TO FIND THE BEAT OF THE FACIAL AfiTERY, In this case the distal phalanx (with nail downwards) is brought to bear from above and from the front 30 HOW TO FEEL THE PULSE against the rounded border of the patient's inferior maxilla, immediately anterior to the masseter muscle. Firm pressure must be made at first, which will cause the edge of the bone, and perhaps the arterial groove, to be felt. Pressure is then relaxed so that the ringer remains only in distant touch with the bone, and lies with hardly any weight on the skin. The arterial beat will at once be perceived. The facility with which this artery is obliterated is very great ; indeed it is more apt than the temporal to be unintentionally compressed because although the skin is thicker and better provided with subcutaneous fat, the artery itself, lying in a groove, is in hard bony contact for almost half its circumference. The artery, as it lies in a loose curve over the slightly convex horizontal surface of the bone, in the angle formed by the masseter and the buccinator muscles, affords an excellent opportunity for some pulse observations. How to Find the Beat of the Temporal Artery. It is often necessary to find this beat quickly in an emergency, or during the administration of anaesthetics. Every student should be trained to do this successfully; and with that view the following directions will be found useful. (1) Whilst you stand behiud the patient's head, or at his side, approach the zygomatic process from below with the pulp of the median finger turned upwards. The finger is to be gently pressed between the condyle of the jaw below, and the zygoma, the side of the finger just touching the tragus. Having made firm pressure so as to feel the border of the bone, gradually AND WHAT TO FEEL JN IT. 31 reduce the pressure so that the bone is only distantly- felt. At this sta^e the artery will probably be detected. This is the inferior method. Fig. 7. J .Vaifc Illustrating the anatomy of the External Carotid, Temporal, Anterior and Posterior Temporal, Facial, Transverse Facial, Coronary, Angular and Occipital Arteries ; and the situations in which their pulsations may be felt. {From Grays "Anatomy," by permission.) 32 HOW TO FEEL THE PULSE (2) Exactly analogous is the superior method which finds the artery as it crosses the upper edge of the zygo- matic process. In this case additional facility is given by the fact that the further course of the artery is superficial, and easily felt. Fro. 8. Maiiai Ilcczrrciie. Illustrating the course of the Brachial Artery at the bend of the elbow. {From Gray's "Anatomy" by permission.') Either of these two methods is to be preferred to the attempt to feel the arteiy on the dorsum or surface of the zygoma. Here a very nice adjustment of pres- sure is necessary. The artery, being quite superficial and immediately backed by bone without any padding, is readily obliterated in the effort to find it. AND WHAT TO FEEL IN IT. 33 HOW TO FIND THE CAROTID BEAT. The pulsation of the common carotid will be found with great ease, on pressing the tip of the finger back- wards towards the spine, at or above the level of the cricoid cartilage, and close to its side. The line passing from the horn of the hyoid bone to the tragus roughly corresponds to the course of the external carotid^ the beat of which is readily felt, although the pressure of the finger is not opposed by any bony surface. HOW TO FIND THE BRACHIAL PULSE. Unusually good, and in some ways unique, oppor- tunities for studying the pulse are afforded by the brachial artery. The procedure is so simple that it hardly calls for a special description. The artery is accessible along the entire leDgth of the upper arm. The tip of the finger is thrust under the biceps from its inner side, so as gently to lift the muscle with the dorsum of the phalanx, whilst the pulp exerts pressure on the artery and on the humerus behind the artery. CHAPTER II. ELEMENTARY NOTIONS OX THE PHYSIOLOGY OF THE PULSE. In tliis chapter it is proposed very briefly to consider the following subjects for study : — The Structure of Arteries. The Pulse -wave. The Intra-arterial Blood-pressure. The Arterial Tension. The Structure of Arteries. All arteries agree in possessing — (1 ) An epithelioid membrane supported by an clastic membrana propria. This is the tunica intima. (2) A more or less spirally arranged layer of plain muscular fibres, supported by a connective-tissue layer. This is the tunica media. (3) A connective-tissut membrane, consisting mainly of longitudinal bundles and of a varying proportion of elastic fibres. This is the tunica externa, which is continuous with the connective tissue surrounding the artery. In the larger arteries (as such we may reckon the radial) the tunica intima possesses a much thicker mem- brana propria, described, owing to the cribriform arrange- ment of its elements, as fenestrated membrane; and this membrane, when free from distending pressure, falls HOW TO FEEL THE PULSE. 35 into longitudinal wrinkles, seen in transverse sections as festoons. The media is thick, and consists of alternating mus- cular and elastic planes united by a small quantity of white connective tissue. The arrangement of the muscular fibres is circular ; that of the elastic elements chiefly longitudinal. The externa contains, besides connective tissue, a quantity of elastic fibres and a few plain muscular fibres. The arrangement is chiefly longitudinal. The nutrient vessels and the nerves ramify in the externa and penetrate into the media, but not, so far as known, into the intima. The larger arteries generally possess in addition a tough fibrous sheath containing but little elastic tissue. The Cardiac Systole and the Pulse- wave. The systolic charge of the left ventricle, in the adult, is 6 oz. or may vary from 3 to 5 oz. This amount is at each beat of the heart injected with powerful effort into the aorta. The latter, already containing blood, opposes some resistance to the raising of the semilunar valves. The rising intra-ventricular pressure soon disposes of this obstacle and of the resistance offered to further distension by the aortic coats themselves ; and a powerful spasm empties the heart. Two events occur in the arterial system as a result of the systole of the left ventricle : (1) The aortic contents are increased, and the aortic stream accelerated; and (2) A wave of pressure is sent through the whole arterial system. Inasmuch as the healthy arterial coats are yielding, the wave of increased pressure produces a wave of 36 HOW TO FEEL THE PULSE dilatation of the arterial walls, visible to the naked eye, and appreciable to the touch. The pulse as it is felt at the wrist is connected with the passage of this wave. Velocity of the Pulse-wave. The velocity of the wave is influenced by various circumstances, but, at its lowest, is still very great (it varies from 16*5 to 33 feet per second). Velocity of the Blood-stream. Meanwhile the blood travels in its arterial bed at much slower rates (twenty to thirty times less rapidly). If therefore, the radial artery be divided, each spirt (which now takes the place of a pulse) of the arterial jet will belong to the ventricular systole which shall have occurred within the same third of a second ; but the jet itself consists of blood which has left the heart many seconds earlier. The velocity of the blood-current varies greatly in the various sections of the vascular system. The following values, taken from Gerald Yeo's "Physiology,"* will give some idea of these variations, and from them an estimate may be formed of the average rate of pro- gress of the blood. Rapidity of Blood-stream. Mm. per Second. Near the Valves of Aorta, —while the ventricles are contracting . ..... 1200 In the Descending Aorta ..... 300-600 >> Carotid . . ..... 205-357 >> 100 j» Metatarsal . ..... 57 >> Arterioles • 50 * Edition 1884, pp. 252, 253. AND WHAT TO FEEL IX IT. 37 Mm. per Second. In the Cap&ari •'> ,, Venous Radi ..... „ /Small Veins on dorsum of hand „ Vena Cava 200 The distinction between pulse-wave and blood-stream having been made clear, the latter need not be again referred to, and subsequent remarks will exclusively apply to the pulse-wave or pressure-wave. Length of the Pulse-wave. The length of the pulse-wave is variously estimated by physiologists at 2 to 6 metres. Prof. Gerald Yeo* says : " Knowing the rate at which the pulse travels (10 m. per sec.) and the time it takes to pass any given point (J sec), its length may be calculated to be about o metres, or about twice as long as the longest artery. Thus the pulse-wave reaches the most distant artery in one-sixth of a second, or about the middle of the ventricular systole, and when the wave has passed from the arch of the aorta, its summit has just reached the arterioles." " Hardly more than J to J of a second lapses between the beat of any two arteries, however distant from each other.'' The Pulse-wave, and the Sphygmogram. A wave travelling at the rate of 20 to 30 feet a second and occupying a length equal to that of two or three men : — this, then, is the pulse-wave. Neither from a casual feel, nor from the sphygmograph, had we gained any idea of these magnitudes, ascertained by experi- ment. Let us bear them in mind whilst feeling the pulse. ■ " Manual of Physiology,'' 2nd edit. 1887, p. 255. 38 HOW TO FEEL THE PULSE Not only shall we more correctly interpret the sensa- tions conveyed to the finger, but we shall probably feel more than we otherwise should have felt. The sphygmogram differs so completely from the wave itself that its study is not well fitted to assist our notions of the pulse at the present stage, although invaluable to the advanced student once familiar with the pulse as it is felt. Intra- arterial Blood-pressure ; and Peripheral Resistance. Arteries during life are always the seat of interned positive pressure. Therefore they not only contain blood at all times, but an amount of blood sufficient to oppose some resistance to the elasticity of the arterial coats. The existence of a permanent positive pressure is sufficient proof that, whilst the inflow is periodically renewed, the outflow from the arteries is controlled in some permanent manner. This control or impediment is known under the name "peripheral resistance." The peripheral resistance is made up of — 1. A more or less constant factor — the friction experienced by the blood-stream in its multi- tudinous channels; and 2. An eminently variable factor — the degree of contretction of the capillaries, and especially of the arterioles. From the latter cause variations will arise in the arterial pressure as a result of analogous variations in the peripheral resistance. AND WHAT TO FEEL IN IT. 3$ The Mean Arterial Pressure.- — The Pulse curves and the Respiratory Undulations of Blood-pressure. Assuming for a moment that the resistance is steady, the recurring systoles of the heart will cause rhythmic variations of the pressure. These are termed the (i pulse- curves. 19 Inasmuch as the rise and the fall which they occasion are small, these oscillations do not greatly affect the main level of pressure ; and we are able to speak of the mean arterial pressure as being steady. The same is true of the rather larger oscillations duo to respiration, known as " respiratory undulations? As soon, however, as the peripheral resistance is altered, whether in plus or in minus, the mean pressure suffers alteration also; and the circulation as a whole requires re-adjustment. This is brought about in various ways, but chiefly by a modification of the strength of the ventricular systole, and of its frequency. Amount of the Intraarterial and Intra-ventricular Pressures. Measured by the height to which the blood in the artery can lift a column of mercury placed in com- munication with it, the blood-pressure in the Brachial Artery (of man) is 120 mm. In the warm-blooded animals the blood-pressure varies (according to the size of each) between 90 mm. and upwards of 200 mm. The blood -pressure within the human aorta has been estimated at 68 oz., or 4 lb. 4 oz. (in the horse it is 11 lb. 9 oz.). In the human pulmonary artery, if we were to adopt as correct the generally received statement that the right ventricular wall is one-third thinner than the left, it would be about one-third less. But according to Michael Foster (book i. chap. iv. 4 o HOW TO FEEL THE PULSE p. 253) the pressure within the right ventricle is probably only 30 to 40 ram., whilst the left ventricle gives a pressure of 200 mm. Now, this great difference must presumably be proportionate to the difference existing between the peripheral resistance of the pulmonary and that of the systemic circulations, and therefore to the difference between the intra-pulmonary and the iutra-aortic pressures. The radial artery at the wrist is usually stated to have in health a pressure of 4 dr. Amount of the Intra- capillary and Intravenous Blood-pressures. The capillary Uood-pressun can be roughly guessed at, rather than determined, with the help of indirect methods. Thus, in the frog's web a pressure of 11 mm. of mercury is required to exclude the blood from the capillaries. In the subungual capillaries of man the pressure requisite varies from 20 to 30 mm. In the veins, blood-pressure is very low, and becomes lower as the heart is neared. In the larger veins which empty themselves into the thorax it is, during the inspiratory effort, negative or " suctional." Arterial Tension. The Artery as an Elastic and Contractile Tube. Excessive internal pressure will shatter a rigid tube, whilst the same tube, if yielding, would be dilated progressively before rupture. In either case the internal pressure is disposed of in the end owing to the tube giving way. The arteries likewise ore AND WHAT TO FEEL IX IT. 41 ultimately responsible for tfu maintenance of tht blood- They are nob rigid. Neither are they merely elastic ; for, if so, they might be well adapted for a given degree of pressure, but only imperfectly adapted for any other degree. Their elasticity is really capabU of ring pitch, thanks to the regulating infh f thi muscular coat. Moreover, the elasticity of an artery is, in some proportion, made up of the elasticity proper to its muscular fibres ; and this is essentially subject to variations. In a word, arteries are contractile as well as elastic. Varying Calibre and Arterial Tension. — "Softness " and " Hardness " of Pulse. So long as the muscular fibres do not contract we may regard the artery as an ordinary elastic tube possessing a definite resistance and power of recoil. Whenever the fibres contract, whether much or little. the lumen or calibre will of course be altered ; at the same time, however, the thickness of the arterial wall will vary, and also its resistance and its elasticity. Let us consider any one of the numerous sizes of which an artery is capable. Just as an india-rubber air-cushion may be inflated much or little, and will become, according to the degree of inflation, tense and hard, or soft and lax, so will the arterial wall be more or less stretched by the blood within. As the tension rises, its surface will become more and more rigid and hard, so that little remains of its natural quality of softness ; neither will the mobile properties by which we are able to recognise the presence of fluid be any longer perceived. Independently, therefore, of the size, the softness or 42 HOW TO FEEL THE PULSE hardness of the arterial surface may become a guide to the degree of the blood -jircssure. Influence of Elasticity on Arterial Tension. The elasticity of the artery we may compare to a buffer, inasmuch as it fulfils a double object — (1) that of protecting the part subjected to pressure, viz., the arterial wall : (2) that of storing up energy to be employed in propelling the blood as soon as the pressure is no longer in excess. In other words, it saves the artery from the danger of rupture and it assists the heart in keeping up the general circu- lation. From that which has preceded it may be gathered that, the greater the systolic pressure, so much the more energy will be stored up. For a moment this energy is held in check by the same resistance which was the means of causing the pressure to rise ; and the artery will collapse only by degrees in proportion as the resist- ance becomes reduced. It is thus explained why, under ordinary circum- stances, arterial tension, if it be greed, will edso be sus- tained. Conversely, if small, it will correspond to a small blood-pressure and peripheral resistance ; and also to a small store of elastic energy, which will be quickly expended in overcoming the small obstacle. Thus low arterial tensions will not be long sustained. DlCROTISM. In some thin persons, if the wrist be held up to a powerful light, each pulse-wave may be seen to ex- perience during its fall a momentary check, as though AND WHAT TO FEEL IN IT. 43 it would swing up again to its previous position. It is this secondary wave or beat which has gwen rise to the name Dicrotism. The normal pulse may be dicrotic ; but this feature is not often so sharply marked as to be felt by the finger. A keen eye will, however, detect it in relaxed arteries, the seat of low tension. In fever, when the arterial walls are relaxed by heat and the blood-tension is low, whilst the heart is working with short and frequent systoles, a careful touch on the radial artery will easily realise the dicrotic jerk, which is then much more prominent than in the normal state. Dicrotism was observed under these circumstances before the days of the sphygmograph. But we owe to the latter the discovery that the dicrotic event occurs also in the healthy pulse- wave. The student will have no difficulty in detecting dicrotism in fever ; but only very close attention will enable him to trace it, when present, in the normal pulse ; this is an exer- cise the practice of which cannot fail to educate his touch in a very high degree. The Arterial Foot-jerk as a Type of the Sphygmograph. The dicrotic wavelet is much more readily detected in the larger arteries than in the radial. It is well for this reason to investigate the axillary, the brachial, the femoral, and the popliteal pulses. The last named affords a very good ocular demonstration of the pulse- wave and of its dicrotism when one leg is crossed over the opposite knee. If the supported limb be allowed to hang loosely, the foot may be observed to oscillate with each cardiac systole. The jerk of the popliteal pulse-wave is in this case multiplied by the length of 44 HOW 10 FEEL THE PULSE. the swinging limb ; and a writing lever suitably fixed to the foot could be made to yield a tracing of the pulse. This simple experiment gives a complete demonstration of the principle and of the essential factors of the sphygmo- graph : (1) The vjeight of the limb represents the pressure applied to the artery ; (2) The leg plays the part of the lev er ; and (3) The action of the spring is supplied by the gravi- tation of the foot bach to its position of rest after each puke-jerk. The dicrotic or secondary jerk is in this case rendered very conspicuous. CHAPTER III. THE CHIEF QUALITIES AXD VARIETIES OF THE NORMAL PULSE. Individual Variety Considerable. — Importance of a Systematic Study of Large Numbers of Pulses. There are certain limits beyond which the exaggera- tion of some one feature of the pulse becomes an abnormality. But within these boundaries there is space for a very large variety of combinations; so much so that it would be difficult to meet with two persons in whom the radial pulse was exactly alike. This endless variety is a source of difficulty in describing to our satisfaction the pulse such as it is felt in any individual case. It accounts for the large assortment of adjectives and for the startling array of figures of speech which have been called to our aid (some of these will be found in the Glossary), and makes it evident that experience is the only means to a comprehensive knowledge of the pulse. Let the student note, however, that a large expt rienee is not necessarily a long one. Nay, it may be held that multiple observations compressed within a short space of time would probably lead to a better and more definite perception of the varieties in type than the same number of impressions spread over intervals too 46 HOW TO FEEL THE PULSE loDg to render comparison easy. He lias an opportunity that he would do well to utilize at an early period of his clinical studies, to systematically feel a consider- ablt number of normal pulses, and to compare at first such large categories as the senile, the adult, and the puerile pulses; the male and the female pulse ; the pulse of short and of high stature, &c. By degrees he will rise to a capacity for discerning finer distinctions ; and when his attention is turned to the study of disease he will find himself competent to observe and to describe wherein any pulse may be abnormal. Systematic Description of the Qualities of the Pulse. In these pages a similar process is adopted. We will proceed to analyse the pulse, that is, to consider one by one the physical qualities which make them- selves known to us, and which alone we are capable of describing accurately. Every pulse will have to be studied on this basis at first, — just as an artist's first sketch is built up on anatomical lines. Coarse differ- ences between pulses will be brought to light by the method, but the finer touches which will make the description so like the original as to convey a complete mental picture of it can hardly be expected at an early stage of study. Large and Small Size or Volume of Pulse. A " large pulse " and a " small pulse " are expressions which appeal to any person who has compared with each other a few examples of the healthy pulse. All beginners are exposed to the risk of getting an in- adequate idea of the size of the radial pulse from not AM) WHAT TO FEEL IN IT. 47 having sufficiently relaxed the tendons with which it is surrounded. If this be done, that which appeared pre- viously to be a small pulse may be ultimately recog- nised as a relatively large one. T/(< largest " volume" of pulse results from a com- bination of two factors : 1. A strong heart-beat, and 2. A yielding arterial wall, alike capable of col- laps* and of distension. Conversely, << small pulse would be found in those whose arteries were not so yielding, or the heart so strong. It must be noted, however, that an artery may be large and yet very unyielding when the superior power of the heart has gradually brought about general arterial dilatation. As a broad statement; it is true to say that a " large pulse" is generally infrequent; a small pulse, frequent. So-called " Fulness " and " Emptiness " of Pulse. " Fulness'' and " emptiness," when applied to the pulse, are expressions almost entirely metaphorical. Arteries are never empty daring life, although they may contain much less blood at one time than at another. In truth, arteries adopt their size to their contents, and in that sense they are always full. Any tendency to a vacuum, if it existed, would produce a collapse of their walls ; and at the same time would act as a negative or suctional force, detaining the blood within them. By "full pulse" is presumably meant a stout and firm pulse, not readily subsiding ; by " empty pulse," one quickly vanishing after a spasmodic beat. Here 4 S HOW TO FEEL THE PULSE again we should gain in clearness by avoiding the words " full" and " empty " and using the equivalents which more truly correspond to the things as they are. "Strength." and "Weakness" of Pulse-wave. It is much less clear what meaning should be attached to the terms "strong" and "weak*' pulse. Nothing is more probable in appearance than that a considerable rise and expansion of the artery should mean a powerful cardiac systole, and therefore a strong pulse. Often enough this is the case. Very frequently, hoivevcr, the size of the pulse is not ei reliable meeisure of its strength. The large and full pulsation is apt to be very short and one easily compressed. Resistance, on the other hand, is often a character of pulses whose beats are not tall, and which possess but moderate volume. We shall therefore connect the expression strong and weak rather with the lifting power of the pulse-wave than with the degree of expansion or height of rise special to the individual beats when no external pressure is superadded. The paradox apparently implied in the association of contradictory terms, such as u large pulse of small strength," will be partly explained away by later remarks on arterial tension, but it may even at this stage be pointed out that the smaller size which a pulsation may possess sometimes coincides with very powerful cardiac effort, and with considerable strength, just as a spiral spring partly weighted down by a heavy load, nevertheless gives us proof of greater power than we can be sure of in the taller spring which no weight has yet tried. Let us be very careful, therefore, in every case of AND WHAT TO FEEL IN IT. 49 large pulsation to try the effect of a strong pressure of the finger, and to notice the relative duration of the pulse-wave, and the condition of the artery in the intervals between successive waves. The Artery during the Interval between Beats. Hitherto we have referred only to the strength of the pulsation. Shifting now the ground of our ob- servation from the pulsation to the condition of the artery between Successive beats we shall find that, among the large pulses, some persist during the interval whilst others fade away after the systolic jerk.* The first set are strong as well as large pulses; the second, weak in spite of their large siz>:. Conversely, a small pulse may become imperceptible between the beats ; it is then weak as well as small. But it may be strong although small, if during the intervals it resist the ordinary attempts at compression. Softness and Hardness of Pulse. " Softness " and ' ; hardness " are qualities of which the touch is an accurate judge : the words in this case are truly descriptive. A pulse may he hard from undue pressure of its fluid contents, or from undue solidifi- cation, of the arterial ivalls. It is not always easy to tell whether the hardness is due to blood-pressure or to tissue condensation of the arterial surface. Both these variations occur as a senile change. A soft pulse is produced when the arterial walls are free * These remarks apply to pulses in general, not to the pathological variety known as Corrigan's pulse, in which the beat is forcible, but ends abruptly. n 50 HOW TO FEEL THE PULSE from thickening, and the blood is free from undue pressure. Softness and elasticity (during the periods of bodily and mental rest) are attributes of a juvenile pulse. Elasticity of Pulse. Arteries in health are both yielding and very elastic. Age sooner or later impairs the natural elasticity and expansibility of the vessels. The same regressive change may also result from disease, independently of age. The presence of the elastic property is easily recog- nised in the recoil of the artery after each pulsation. Its absence, "where this recoil does not take place, is more difficult to prove ; the systolic pressure in some individuals, and at some times, is so great and so long sustained that the elastic force of the artery is over- powered. Elasticity is then not necessarily extinct ; it may be simply latent because maintained on the stretch. The strain which this implies is considerable, and it could not be kept up for protracted periods without lasting impairment and ultimate destruction of the elastic property. Swiftness and Slowness of Pulse ; or Short and Long Duration of the Pulse-wave. A swift pulse is one rapidly passing from the period of arterial expansion to that of collapse. This certainly means that tlie wave travels fast ; it may, in addition, mean that its length is reduced. Rapidity of the pulse- wave is usually associated with frequency of rate. The reverse is the case with the slow pulsation, which is commonly an infrequent one. Swiftness is almost invariably, no less than frequency, the result of AND WHAT TO FEEL IN IT. 51 diminished peripheral resistance; and, conversely, slow- ness and infrequency indicate an abnormal obstacle, occurring somewhere in the arterial or in the capillary circulation. Contraction of the arterioles constitutes an obstacle of this kind. A well-known instance is the contraction of the cutaneous vessels as a result of cold. Rigidity of the arteries, as in senile thickening of their coats, is another form of increased resistance, more seri- ous than the first, because permanent and progressive. Frequency and Infrequency cf Pulse ; or Pulse-rate. Xo uncertainty can possibly attach to the use of these expressions. They correspond to the old Latin terms pulsus creber, pulsus rarus. They are much to be preferred to the words a rapid" and "slow," which are applicable to the rate of progress of the pulse-wave as well as to the rate at which the cardiac beats succeed each other. Nevertheless, the expressions " quick," " fast," or " rapid pulse " — and ; * slow pulse " have passed into currency, and are generally under- stood to apply to the pulse-rate. It is worth while, however, to be absolutely correct in this matter for the sake of complete clearness, and to speak, not of the :; y/?//s''," but of the "pulse-rate," as being either slow or fast. Accelerating and Retarding Influences. The causes which accelerate the pulse-rate are many, and a majority of them are physiological. Among the latter may be specially mentioned physical rti'iiiy psychical excitement, and external heat. Pathologically, an increase in the pulse-rate is bound 52 HOW TO FEEL THE PULSE up with a rise in the internal, or body-temperature, in fever. Apart from fever, it is often witnessed as a result of disordered nerve-function, and as a mechanical consequence of various forms of heart disease. On the contrary, infrequency of pulse is more often due to pathological than to physiological causes. It is true that during rest, and especially in healthy sleep, the heart slackens speed. Again, with some indivi- duals, a remarkable slowness of the heart-rate is "natural" or "constitutional." Of this the most famous historical instance is that of the great Napoleon, whose pulse-rate is stated to have been habitually 40. More commonly, however, infrequency is the result of some definite abnormality, whether cardiac or vascular. A very slow pulse-rate is often witnessed in. fatty degeneration of the heart, but slowness is by no means invariably present in this disease. Sometimes an abnormally slow pulse-rate is the result of excessive feebleness of some of the heart-lints, whereby they are unable to reach the peripheiy (see Abortive Beats and Linked Beats). Putting aside the exceptional cases just mentioned, a determination of the pulse-rate is so easy of per- formance that this subject has been very thoroughly investigated. The following are the results, some of which are familiar to every student of physiology : — I. The Normal Rate in the Two Sexes. The normal frequency per minute is — 72 in the adult male, 80 in the adult female ; (according to Ozanam, respectively 60 and 70). AND WHAT TO FEEL IN IT. 53 II. Influence of Age. The pulse-rate varies with age in the following manner : — Pulse-rate in the foetus ..... 14(1-150 ,, ., at birth 130-140 „ at 1 year of age .... 120-130 „ ,, at 2 years of age .... 105 „ at 3 „„•;.:. 100 „ » at 4 ,, „ . . . . compression. II. The Pulse of Low Arterial Tension. (A) Abnormally low tension means on the one hand little vascular resistance ; and this may be due to — 1. The arteries being relatively capacious; 2. The quantity of blood within them relatively small ; o. The vessels unduly yielding. (B) On the other hand it means a relatively feeble fn rerip)hcral veins is almost invariably onward in character. For the same reason, and for various others also, the true pulsation of large, centrally placed veins is in- variably backwards. True or Direct, and False or Communicated Venous Pulsation. Before proceeding any farther the student must realise that since most veins take their course at no great distance from arteries, arterial pulsation may be conveyed to them. It is essential therefore in every case to determine whether the pulsation is truly venous, or only falsely so called. In addition to the common form of transmitted AND WHAT TO FEEL IX IT. 99 pulsation, we are enabled, with the ophthalmoscope, to witness another variety of venous pulsation communi- cated, from the arteries, it is true, though not directly (since no pulsation can be seen in them), but through the medium of pulsatili variations in the intra-ocular pressm ■ . In tricuspid incompetence the retinal veins not in- frequently pulsate, as a result of venous reflux. How to Tell One from the Other. This is not always possible, but the attempt should be made. In aspect the transmitted (arterial^ pulsa- tion is //'"/■' abrupt and shock-Wei than the truly venous, which may be recognised by its soft undulatory rm - ment. In order to show the spurious character of this pulsation, endeavour by light pressure applied to the artery to isolate it from the vein. Or it may some- times be possible to abolish the arterial pulsation above the position of the vein under observation and without causing any compression of the latter. Most commonly however the slightest touch, by causing indirect pressure on the vein, interferes with the pulsation. The Onward Venous Pulsation and its Cau.-e-. True venous pulsation, of onward direction, occurs chiefly, if not exclusively, in the peripheral venules and veins adjoining the capillary distribution. Its occasioning cause is analogous to that which leads to capillary pul- sation. The blood channels are so much relaxed as to offer no absolute obstacle to the passage of the pulse- wave ; and this is continued, through the capillary district, into the veins as far as a continuous column of blood, unbroken bv valves, extends within them. ioo HOW TO FEEL THE PL'LSE Complete relaxation of the arterioles and capillaries is often limited to a special locality, as in inflammation. Veins under these circumstances may pulsate visibly. The same is true of veins coming from glands in active secretion. But arterio-capillary relaxation may be a general process, and lead to peripheral venous pulsation in many situations. This may be the result of disease, or it may occur as a temporary and functional change. The effect of a full meal, especially combined with alcolvblic stimulation, will be to quicken the heart's action whilst strengthening it, and at the same time to relax the arterioles (febris a prandio). Whilst this condition lasts, it is sometimes possible to detect pulsation in subcutaneous veins of moderate size, especially at the palms, at the soles, and over the face, forehead, nose, and ears ; these being the situa- tions where, according to Sucquet.* communication normally takes place between arterioles and venules only slightly superior in size to capillaries. King's Method of Demonstrating Venous Pulsation. In order the more readily to observe and demon- strate the onward venous pulse King + used fine threads of sealing wax placed across the vein and fastened with wax to the skin close to it, so that any variation in the vein would be indicated by the long end of the thread projecting beyond the vein. To this arrangement he gave the name of sphygmoscqpe. This was the earliest pattern of tic lever sphygmograph which is now in > * s>. * See Ozanarn, Joe. cit.. p. 1007. f Guy's Hosp. Sep., 1837, vol ii. p. 107, and what to feel in it. 101 The Backward or Regurgitant Venous Pulse. Its Causes. This is the only form of venous pulsation which the student need study at first. The cause of backward pulsation is invariably dilatation of the right auricle, and of the great veins opening into it, by a permanent overload of blood. The orifice of the vense cavse, closing imperfectly, does not then exclude the blood which they contain from the influence of the right auricular systole; if at the same time, as is usually the case, the tricuspid valve should be incompetent, the right ventricular systole also takes effect upon the column of venous blood. A more detailed consideration of the backward venous pulse belongs to the second section of this chapter. II. Pulsation in Particular Veins. — Pulsation in the Jugulars and their Tributaries. Its Limits. The jugulars are the chief site for visible true back- ward venous pulse ; and this is readily seen, though not easily told, from the transmitted arterial pulsation which is so commonly present in them. The regurgitant venous pulse commonly extends into the facial vein and its tributaries, and sometimes into the brachial. The extension of the pulsation is limited according to the length of the continuous column of blood filling the veins ; where this stops, there also stops the pulsa- tion. If the vein be full from end to end, the pulse 102 HOW TO FEEL THE PULSE will not always be. propagated through the whole column, but may only affect part of it. Marey is stated to have once observed reflex venous pulsation in varicose veins of the leg * in a subject affected with disease of the right side of the heart. It is very rare, however, to trace the reflex venous pulse through the inferior vena cava beyond the hepatic veins, or through the superior vena cava beyond the brachial veins. Backward Jugular Pulsation and Backward Jugular Flow (or Regurgitation). These two conditions are often associated, but not of necessity. It is easily conceivable and probably often occurs that, without any reflux i venous pulsation should be transmitted through the thin jugular valves stretched across an otherwise continuous column of blood which has been simply retarded in its onward progress by an over full condition of the right side of the heart. This condition is quite different from the graver defect in which not only a pulse-wave, but a flow of blood finds its way into the vein. Regurgita- tion of the blood from the auricle into the jugulars may be taken as a proof that not only the tricuspid valve, but also the jugular valve is incompetent ; and, when- ever reflux takes place, jugular pulsation is necessarily present also. Methods for Ascertaining the Presence of Reflux into the Jugular Vein. The presence or the absence of regurgitation from the heart may generally be made clear with the help * Ozauam, he. cit., p. 1007« AND WHAT TO FEEL IN IT. 103 of a simple experiment. The contents of the distended jugulars are pushed away by running the finger in an upward direction (doing the vessel. If the tricuspid valves be incompetent a fresh quantity of blood may be sent into the emptied channel by the next ventri- cular systole. Should they be competent, no reflux will take place. The Subcostal Pressure Method. Another method is based upon a mode of exploration suggested by Dr. Pasteur " for the purpose of esti- mating the condition of the right side of the heart."* " Under certain circumstances, a distension or over- filling of the external jugular veins, apparently from below, with or without pulsation or undulation, takes place when pressure is exerted in the right hypochon- driac or epigastric regions with the flat of the hand, the direction of pressure being backwards and upwards." As a result of a procedure of this kind, if the jugular valve be incompetent, a regurgitation would be occa- sioned into the jugular through the intermediary of the inferior vena cava, of the right auricle, and of the superior vena cava, all of which are supposed to be distended with blood. In looking for this sign the observer should remember that he is dealing with a congested and extremely tender organ. The Presystolic and the Systolic Jugular Pulsations. Let us now examine more closely the backward venous pulsation noticeable at the root of the neck in cases of tricuspid and jugular incompetence. As * The Lancet, May 15, 1886. 104 HOW TO FEEL THE PULSE regards time this form of pulsation is always either systolic or presystolic (auricular-systolic). A diastolic retraction of the jugular during each cardiac diastole has been described among the signs of pericardial adhesions ; but this diastolic negative pulse has nothing to do with the valvular affections we are now considering. Since neither the superior nor the inferior vena cava possess any valves capable of period- ically closing their cardiac orifice, reflux into them with each auricular systole might have been regarded as normal and unavoidable. This is however pre- vented by the fine adjustment of the auricular fibres surrounding the orifices ; and by the fact that the blood is urged onward into the ventricle as in ihediree- tion of least resistance. Both these arrangements are disturbed when the auricular wall is stretched by the presence of too largt a quantity of blood, and when the passage of blood into the ventricle becomes difficult. As we might expect, the overloaded auricle then sets up a backward pulsation in the jugular at the moment of its own contraction, that is, immediately before the ventricular systole. This auricular or presystolic pulsation is known by its time, by its rapidity and short duration, and fre- quently also by the double oscillation of which it is composed. Upon this usually follows the systolic or ventricular pulse-wave, known by its larger size and greater dura- tion. Very often this wave alone is perceptible. Varying Degree of Jugular Distension as Affecting the Pulsation. In addition to the pulsations just described, further changes are connected with the varying degree of AND WHAT To FEEL IN IT. 105 distension of the veins, under the influence of lessening or increasing impediments to the circulation. In the foregoing description we have imagined the jugulars to be kept permanently full. But matters are often com- plicated by their fulness not being constant but intermit- tent ; and, therefore, the visible pulsation being also intermittent. It then becomes necessary to distinguish between a true blood reflux and a mere refluent blood' Wa Pi . Inspection of the Episternal Notch and of the Supra-clavicular Fossae. A mere inspection of these regions affords valuable indications. The student will note the absence — ( 1 ) Of ven us fulness^ (2) Of transm itU d arterial pulsation , (3) Of. t 1 ' 1 '' '"' nous pulsation : or if these be present he will proceed to describe them. In addition to inspection, palpation (especially deep palpation) of the episternal notch and of the supra-clavi- cular fossa: will help us in determining whether a jugular pulsation may be merely the arterial beat communicated from the arch of the aorta and from the innominate (a frequent occurrence) ; or, as in the case of the subclavian venous pulsation, one propagated from the subclavian artery. Backward Pulsation into the Inferior Vena Cava. HErATic Pulsation, Spurious and True. The over full condition of the right auricle must make itself felt, not only in the superior vena cava and the jugulars, but also in the inferior vena cava. Into this vein the capacious hepatic reins open just below the 106 HOW TO FEEL THE PULSE diaphragm, and they receive a share of the regurgi- tated wave. Commonly, however, the pulsation is limited to the primary divisions of these large veins. The liver itself, already subjected to passive pulsation by contact with the distended right heart, receives an additional impulse from the regurgitation into the hepatic venous trunks. The resulting movements of the organ may properly be designated as transmitted. In a few cases the intra-hepatic circulation is more deeply influenced, and the regurgitant pulsation, ex- tending down the hepatic venous system, produces at each systole a perceptible increase in the vclv/nu of the liver. If this organ, which, under these circumstances, is always enlarged, be palpated as closely as possible between the two hands, a (list ensile pulse will be per- ceived at each systole. This is true pulsation of the liver, as opposed to the transmitted, spurious, hepatic pulsation, or common diffused hepatic impulse, described in the preceding paragraph. Arterial Hepatic Pulsation. It will be noticed that the true hepatic pulse is usually regarded as a venous and a regurgitant one. Since however both the hepatic artery and the hepatic vein are continuous with the portal capillaries, pulsation might conceivably be propagated to the latter from the hepatic artery. This would be a direct or arterial hepatic pulsation. Conceivably also pulsation might arise in one and the same case from both artery and vein. As regards time, a slight difference would exist between the longer circuit of the direct arterial pulsation from the left ventricle, and the shorter route taken by the refluent pulsation from the right auricle. AND WHAT TO FEEL IN IT. 107 Theoretically a single impulse would be proof that the hepatic pulsation was entirely of one kind. But in practice, since the delay between the venous and the arterial wave is trifling, it would be exceedingly diffi- cult to decide, on this ground alone, and in the absence of the usual signs of dilatation of the right auricle and ventricle, whether the pulsation was venous or arterial. GLOSSARY OF TERMS IN USE AT THE PRESENT TIME OR IX THE PAST, IN' CONNECTION WITH THE PULSE.* Abdominal pulsation Abortive beats Accessory beats ABorhytkymia (see p. 63) Anacrotic pulse Anacrotism (secondary wave during the ascent) Anastomosis Ant-like pulse (faintest pulsation) Aortic pulse Arhythrma or Arrhythmia (see p. 64 Asynchronism Auricular pulsation Bigeminal pulse Bounding pulse Capillary pulsation Cerebral pulsation Collapsing pulse Compressible pulse Corrigan's pulse Dicrotic or dicrotous pulse Dicrotism (secondary beat or wave in the pulse) Diffluent pulse Direct pulse Distal pulse Epigastric pulsation Equal pulse Even pulse Eurhijthmla (normal rhythm) Faint pulse Faltering pulse Flabby pulse Flagging pulse Foetal pulse Frail pulse Frequent pulse Full pulse Hard pulse Hectic pulse Hepatic pulsation Heterochronism Heteromorphism High tension of pulse Hurried pulse Hyperclicrotism (excessive di- crotism) * For an explanation of the few English words of which the meaning is not obvious, the reader is referred to the corresponding page. Many obsolete expressions have been left out which would not be understood without an account of the erroneous pulse-theories upon which they were based. no GLOSSARY OF TERMS. Ictus (the actual beat) Incompressible pulse (see p. 07) Inequality Infrequent pulse Intermittent pulse Irregular pulse Jerky pulse Jugular pulse Katacrotism (secondary wave during the descent) Laboured pulse Lean pulse Linked beats (see p. 6) Locomotor pulse (see p. 83) Low tension of pulse (see p. 77) Meagre pulse Moderate pulse Paradoxical pulse (see p. 66) Pararhythmia (abnormal rhythm) Peripheral pulse Poor pulse Pulsation by anastomosis Pulse of aneurysm Pulse of " unfilled arteries" Pulsus acceleratus, &c. (See Latin list) Quick pulse Recurrent pulse Refluent pulse Reflux pulse Regularity of pulse Regurgitation Reptation of pulse Renal pulse Retardation of pulse Rhythm Running pulse Serpiginous pulse Senile pulse Shabby pulse Shallow pulse Slender pulse Slight pulse Slow pulse Spurious pulse Strong pulse Swift pulse Stumbling pulse Symmetrical pulses Synchronous pulses Tall pulse Tense pulse Thin pulse Thready pulse Thrilling pulse Thumping pulse Tortuous pulse Tremulous pulse Tripping pulse Trigeminal pulse Tumbling pulse Turgid pulse Vehement pulse Venous pulse Ventricular pulse Vermicular pulse Vibratory pulse Uneven pulse Water-hammer pulse Wavy pulse Waxing and waning pulse Weak pulse Wiry pulse Worm-like pulse LATIN LIST. Pulsus acceleratus, quickened acutus, sharp cequalis, even alter nans (see p. 60) alius, deep amplus, wide angustus, narrow apertus, plain ; not latent bigeminus (see pp. 60-65) bix feriens, dicrotic brevis, short caprizans, hyperdicrotic celer, swift ritatus, quickened concisus, short and defined contractus, small creber, frequent debilis, weak deficiens, failing differens, unlike its fellow difficilis, laboured durus, hard exilis, thin Jiliformis, thready formicans, ant-like fortis, strong gracilisy slender humilis, low, shallow impar citatus, irregular impetuosus, violent inaqualis, uneven Pulsus incequaliter incequalis (see p. 60) inciduus, waxing and waning inordinatus, irregular intermittens, intermittent intermittens cum inspiratione (see p. 66) i/ttercidens, interrupted intercurrent, with accessory beats languidus, languid latens, latent lotus, broad longus, long magnus, large manifestus, not latent medius, middle-sized moderatus, moderate mollis, soft myurus, like a rat's tail obscurus, ill defined obtusus, thick oppresstis, depressed ordinatus, regular oscillans, oscillating paradoxus (see p. 66) parvus, small plenus, full profundus, deep rarus, infrequent recurrens, recurrent 112 LATIN LIST. Pulsus reptans, crawling robustus, strong serratus, saw-like spasticus, jerky tardus, slow tensus, tense tremuhis, tremulous trigeminus (see pp. 60, 65) Pulsus turgidus, distended vndosus, wavy vacuus, empty raJidus, strong vehemens, vehement relox, rapid, swift vermictdaris, worm-like ribratu*, vibratile PRINTED BY BALLANTYNE, HANSON AND C3. LONDON AND EDINBURGH RK 35r. l M31887cT R,ES,hs,stx » The manaopmpfu nf n,d*i~l. .„~ t u ll I I II || | 2002403315 II