means some giving way of the heart muscle, that is, cardiac muscle failure, but not necessarily so; or 2. An abnormal excitability of the nervous mechanism which causes an abnormally increased number of stimuli sent to the ventricles. These points will be referred to again under the headings tachycardia and irregular pulse. <Callout type="important" title="Important">An abnormally slow pulse in heart disease—that is, a rate below 50; especially one below 80—frequently means some pathological change in the auriculo-ventricular (a.-v.) bundle, which impedes the conduction of stimuli from the auricular nervous mechanism. (See Brady-cardia.)</Callout> In this case the auricles will be contracting more frequently than the ventricles. A certain but small number of persons have a heart-rate below 50 with auricles contracting as slowly as the ventricles. The volume of a pulse, that is, whether it is large and full or small and empty, depends chiefly on the amount of blood propelled by the ventricle into the aorta at each systole, <Callout type="risk" title="Risk">Small and empty pulses.—In mitral disease the pulse is often small and empty, because in stenosis less than the normal amount of blood enters the left ventricle during its diastole, and in incompetence some regurgitates into the auricle. In either case an abnormally small amount passes from the ventricle into the aorta with each beat.</Callout> Furthermore, when the ventricles in mitral disease are contracting with increased rapidity, irregularity in rhythm, and inequality in force, only a considerably reduced amount of blood has time to pass into the left ventricle for it to contract on. With marked aortic stenosis the pulse is a small one, and there is delay in its transmission to the wrist. A large and full pulse is met with when there is an abnormal amount of blood expelled from the ventricle into the aorta, and this is met with in cases of dilatation of the left ventricle with hypertrophy. In dilatation without adequate compensation the pulse often has a soon-full, soon-empty, or slapping character, which may simulate very closely a Corrigan’s or water-hammer pulse (7.v.). Regularity.—Normally the heart, and therefore the pulse-beats, follow each other regularly in rhythm and uniformly in character. It is very common, however, to meet with irregularity in rhythm and varying character of heart-beat and pulse-wave, not only when the heart is diseased, but also when it is quite sound. In healthy children the heart may be irregular, its rate varying with inspiration and expiration, <Callout type="beginner" title="Beginner">A similar irregularity in rhythm is often met with in nervous people.</Callout> The commonest form of irregularity in adult life is the so-called missed beat, in which a heart-beat and a pulse-wave apparently drop out. What happens is that the heart gives a premature and weak contraction, which does not create a pulse-wave. (See Premature or extra systole.) ‘This frequently occurs in normal hearts as the result of digestive disturbances. The other extreme is met with in certain forms of heart disease when scarcely two successive beats of the heart and pulse are regular in rate or uniform in char- acter. The beats occur in a most irregular way (delirium cordis), and with more or less greatly increased rapidity. Sometimes the pulse-rate is uncountably fast. (See Intermittent pulse and Auricular fibrillation.) Between these two extremes lie varying degrees of irregularity. Tension.—Increased tension is an important indication of pathological processes taking place in the system, the most important of which are arteriosclerosis and interstitial nephritis. It may be the first physical sign of these diseases, and when it is present the urine must be examined carefully by boiling and acidulation—the most delicate test for albumen. The specific gravity of the urine will probably be low, and often only a very faint trace of albumen is found, or none at all. Nocturnal polyuria.—There will, however, generally be obtained a history of nocturnal polyuria as well— that is, the necessity of getting up regularly at night two or three times to pass a considerable amount of urine. In making this point, it must be ascertained how much fluid is drunk late at night, for many men take half a pint at least of nightcap fluid, such as whisky and water, hot milk, or plain hydropathic hot water; but this will rouse them only once in the night as a rule, and generally early in the morning, Further, the increased frequency of micturition in small amounts caused by an irritating prostate must not be confused with high tension polyuria. Increased tension may be caused by absorption of toxins from the alimentary canal without there being any primary interstitial nephritis. This condition may last for years, with its attendant discomforts. In mitral stenosis the pulse, though small, is often one of considerable high tension. The distinction between hardness of the wall of the artery and increase of arterial tension must be borne in mind. Either may be present without the other, or both may be present together, Abnormally low tension is rather more difficult to make out. It is present in debilitated states in children who are subject to fainting attacks with no definite ascertainable cause. The condition of the wall of the artery must be made out by rolling it under the fingers against the end of the radius. When this is done, a normal artery can scarcely be felt at all after the pulse-wave has been obliterated, whilst a diseased one feels more or less hard, like w piece of string when there is fibroid degeneration of the middle coat, or like a hard calcareous tube (pipe- stem artery) with marked atheromatous degeneration. Movements of the fingers in the long axis of the end of the radius will reveal any annular deposits of cal- careous material. Venous Puss. The venous pulse affords valuable information in heart disease, especially of the condition of the right side of the heart. <Callout type="tip" title="Tip">The only vein in which it can be observed is the jugular vein, between the thoracic attachments of THE VENOUS PULSE 15 the sterno-mastoid muscle.</Callout> When there is obstruction to the flow of blood from the right auricle into the ventricle, the jugular veins are distended, and stand out a Via. v4 | it iN vs NI jo NI KI R LI | MN ql +r £. 4 C. WV LR I qf Es . Fic. 3. 7. a., Auricular form of venous pulse ¥. v., Ventricular form of venous pulse. R., Radial pulse, B. C., Flectrocardiogram, P., — Phonoscope tracing showing heart sounds and murmur a., Auricular wave; v., ventricular wave; ¢., carotid waves. Land IL, first and second heart sounds. “1 second intervals of time. prominently, but often there is no visible distension, let alone pulsation, of the veins. With obstruction to the large veins in the chest there will be distension of the veins in the neck but no pulsation. 16 HEART DISEASE The venous pulse cannot be felt by the finger like the arterial pulse, but requires a special recording apparatus for its investigation. For the use of this clinical polygraph considerable experience and practice is necessary. Its application is consequently limited to hospital practice or to the work of a few specialists, Whilst it gives information which helps in the understanding of the conditions present in heart disease, especially concerning the condition of the auricles and the relative number of auricular and ventricular contractions, it does not as often afford much assistance in treatment beyond that gained by other and more manifest evidence of cardiac muscle failure. Jugular pulse waves.—The common form of jugular pulse tracing is known as the auricular form, and shows three waves. The first, or the auricular (a.) wave, is caused by auricular systole; the next and smaller wave is called the carotid (c.) wave, and is probably caused by the pulse-wave in the carotid artery being transmitted through the jugular vein to the surface ; and the last, or ventricular (v.) wave, is caused by the rebound of blood in the filling auricle against the closed tricuspid valve (Fig. 3, V. a). In the other form of venous pulse, known as the ven- tricular venous pulse, there is no a. wave, the v. wave predominating. In this case there is no contraction of the auricle, this organ being paralyzed and acting merely as a reservoir (Fig. 3, V. v). The jugular pulse, then, gives information as to what is going on in the right side of the heart chiefly. It is recorded synchronously on paper by means of a polygraph with the radial pulse, or occasionally with the apex-beat, and for its interpretation some time standards THE VENOUS PULSE 17 and a pair of compasses are necessary. The time standards are the following : The radial pulse follows one-tenth of a second, and the carotid pulse one-twentieth of a second after the onset of ventricular systole, which in its turn is preceded by auricular systole by one-fifth of a second. Before the tracings are taken, the two recording pens are moved up and down across the paper to mark the relative positions of the venous and arterial pulses at the same moment of time, and to give the “ordinate” for accurate measurement. A time-recorder constantly marks intervals of one-fifth (two-tenths) of a second. When a tracing is completed, the distance between the ordinate for the artery tracing and the beginning of the upstroke of its pulse-wave is measured accurately with the compasses. The stretch between the points of the compasses is then decreased by a distance exactly equal to a one-tenth of a second interval on the time-marker. The compasses are now applied to the venous pulse, one limb being placed accurately on its ordinate, and the other on the tracing, where it will fall exactly where the carotid wave ought to be developing. This spot is then marked as the rise of the c. wave. Each successive c. wave is marked out by resetting the compasses to a space equal to the distance between the commencement of the upstroke of the arterial pulse tracings, and measuring successive complete pulse-waves along the venous tracing from the originally marked a. wave, marking each a. wave as before. The auricular wave ought to begin two-tenths of a second before the c. wave. General Inspection in Cases of Heart Disease. The general inspection should always be carried out with the patient facing a good natural daylight, as artificial light destroys the delicate changes in shades of colour, especially the yellow of jaundice, which are such important indications of the health, Whilst patients suffering from heart disease, even in its most serious forms, may look “the picture of health,” with a general natural freshness of complexion, there are certain signs in the face and general aspect pointing to cardiac disease which are visible to the eye of a skilled observer. The general signs are those of shortness of breath on slight exertion, or even without any, inability to breathe in any but the erect position (orthopnea), oedema, —especially swelling of the legs and dependent parts. Marked throbbing, with short and sudden pulse-waves, in the carotid or other arteries, may be seen, and generally means aortic regurgitation, but a quickly acting dilated heart may cause similar appearances. Distension of the veins of the neck with or without visible pulsation may be present. In the face, in addition to signs of the general distress, there may be seen, but not always, some special changes. Mitral stenosis often gives rise to a high colour, localized more or less to the malar eminences of the cheeks, and due to dilated veins (ven stellate), An exactly similar condition is met with in people who have been exposed to the weather, and a somewhat similar condition, and one which often deceives the student, is met with in myxcedema. Here, however, there is a peculiar yellowish, waxy appearance of the rest of the face. In aortic disease, when it is severe, there is generally much pallor, from the tendency which incompetence of the valve has to empty the blood vessels rapidly, and often also marked “lines” running from the nose to the outer angle of the mouth. Capillary pulsation may be seen if looked for carefully over the forehead; but to see this properly it is generally necessary to make a small patch of blush by rubbing the forehead with the back of the finger-nail. Cyanosis.—When the cardiac muscle, especially that of the right heart, fails, the pulmonary: circulation cannot be carried on effectively, with the result that the venous blood is imperfectly oxygenated. It then collects in the systemic circulation, and is seen in the skin and mucous membranes as a bluish discoloration, or cyanosis. Cyanosis is most marked in dependent parts, the lobes of the ears, the fingers and toes, but it is well seen in the face. This form of cyanosis is the result of a deficient force pumping blood through the lungs. With heart disease of long standing, especially of congenital origin, the fingers and toes are often clubbed as well as purple. A bluish, ashy grey appearance is, however, often met with in chronic bronchitis and emphysema with the heart working well. This is due to inability of the lungs to expand freely and oxygenate the blood properly, In congenital heart disease there is generally a very deep red, purple, or bluish aspect. When congenital heart disease is met with in people over puberty, especially over twenty, as it occasionally is, it is almost always due to pulmonary stenosis. Other congenital heart lesions generally terminate in childhood, but I saw one adult of thirty-one who died from the effects of a congenital septum in the auricle, which simulated mitral stenosis. How he lived as long as he did was a wonder. Jaundice is also often present. For this to be definitely established the conjunctive under the upper eyelids must be examined, the yellow discoloration so often seen in the exposed parts not being due to bile pigments. Anxiety.—In angina pectoris or severe intrathoracic aneurysm there is often an appearance of extreme anxiety, and, if the pain be present, of great distress. The attitude is fixed and immobile as though movement of any sort were feared, in marked contrast to the excited movements of hysterical angina. Inspection Or THE NECK. Arterial pulsation.—Pulsation or throbbing of the carotid arteries, varying in degree, will often be seen, a thin neck favouring its visibility. In the majority of cases of slighter degree it means nothing abnormal, merely a favourable position of the arteries for their pulsation to reach the surface. Even when marked it may be due simply to nervous overaction of the heart. With aortic regurgitation it reaches its highest development, when the throbbing of a soon-full, soon-empty vessel is very striking. The frontal artery may also be seen to throb in aortic incompetence, but a visible pulse wave in any exposed artery may occur without any heart disease being present. In dilatation with hypertrophy, the carotid arteries may pulsate in a way very suggestive of an aortic pulse. The condition of the veins must be noted, distension indicating obstruction to the return of blood to the right auricle, or to its flow through the right side of the heart. The jugular veins are often seen to be very full, and if examined carefully between the attachments of the sterno-mastoid to the clavicle and sternum pulsation in them may be seen and felt. A transmitted impulse from the carotid artery must be discriminated from true venous pulsation. The direction in which blood flows to fill the veins is important. If a stretch of vein be emptied between two fingers the vein will fill from below upwards if there is tricuspid regurgitation, and from above downwards when auricular distension alone or venous obstruction is present. Any general swelling of the neck, if present, must be noted, as it is generally a sign of serious intra-thoracic disease or venous obstruction. Inspection Or THE Precorpia. Inspection of the precordia must never be omitted, as it gives most valuable information in disease. A side or tangential view should be taken if the direct inspection is negative, pulsation being sometimes seen by it, and not otherwise. The normal cardiac impulse may be invisible, and negative observation may mean nothing abnormal. The anterior and mid-axillary regions should be most carefully examined, as the impulse is often surprisingly far out in disease. Diffuse pulsation between the mid-clavicular line and the sternum generally means disease of the right ventricle, and widely spread pulsation, outwards as well, means enlargement (dilatation with hypertrophy) of both ventricles. Auricular pulsation is never seen, Pulsation over the base of the heart generally indicates aneurysm of the arch of the aorta. The impulse of a forcibly beating normal heart may extend outwards to the nipple line. Bulging of the precordia is generally best seen in children, whose chest walls give easily in front of enlarged hearts. When limited to intercostal spaces it often indicates pericardial effusion. Systolic retraction of the interspaces may be seen ; it is often diffuse, and means adherent pericardium or great cardiac enlargement, the contraction of the heart causing negative pressure in the thorax, and consequent retraction of the intercostal spaces.
Key Takeaways
- An abnormally slow pulse can indicate pathological changes in the heart's conduction system.
- Small and empty pulses are often seen in mitral valve diseases, while large and full pulses occur with left ventricular dilatation and hypertrophy.
- Venous pulse examination provides valuable information about the right side of the heart.
Practical Tips
- Regularly monitor your pulse for irregularities that could indicate underlying heart conditions.
- Pay attention to changes in skin color, such as cyanosis or jaundice, which can be signs of heart disease.
- Use a stethoscope to listen to heart sounds and murmurs, which can provide additional diagnostic information.
Warnings & Risks
- Do not rely solely on pulse examination for diagnosing heart diseases; other symptoms and tests are necessary.
- Incorrectly interpreting venous pulses can lead to misdiagnosis or delayed treatment of heart conditions.
- Prolonged exposure to cold temperatures can cause false positives in cyanosis, so ensure proper environmental conditions.
Modern Application
While the techniques described in this chapter are rooted in historical practices, they still provide valuable insights for modern survival preparedness. Understanding pulse examination and venous pulse can help identify potential heart issues early, which is crucial during situations where medical facilities may be limited or unavailable. However, it's important to combine these methods with other diagnostic tools and seek professional medical advice when necessary.
Frequently Asked Questions
Q: What does a small and empty pulse indicate in mitral disease?
A small and empty pulse in mitral disease often indicates stenosis or incompetence, where less blood enters the left ventricle during diastole, leading to reduced blood flow into the aorta with each heartbeat.
Q: How can one differentiate between a normal and pathological increase in arterial tension?
A pathological increase in arterial tension may be associated with conditions like arteriosclerosis or interstitial nephritis. It often presents as low specific gravity of urine, nocturnal polyuria, and the presence of albumin in the urine.
Q: What is the significance of observing venous pulsation in the neck during heart disease diagnosis?
Observing venous pulsation in the neck can indicate obstruction to blood flow from the right auricle into the ventricle, which may be due to mitral stenosis or other conditions affecting the right