how to feel the pulse

8/3/2019 HOW TO FEEL THE PULSE

1/136


2/136


3/136


4/136


5/136

HOW TO FEEL THE PULSEAND "WHAT TO FEEL IN IT


6/136

Works by the same Author.Price 21s.

THE BRONCHI AND PULMONARY BLOOD-VESSELS. Their Anatomy and Nomenclature; witha criticism of Professor Aeby's views on the BronchialTree of Mammalia and of Man. With 20 Illustrations.

J. & A. Churchill, London. 1889.Price 5s. 6d.

CARDIAC OUTLINES FOR CLINICAL CLERKSAND PBACTITIONERS; and firat principles in thePhysical Examination of the Heart ior the beginner.With upwards of 60 Illustrations.

Intended as a Pocket Companion at the bedside. TheOutlines are designed to illustrate the methods and theresults of the examination of the heart in health andin disease, and to assist the student in recording hisclinical observations.A supply of Thoracic and Cardiac Outlines (4^ \>x 3-Jinches), on gummed paper, will be included in eachcopy.Baillire, Tixdall & Cox, London. 1892.

[In the Press.


7/136

HOW TO FEEL THE PULSEAND WHAT TO FEEL IN IT /

PRACTICAL IIIN IS FOR BEGIXXERS

BY

WILLIAM EWART, M.D. Cantab., F.R.C.P.PHYSICIAN TO ST. GEORGE'S HOSPITAL; CLINICAL LECTURER ANDTEACHER OF PRACTICAL MEDICINE IN THE MEDICAL SCHOOL ; PHYSICIAN TO THEBELGRAVE HOSPITAL FOR CHILDREN; ADDITIONAL EXAMINER IN 1S91 FORTHE 3RD M.B. OF THE UNIVERSITY OF CAMBRIDGE; LATE ASSISTANTPHYSICIAN AND PATHOLOGIST TO THE BROMPTON HOSPITAL FORCONSUMPTION AND DISEASES OF THE CHEST

WITH TWELVE ILLUSTRATIONS

NEW YORKWILLIAM WOOD & COMPANY

1892\AU rights reserved]


8/136

74

/8U


9/136

2>

I

^

TOWILLI A M W A D H A MM.D., F.B.C.F.

CONSULTING PHYSICIAN TO ST. GEORGE'S HOSPITALAND FOB MANY TEARS

DEAN OF THE MEDICAL SCHOOLAND

THE STUDENTS* FRIENDTHIS LITTLE BOOK FOR STUDENTS IS

GRATEFULLY INSCRIBED BV HIS CLINICAL PUPILTHE AUTHOR


10/136

Digitized by the Internet Archivein 2010 with funding from

Columbia University Libraries

http://www.archive.org/details/howtofeelpulsewhOOewar


11/136

PREFACE.The old-fashioned arfc of feeling the pulse holds itsown in medical practice, although very scant noticshas been taken of it in modern medical literature.On the subject of the Sphygmograph, the student hasat his disposal many and excellent books, and thisvolume would have had no purpose had it attemptedto follow the same lines. It is specially devoted tomatters which are scarcely touched upon in mostbooks on the Pulse ; but which are deemed ofpractical importance. It has been my aim to treatthese in an elementary fashion, reserving for laterpublication merely theoretical or personal opinions.In spite of their imperfections these pages mayperhaps be of service in directing the young student'sattention to the oldest and not the least importantof 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


12/136

viii PREFACE.plates from that work, and to Dr. Douglas Towell forhis kind permission to reproduce his valuable diagramsof the pulse ; also to my nephew, Mr. P. de Vaumas,and to Dr. H. B. Grimsdale for their assistance in theproduction of the other illustrations ; and lastly, to myfriend Mr. Godfrey Thrupp for his valuable help inrevising the proofs.

WILLIAM EWART.S3 Curzon Street, Mayfair,

March 1S92.


13/136

TABLE OF CONTENTS.

Preface viiIntroductory Remarks 1

CHAPTER I.THE PULSE AND THE PRACTICAL METHODS FOR

ITS STUDY.The Pulse ; Circumstances and Situations favourable

for its Detection .3The visible pulse and the tangible pulseCircumstances

favouring or hindering the detection of arterial pulsationSituations in which pulsation may be seen in lean subjectsThe influence of positionSituations in which the arterialpulse may be felt in most subjectsThe common pulses.

The Mode of Feeling the Various Pulses .... 8The Seats of Election for a Study of the Pulse. The Radial

Artery; its Advantages 9

Description of the Practical Methods for the Studyof the Pulse 10

The Method for Counting the Pulse . . . .10Various sites for counting the pulseCounting the pulse

at the Carotid and at the HeartDuration of the observa-tionPreliminary precautionsRules to be followed incounting the pulse.


14/136

x TABLE OF CONTEXTS.TAGKThe Method of Feeling the Pulse 14

I. General Rules relating to the Attitude of Body and LimbAttitude of the bodyThe observer's attitudeThe

patient's attitudeAttitude of the armSteadiness essen-tial ; how securedPatient's arm supported by the observerMuscular relaxation essential, in the observer, in thepatientManagement of the patient's wristThe attitudeof the hand"Which pulse to hold ?Which hand to use ?The attitude of the observer's handThe superior andthe inferior position of handThe arrangement of thefingers and their relation to the wristThe distal positionand the proximal position of the index fingerThe exactspot where the finger should be placedThe inclination ofthe fingers.

II. Exploration of the Pulse .25The degrees of pressure to be appliedHow to regulate

the pressureThe behaviour of the pulse under varyingpressureThe manipulation or fingering of the pulse.

IIT. Methods for rapidly finding the Pulsation of someother Arteries 20

How to find the beat of the Facial Artery ; of theTemporal ; of the Carotid ; of the Brachial.

CHAPTEE II.ELEMENTARY NOTIONS ON THE PHYSIOLOGY OF

THE PULSE.The Structure of Arteries. 34The Cardiac Systole and the Pulse-Wave . ^ . .35

Velocity of the pulse waveVelocity of the blood streamLength of the pulse-waveThe pulse-wave and the sphyg-mogram.


15/136

TABLE OF CONTENTS. xlI'ii.i:

Intra-arteiual Blood Pressure, and Peripheral Resist-ance 38

The mean arterial pressure ; the pulse curves and the re-spiratory undulationsAmount of the intra-arterial andintra-ventricular pressuresAmount of the intra-capillary,and of the intra-venous blood pressure.

Arterial Tension 40The artery as an elastic and contractile tubeInfluence

of varying calibre on arterial tensionSoftness and hard-ness of pulseInfluence 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 pulseSo-calledfulness and emptiness of pulseStrength and weakness ofpulseThe artery during the interval between beatsSoft-ness and hardness of pulseSwiftness and slowness ofpulse ; or short or long duration of the pulse-wave.

Frequency and Inprequency of Pulse ; or Pulse-Rate 51Accelerating and retarding influences.

I. The normal rate in the two sexes.II. Influence of age.

III. ,, stature.IV. the hour of dayV. sleep, and of the waking state.

VI. ,, meals, and of fasting.


16/136

xii TABLE OF CONTEXTS.VI 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.

PAGEThe Variations eh Size 59

Unevenness of pulsePeriodic unevennessAbortivebeatsXon-periodic unevennessLinked beatsDiffer-ence between linked beats and pulsus trigeminus and trige-minusCombined unevenness and irregularity.

The Vabxatiohs in Rhythm 62Irregularity of pulseIntermittenceAllorhythmia andArhythmiaIntermittence at the wristThe varieties of

Rhythm in intermittenceAbsolute ArhythmiaClassicalvarieties of uneven and irregular pulse known under specialnames Pulsusparadoxus.

The Incompeessible Pulse, So-called . . . .67Arterial sclerosisCalcification of the arterial wall.

The Recueeext Pulse 60Circulation by AnastomosisRefluent radial pulse.


17/136

TABLE OF CONTENTS. xiii

CHAPTER V.ON THE SIX CHIEF MORBID PULSE TYPES ; AND ON THE

METHODS OF TESTING PULSES AS TO TENSION.PAGKPreliminary Description of the Methods for Gauging

Arterial Tension with the Finger . .72I. The obliterating pressureII. The test for successful

obliteration The elementary or "bimanual" method oftesting the nature of the distal pulseThe


18/136

xiv TABLE OF CONTENTS.PAGEHow to Test foe Equality of the Two Radial Pulses 85

The two best positions for the patient's handsThe twomethods which the observer may adopt.

How to Test foe Synchronism in the Two Pulses . 87Check Observations Essential 89

CHAPTER VII.Capillary Pulsation 90

Elasticity and contractility of capillariesCapillarypulsation normally absentPathological occurrence ofcapillary pulsationThe methods for detecting capillarypulsation: I. The "Tache" method; how to examine thetache for pulsationII. The "lip" methodIII. The"nail "methodBackward or regurgitant capillary pulsa-tionMode of distinguishing the backward from theonward capillary pulsationLocal throbbing.

CHAPTER Till.VENOUS PULSATION.

I. Venous Pulsation in General 97Venous pulsation a tergo, a fronteTheir respective

districtsTrue or direct, and false or communicated venouspulsationHow to tell one from the otherThe onwardvenous pulsation and its causesKing's method of demon-strating venous pulsationThe backward or regurgitantpulse ; its causes.

II. Pulsation in Particular VeinsPulsation in theJugulars and their Tributaries . ' . 101

Its limitsBackward jugular pulsation, and backwardjugular rlow (or regurgitation}Methods for ascertaining


19/136

TABLE OF CONTENTS. xvI- U.K.

the presence of reflux into the jugular veinThe subcostalpressure methodThe presystolic and the systolic jugularpulsations Varying degree of jugular distension as affect-ing the pulsationInspection of the episternal notch andof the supra-clavicular fossa?.

Backward Pulsation into the Inferior Vena CavaHepatic PulsationHepatic Arterial Pulsa-tion 105


20/136


21/136

HOW TO FEEL THE PULSEAXD WHAT TO FEEL IX IT.

INTRODUCTORY.The vast importance of the various features of thepulse was guessed by physicians long before the dis-covery of the circulation, but it has only been fullydemonstrated within the memory of living men. Itwould be unfair to suppose that all the labour whichwas devoted to the pulse by our early predecessors intheir numerous treatises (Galen alone wrote seven) hadbeen wasted and barren in practical results, butthe amount of definite information to be extractedfrom them is remarkably small and buried in a massof extravagant assumption. All empty surmises havenow been cleared away, and the clinical uses of thepulse narrowed down to substantial facts connectedwith it, which might be recorded in a few pages. Butthe value of these clinical facts, few as they may be, isin advance of anything dreamt of before, and is theresult of vastly improved anatomical and pathologicalknowledge. It is already capable of demonstration bythe instrumental methods of physiology, and we arerapidly approaching a stage when some of the qualitiesof the pulse will find a mathematical expression.

A


22/136

2 HOW TO FEEL THE PULSE.Meanwhile, the pulse has still to befelt. But it is an

operation of far greater importance to students ofmedicine 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 theattention bestowed upon the examination. Moreover,since all experimental results are dependent upon theconditions of the experiment, we should take care that,even in apparently so trivial an operation as feelingthe pulse, we use the best available method ; inseeking for which we must be prepared to considermatters in some detail.

The following are the subjects dealt with in thisbook, and their orderCHAPTER

I. The pulse and the practical methods for itsstudy.

II. Elementary notions on the physiology of thepulse.

III. The chief qualities and varieties of thenormal 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 deemednecessary ; but a short glossary of the terms usedformerly, and at the present time, has been appended.


23/136

CHAPTER ITHE PULSE AXD THE PRACTICAL METHODS

FOP ITS STUDY.

THE PULSE : CIRCUMSTANCESAND SITUATIONSFAVOURABLE FOR ITS DETECTION.

The Visible Pulse and the Tangible Pulse.In common language " pulse " is synonymous withthe pulsation at the wrist. But accuracy demands theprefix of " radial " to this particular pulse as thereare various situations in which arterial pulsation can beseen as well as felt ; while in others it can be felt,though not seen. When we speak of the pulsationbeing visible or palpable, we do not always mean thatthe 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 bevisible ; and in the same manner we must feel and feelagain before we may safely say that we are unable todiscover pulsation where pulsation should be felt.

Circumstances Favouring or Hindering theDetection of Arterial Pulsation.

No device except position, a good light, and the me ofa lens, can help the eye in perceiving the pulsation of


24/136

4 HOW TO FEEL THE PULSEan artery if feeble. Palpation, on the other hand, ismuch assisted by a little knowledge and previouspractice. Independently, moreover, of personal experi-ence, there are definite conditions assisting, and othersthat hinder, success in the finger's search for the pulse.This is amply borne out by the experience of surgeousin various operations by which vessels are laid bare,and especially in those where an artery has to befound and tied. The operator, after exposing thevessel and whilst able to touch it, may be left in doubtas to its identity, or may even mistake it for somesimilar structure, ' ' because unable to feel in it anypulsation." Yet, before the operation, the vessel mayhave been felt to 'pulsate when pressed against lone ormuscle. Similarly, if the various arteries which areeasily accessible to the touch be explored, it will befound that some pulsate much more distinctly and othersless so ; that those arteries which are supported by afirmer back-ground pulsate more powerfully thanothers ; and, lastly, that pulsation is most strongly feltin those which are in proximity with bone. On theother hand, we shall become acquainted with arteriesso superficially placed between thin skin and hard boneimmediately underlying the skin, that the fingeralmost inevitably obliterates them in the attempt tofeel their pulsation. Arteries thus situated do notafford very good opportunities for palpation, in spiteof their superficial position. In conclusion, thefavourable 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).


25/136

AND WHAT TO FEEL IN IT. 5The unfavourable conditions are : the reverse of the

preceding ; and, in addition, immediate contact of anartery with underlying bone, especially if the skin (asover the temple) be tightly stretched over the bone.Bony contact becomes then relatively a disadvantage.

I.

Situations in which Pulsation may be Seenin Lean Subjects.

In the young, even when spare, and especially inchildren, the arterial pulses are hardly ever visible.At most, it may be possible to perceive the beat ofthe radial.

In. old 'people, and especially in those of lean habit,several of the arteries will be seen to pulsate. Thisis 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 speciallyfavourable opportunities, their pulsations being ofexaggerated type, and their arteries large, whilst thepatients themselves are generally thin.

Taking, then, the most favoitrablc sidy'cct, a leanman, advanced in years, and suffering from aorticvalvular incompetence, the following arteries wouldprobably 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).


26/136

6 HOW TO FEEL THE PULSEThe 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 sometimesin 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 thelimb. As special instances should be mentioned, theradial at the wrist, whose beat is favoured by veryslight flexion, or at least by the absence of extensionthe vlnar, whose pulsation may be visible, in slightextension only ; and especially the brachial, whichbecomes curved into a prominent loop above the foldof the elbow when the limb is flexed.


27/136

AND WHAT TO FEEL IN IT. 7II.

Situations in which the Arterial Pulsemay 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 inwhich it is observed by the eye.

It is unnecessary to repeat here the list previouslygiven, which applies to the special combination ofsenility and of emaciation with cardiac disease.

It was stated that during health, and in the youngand sleek, the number of visibly pulsating arterieswould be very small. This is not the case with thepulse as felt. In adults, even when presenting fairlythick integuments, the beat of the following arteriesmay 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.


28/136

8 HOW TO FEEL THE PULSEThe external iliac.The femoral (in the upper half the thigh).The popliteal {in the lower part of the poplitealspace).The posterior tibial (at the ankle-joint).Sometimes the anterior peroneal.The anterior tibial (just above the ankle).The dorsails pedisIn 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 offinding the other four will be thereafter briefly in-dicated.

Among the remaining pulses that of the eoronariesmay be felt from the outside, against the teeth as abackground ; but better from the inside, by graspingthe thickness of the lip between two lingers.

The innominate and the subclavian beats will befelt by deeply plunging the finger into the cpisterncdnotch and into the supra-clavicular fossa respectively.

The beat of the subclavian is best felt where the


29/136

AND WHAT TO FEEL IX IT. 9vessel lies on the surface of the first rib. That of theinnominate is not readily, except in special case?, dis-tinguishable from the strong impulse of the arch of theaorta communicated upwards.

In order to perceive the axillary pulsation the armmust be raised. The vessel can then be felt beatingbetween 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'sligament.

Rather strong pressure is also required in the caseof the femoral, if the thigh be muscular or very fat.The femur forms the background.

The popliteal pulse is more readily perceived whenpartial flexion has relaxed the tension of the powerfulmuscles among which the artery lies concealed.

The easiest way to feel the posterior tibial heat is toplace the flat of the finger (whole length) in a verticaldirection just behind the inner malleolus. Soft pri ssureof the phalanx against the os calcis will suffice.

The dorsalis pedis is readily felt pulsating when thefinger is applied across the upper part of the arch ofthe foot. Here again the pressure should be soft, andthe 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 besuccessfully studied. For this purpose the seats ofelection are the face for the temporal and the facialarteries, the arm for the brachial, and the wrist for


30/136

ic HOW TO FEEL THE PULSEthe radial. The first two vessels are almost too super-ficial. The radial, besides being much larger, possessesgreat advantages over them ; and over the brachial, ithas that of personal convenience.

(1) The radial presents to perfection those ana-tomical conditions which were described on page p. 4 asrendering pulsation easy to feel. It is superficial, andit is backed by a bony plane. But it is not in imme-diate contact with bone at that part where the pulseis felt : although, nearer the wrist-joint, it lies on thestyloid process, in close contact with its surface.

( 2 ) Another great advantage of the radial is theconsiderable length (quite three inches) over which it isaccessible to the touch. This enables the observer tofeel the pulse with three or even four fingers.

DESCRIPTION OF THE PRACTICAL METHODSFOR 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. Thisis quite distinct from the operation of " feeling thepulse." which is an active and rather difficult inquiry.Here the touch is almost entirely passive. The pointsrequiring attention are :

(1) To keep touch with the pulse by a gentlepressure, so that none of the beats are lost to thefinger


31/136

AND WHAT TO FEEL IX IT, i r

>tiT!Tftfla2 * s>.

* See Ozanarn, Joe. cit.. p. 1007.f Guy's Hosp. Sep., 1837, vol ii. p. 107,


121/136

and what to feel in it. 101The 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 backwardpulsation is invariably dilatation of the right auricle,and of the great veins opening into it, by a permanentoverload of blood. The orifice of the vense cavse, closingimperfectly, does not then exclude the blood which theycontain from the influence of the right auricular systole;if at the same time, as is usually the case, the tricuspidvalve should be incompetent, the right ventricularsystole also takes effect upon the column of venousblood.

A more detailed consideration of the backward venouspulse 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 noteasily told, from the transmitted arterial pulsation whichis so commonly present in them. The regurgitantvenous pulse commonly extends into the facial veinand its tributaries, and sometimes into the brachial.The extension of the pulsation is limited according tothe length of the continuous column of blood filling theveins ; where this stops, there also stops the pulsa-tion. If the vein be full from end to end, the pulse


122/136

102 HOW TO FEEL THE PULSEwill not always be. propagated through the wholecolumn, but may only affect part of it.

Marey is stated to have once observed reflex venouspulsation in varicose veins of the leg * in a subjectaffected with disease of the right side of the heart. Itis very rare, however, to trace the reflex venous pulsethrough the inferior vena cava beyond the hepaticveins, or through the superior vena cava beyond thebrachial veins.

Backward Jugular Pulsation and BackwardJugular Flow (or Regurgitation).

These two conditions are often associated, but not ofnecessity. It is easily conceivable and probably oftenoccurs that, without any refluxi venous pulsationshould be transmitted through the thin jugular valvesstretched across an otherwise continuous column ofblood which has been simply retarded in its onwardprogress by an over full condition of the right side ofthe heart. This condition is quite different from thegraver defect in which not only a pulse-wave, but aflow of blood finds its way into the vein. Regurgita-tion of the blood from the auricle into the jugulars maybe 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 necessarilypresent also.

Methods for Ascertaining the Presence ofReflux into the Jugular Vein.

The presence or the absence of regurgitation fromthe heart may generally be made clear with the help

* Ozauam, he. cit., p. 1007


123/136

AND WHAT TO FEEL IN IT. 103of a simple experiment. The contents of the distendedjugulars are pushed away by running the finger in anupward direction (doing the vessel. If the tricuspidvalves be incompetent a fresh quantity of blood maybe sent into the emptied channel by the next ventri-cular systole. Should they be competent, no refluxwill 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 frombelow, with or without pulsation or undulation, takesplace 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 jugularvalve be incompetent, a regurgitation would be occa-sioned into the jugular through the intermediary ofthe inferior vena cava, of the right auricle, and of thesuperior vena cava, all of which are supposed to bedistended with blood. In looking for this sign theobserver should remember that he is dealing with acongested and extremely tender organ.

The Presystolic and the Systolic JugularPulsations.Let us now examine more closely the backward

venous pulsation noticeable at the root of the neck incases of tricuspid and jugular incompetence. As

* The Lancet, May 15, 1886.


124/136

104 HOW TO FEEL THE PULSEregards time this form of pulsation is always eithersystolic or presystolic (auricular-systolic).A diastolic retraction of the jugular during eachcardiac diastole has been described among the signs of

pericardial adhesions ; but this diastolic negative pulsehas nothing to do with the valvular affections we arenow considering. Since neither the superior nor theinferior vena cava possess any valves capable of period-ically closing their cardiac orifice, reflux into themwith each auricular systole might have been regardedas normal and unavoidable. This is however pre-vented by the fine adjustment of the auricular fibressurrounding the orifices ; and by the fact that theblood is urged onward into the ventricle as in ihediree-tion of least resistance. Both these arrangements aredisturbed when the auricular wall is stretched by thepresence of too largt a quantity of blood, and when thepassage of blood into the ventricle becomes difficult.As we might expect, the overloaded auricle then setsup a backward pulsation in the jugular at the momentof its own contraction, that is, immediately before theventricular systole.

This auricular or presystolic pulsation is known byits time, by its rapidity and short duration, and fre-quently also by the double oscillation of which it iscomposed.

Upon this usually follows the systolic or ventricularpulse-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


125/136

AND WHAT To FEEL IN IT. 105distension of the veins, under the influence of lesseningor increasing impediments to the circulation. In theforegoing description we have imagined the jugulars tobe kept permanently full. But matters are often com-plicated by their fulness not being constant but intermit-tent ; and, therefore, the visible pulsation being alsointermittent. It then becomes necessary to distinguishbetween a true blood reflux and a mere refluent blood'Wa Pi .

Inspection of the Episternal Notch and of theSupra-clavicular Fossae.

A mere inspection of these regions affords valuableindications. 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 deeppalpation) of the episternal notch and of the supra-clavi-cular fossa: will help us in determining whether ajugular pulsation may be merely the arterial beatcommunicated from the arch of the aorta and fromthe innominate (a frequent occurrence) ; or, as in thecase of the subclavian venous pulsation, one propagatedfrom the subclavian artery.

Backward Pulsation into the Inferior Vena Cava.HErATic Pulsation, Spurious and True.

The over full condition of the right auricle must makeitself felt, not only in the superior vena cava and thejugulars, but also in the inferior vena cava. Intothis vein the capacious hepatic reins open just below the


126/136

106 HOW TO FEEL THE PULSEdiaphragm, and they receive a share of the regurgi-tated wave.

Commonly, however, the pulsation is limited to theprimary divisions of these large veins. The liveritself, already subjected to passive pulsation by contactwith the distended right heart, receives an additionalimpulse from the regurgitation into the hepatic venoustrunks. The resulting movements of the organ mayproperly be designated as transmitted.In a few cases the intra-hepatic circulation is moredeeply influenced, and the regurgitant pulsation, ex-tending down the hepatic venous system, produces ateach systole a perceptible increase in the vclv/nu of theliver. If this organ, which, under these circumstances,is always enlarged, be palpated as closely as possiblebetween the two hands, a (listensile pulse will be per-ceived at each systole. This is true pulsation of theliver, as opposed to the transmitted, spurious, hepaticpulsation, or common diffused hepatic impulse, describedin 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 hepaticvein are continuous with the portal capillaries, pulsationmight conceivably be propagated to the latter from thehepatic artery. This would be a direct or arterialhepatic pulsation. Conceivably also pulsation mightarise in one and the same case from both artery andvein. As regards time, a slight difference wouldexist between the longer circuit of the direct arterialpulsation from the left ventricle, and the shorter routetaken by the refluent pulsation from the right auricle.


127/136

AND WHAT TO FEEL IN IT. 107Theoretically a single impulse would be proof that thehepatic pulsation was entirely of one kind. But inpractice, since the delay between the venous and thearterial wave is trifling, it would be exceedingly diffi-cult to decide, on this ground alone, and in theabsence of the usual signs of dilatation of the rightauricle and ventricle, whether the pulsation was venousor arterial.


128/136


129/136

GLOSSARY OF TERMSIN USE AT THE PRESENT TIME OR IX THE PAST,

IN' CONNECTION WITH THE PULSE.*

Abdominal pulsationAbortive beatsAccessory beatsABorhytkymia (see p. 63)Anacrotic pulseAnacrotism (secondary wave

during the ascent)AnastomosisAnt-like pulse (faintestpulsation)Aortic pulseArhythrma or Arrhythmia (see

p. 64AsynchronismAuricular pulsationBigeminal pulseBounding pulseCapillary pulsationCerebral pulsationCollapsing pulseCompressible pulseCorrigan's pulseDicrotic or dicrotous pulseDicrotism (secondary beat or

wave in the pulse)

Diffluent pulseDirect pulseDistal pulseEpigastric pulsationEqual pulseEven pulseEurhijthmla (normal rhythm)Faint pulseFaltering pulseFlabby pulseFlagging pulseFoetal pulseFrail pulseFrequent pulseFull pulseHard pulseHectic pulseHepatic pulsationHeterochronismHeteromorphismHigh tension of pulseHurried pulseHyperclicrotism (excessive di-

crotism)

* For an explanation of the few English words of which themeaning is not obvious, the reader is referred to the correspondingpage.Many obsolete expressions have been left out which would notbe understood without an account of the erroneous pulse-theoriesupon which they were based.


130/136

no GLOSSARY OF TERMS.Ictus (the actual beat)Incompressible pulse (see p. 07)InequalityInfrequent pulseIntermittent pulseIrregular pulseJerky pulseJugular pulseKatacrotism (secondary wave

during the descent)Laboured pulseLean pulseLinked beats (see p. 6)Locomotor pulse (see p. 83)Low tension of pulse (see p. 77)Meagre pulseModerate pulseParadoxical pulse (see p. 66)Pararhythmia (abnormal

rhythm)Peripheral pulsePoor pulsePulsation by anastomosisPulse of aneurysmPulse of " unfilled arteries"Pulsus acceleratus, &c. (See

Latin list)Quick pulseRecurrent pulseRefluent pulseReflux pulseRegularity of pulseRegurgitationReptation of pulseRenal pulseRetardation of pulseRhythm

Running pulseSerpiginous pulseSenile pulseShabby pulseShallow pulseSlender pulseSlight pulseSlow pulseSpurious pulseStrong pulseSwift pulseStumbling pulseSymmetrical pulsesSynchronous pulsesTall pulseTense pulseThin pulseThready pulseThrilling pulseThumping pulseTortuous pulseTremulous pulseTripping pulseTrigeminal pulseTumbling pulseTurgid pulseVehement pulseVenous pulseVentricular pulseVermicular pulseVibratory pulseUneven pulseWater-hammer pulseWavy pulseWaxing and waning pulseWeak pulseWiry pulseWorm-like pulse


131/136

LATIN LIST.Pulsus acceleratus, quickened

acutus, sharpcequalis, evenalternans (see p. 60)alius, deepamplus, wideangustus, narrowapertus, plain ; not latentbigeminus (see pp. 60-65)bix feriens, dicroticbrevis, shortcaprizans, hyperdicroticceler, swiftritatus, quickenedconcisus, short and definedcontractus, smallcreber, frequentdebilis, weakdeficiens, failingdifferens, unlike its fellowdifficilis, laboureddurus, hardexilis, thinJiliformis, threadyformicans, ant-likefortis, stronggracilisy slenderhumilis, low, shallowimpar citatus, irregularimpetuosus, violentinaqualis, uneven

Pulsus incequaliter incequalis (seep. 60)

inciduus, waxing and waninginordinatus, irregularintermittens, intermittentintermittens cum inspiratione

(see p. 66)i/ttercidens, interruptedintercurrent, with accessorybeats

languidus, languidlatens, latentlotus, broadlongus, longmagnus, largemanifestus, not latentmedius, middle-sizedmoderatus, moderatemollis, softmyurus, like a rat's tailobscurus, ill definedobtusus, thickoppresstis, depressedordinatus, regularoscillans, oscillatingparadoxus (see p. 66)parvus, smallplenus, fullprofundus, deeprarus, infrequentrecurrens, recurrent


132/136

112 LATIN LIST.Pulsus reptans, crawling

robustus, strongserratus, saw-likespasticus, jerkytardus, slowtensus, tensetremuhis, tremuloustrigeminus (see pp. 60, 65)

Pulsus turgidus, distendedvndosus, wavyvacuus, emptyraJidus, strongvehemens, vehementrelox, rapid, swiftvermictdaris, worm-likeribratu*, vibratile

PRINTED BY BALLANTYNE, HANSON AND C3.LONDON AND EDINBURGH


133/136


134/136


135/136

RK 35r.lM31887cTR,ES,hs,stx The manaopmpfu nf n,d*i~l. .~ tull I I II || |

2002403315 II


136/136

how to feel the pulse

Documents