I

t

THE USE

OK THE

Sphygmograph in

Clinical Medicine

BY

GRAHAM STEELL, M.D. Edin., F.R.C.P. Lond.,

PHYSICIAN TO THE MANCHHSTER ROYAL INFIRMARY; LECTURER
CLINICAL MEDICINE AND ON DISEASES OF THE HEART,
OWENS COLLEGE.
..i

MANCHESTER :
SHEKKATT & HUGHES, 27, ST. ANN STKEET.

1899.'

WELLCOME INSTITUTE
LIBRARY

Call
No.

1

A. MAHOMED
Bn /nbemonatn.

THE USE OE THE SPHYGMOGRAPH IN
CLINICAL MEDICINE.

Chapter I.
Introductory.

In the following pages it is intended to give a short account
of the practical use of the sphygmograph at the bedside or in
the consulting room. The instrument (which owes most of
sucli popularity as it enjoys in England to the eloquent advocacy
of the late lamented Dr. F. A. Mahomed) is often spoken of as
if it were the mere toy of faddists and an invention devoid of
practical usefulness. I must protest against such opinions,
which belong generally to those who have had but little
experience with it.

Again, we are told that the physician's "finger" should be
educated, and instrumental aid eschewed. My answer is that
as an educator of the "finger" ("finger" standing, of course,
for the cerebral centre that receives the impressions conveyed
by the finger) the sphygmograph is facile 23}-i7iceps. This fact
alone should render the instrument at least deserving of respect.
To those who would-trust the "finger" absolutely, I might say
that I believe the most cultured "finger" will occasionally err
without an appeal to instrumental aid.

Moreover, the sphygmograph gives us valuable records of the
pulse at definite dates. It is idle to trust to the recollection of
such and such sensations, and even the verbal description of
them, written at the time of observation, gives later but a feeble
representation of the status quo antea.

6

Lastly, I unhesitatingly affirm that the sphygmograph is of
greatest value as an aid to treatment, of less value in prognosis,
and of least value in diagnosis.

A description of tlie sphygmograph itself would be worse than
useless in this place. The student must study the instrument
with it in his hand, and learn to apply it and adjust it himself.
In doing the former he must take care to turn the index on the
pressure dial to zero befoie fixing the strap round the wrist.
The actual measurement of pressure indicated on the dial is,
however, hardly trustworthy for reasons that need not be
discussed here. The simplest rule is to take the tracings at the
degree of pressure that gives the longest sweep of the writing
point. This degree of pressure will usually be found to be
considerable in high-tension pulses and small in low-tension
pulses.

It is difficult to define the characters of a normal pulse-
tracing, inasmuch as there are physiological differences in the
pulses of different individuals. One man has normally a fairlj'
high-tension pulse, another, equally healthy, a fairly low-tension
pulse, and the pulse of the same man at different times and
under the influence of temporary circumstances may vary as
greatly in its characters.

It is necessary for purposes of description to make use of
certain terms in describing the curves of a tracing. These are
very simple : (1) An imaginary line drawn through the inferior
extremities of the upstrokes is called the respiratori/ line,
(2) The upstroke may be said to reach from it to the apex of
the curve. (3) The peak at the top of the curve or first wave
is called the percussioti tvave* (4) The wave immediately

*Drs. Roy and Adami in their well-known jjaper "Heart Beat and Pulse
Wave," ijroposed to call this the Papillari/ Ware.

following is the tidal wave.'' Its degree of development is of
chief importance in estimating the tension of tlie piilse. In
high-tension pulses it is well developed and (what is perhaps of
greater importance than its height) it is sustained or j)rolonged.
(Fig. 1.) On the other hand in low-tension pulses, the tidal

Fig. 1-

wave is either absent or ill developed (Fig.- 2), and it is never

Fig. 2.

sustained or prolonged. (5) The wave that follows is the dicrotic
wave. It is best developed in low-tension pulses, in some of
which it may actually be felt with the finger as a second and
feebler impulse. In low-tension pulses the tidal wave may
disappear altogether so that the dicrotic wave follows the
percussion wave immediately (Figs. 3, 4, 5), whether this happen

*Drs. Roy and Adami proposed to call this the Onlfloiu-remainder Wave :
for the reasons in favour of such change in nomenclature their
paper referred to must be con.sulted.

8

Fig. 5.

or not/ there will be a notch, the " aortic " between the tidal or
Ijercussion wave, as the case may be, and the dicrotic wave. In
low-tension pulses this notch is situated low down, i.e., it
approaches the respii-atory line, while in high-tension pulses it
is situated at a considerable distance above the respiratory line ;
in the former type of pulse the dicrotic wave is apt to be
exaggerated while the opposite is the case in true high-tension
pulses.

These are the points in a sphygmogram that demand our
attention in studying pulse-curves. For instance : When a
tracing is taken of a low-tension pulse, while the patient is
suffering from severe dyspnoea, the respiratory (Fig. 3) line is
often seen to become undulating instead of being straight. In
obstruction of the aortic orifice the upstroke often slopes instead
of being perpendicular. In the same lesion the percussion wave
is often practically abolished, the top of the curve being formed
by the tidal wave (Fig. 6) while in incompetence of the aortic

9

valves it is exaggerated. (Fig. 7.) In tlie high-tension pulse
the tidal wave is well developed and sustained, while the

Fitr. 7. "

" aortic " notch is situated at a distance from the respiratory
line. (Fig. 1.) In the low tension pulse, on the other hand,
the tidal wave is small or absent while the dicrotic wave is well
developed, and the " aortic " notch approaches the respiratory
line. (Fig. 2.) When it reaches the respiratory line the pulse
is said to be fully dicrotic (Fig. 4), and when it actually passes
below this line the pulse is said to be hyper dicrotic. (Fig. 5.)
Very rarely the tidal wave — a j^eculiarly modified one, we shall
see — becomes perceptible by the finger. This is called the
bisferiens pulse, and is met with most commonly in cases of
aortic obstruction. (Fig. 8.) Without the sphygmograph it

Fig. 8.

would be impossible to say in these cases which wave it is that
has become so exaggerated as to simulate a second pulse-beat,
lu aortic incompetence the dicrotic wtxve is usually ill-developed
or absent. (Fig. 7.)

*The loop formed at the toi. ot tliis curve is a, defect in the tracing,
but it is not uncommon in Aortic Incompetence, and is due to the great
jerk given to the lever.

10

We have spoken of the pulse-curves as yet as if iu a given
case they were all alike, but this does not always happen so
that we have to consider a tracing as a series of curves the
individual members of which may be very different. This
introduces the important subject of irregularily of the pulse.
(Figs. 9 and 10.) Again, the interval between a couple of

Fig. 10.

curves may be prolonged, producing intermission of the pulse.
(Fig. 11.) The pulses may occur iu couples, bigeminal, a large
beat being followed by a small abortive one, whose curve appears
in the tracing on the line of descent of the preceding curve.

11

Fig. 12.

(Fig. 12.) This second beat may or may not be perceptible by
the finger. In the alternating pulse there is a regular
alternation of long and short upstrokes. (Fig. 13.)

Fig. 13.

We have, then, to consider the individual curve of the pulse-
beat in detail, next the series of curves, and lastly we have to
compare the tracings of the right and left pulses. The radial
artery, which usually serves for our observation of the pulse-
beat, may be irregularly distributed, only a small vessel being
found in the usual situation of the " pulse " — quite 'unsuited
for the sphygmograph — while the larger branch curves round
the radius to get to its outer side. When difficulty is experienced
in finding the pulse, this is the first explanation that should
occur to our mind. As a routine practice we should feel both
" pulses" or radials. If there is a difference it may depend on
aneurysm or upon local disease— atheroma— of the subclavian
artery at its origin. In aneurysm, the pulse-tracing of one side

12

may become a mere undulating line, while that of the other
side shows well-developed ordinary pulse curves. (Figs. 14 and

Fig. 15.

15.) A radial pulse may be obliterated suddenly from
embolism.

13

Chapter II.

The Pulse in Aortic Disease of the Heart.

I use the term Aortic Disease of the Heart to designate cases
of disease of the aorta implicating the heart. Aneurysms
confined to the 2nd and 3rd parts and some aneurysms of the
1st part of the arch do not come under the category, and we
shall consider all aneurysms of the arch together in a separate
section.

The subject " aortic disease of the heart " is naturally di-
visible into two sections accordingly as the essential lesion
is (1) Stenosis or narrowing of the aortic orifice, or (2) Incom-
petence of the aortic valves. The two conditions are often
combined, but usually one or other is predominant with regard
to its influence on the pulse. It rarely happens that the two
lesions are so equally balanced that the influence of the one
negatives that of the other on the pulse.

(A) Aortic Stenosis. There are two types of sphygmogram
commonly associated with aoi-tic stenosis, which lesion must be
jaronounced in order to impress special characters on the pulse.
The two types in question are commonly known by the names
(a) Anacrotic, and (b) Bisferiens. The former is the more
common and pei-haps the more characteristic, but it .must not
be supposed that either is pathognomonic ; we are not entitled
to make the diagnosis of aortic stenosis as soon as we find a
characteristic example of either of the pulses in question, more-
over, the tracing of any pulse that affords a tidal wave can
readily be rendered anacrotic by the application of too great
pressure, and this possible fallacy must be borne in mind.

The features of the (a) anacrotic pulse-curve may be enumer-

14

ated as follows :—(] ) The upstroke slopes instead of being
perpendicular ; (2) the percussion wave is practically abolished ;
(3) tlie tidal wave forms the summit of the curve ; and (4) the
dicrotic wave is usually ill-developed. From a cousideration of
these features of the sphygmogram, a good idea may be obtained
of the impression such a pulse affords on palpation with the
finger. The anacrotic pulse of aortic stenosis is characteristically
infrequent. The patient from whose pulse Fig. 1 6 was taken,

Fig.

however, was subject to temporary rapid action of the heart,
din-ing which the sphygmogram lost most of it characteristic
features. (Fig. 17.) At the same time the systolic thrill

Fig. 17.

usually to be felt over the aorta disappeared, while the murmur
became comparatively feeble, and it is doubtful if the lesion
could have been recognised clinically had the pulse remained
frequent. As already indicated, diagnosis of the lesion must never
be based alone upon the sphygmogram, although the latter may
supply most valuable evidence. The auscultatory sign assoc-
iated with the lesion is a systolic murmur, with maximum

15

intensity in the aortic region, well conducted in the course of
the circulation. Such murmur is often accomijauied by pal[)able
thrill. The course of the aorta, as the vessel forms the great
stem of tiie heart, from the centre of which it springs, to the
aortic area {2nd rt. costal cartilage at its junction with the
sternum) must be kept in mind, and a thrill need not be limited
to or even best felt in the "aortic area." A systolic aortic
murmur is hi/ iUelj of little or no diagnostic value, for it is
often present, when the stenosis — if such it can be called — is
nominal only as the result of a tiny nodule on a valve, or slight
thickening and stiffening of a valve, or when the orifice of the
aorta is actually larger than in health, though the current of
blood spreads out as it passes into the still wider channel of the
vessel beyond in cases of dilated atheromatous aorta. Lastly,

Fig. 18.

a systolic murmur, though such a murmur is usually best
developed in the " pulmonary area," is commonly enough heard
in the " aortic area " independently of any lesion, in cases of
simple anemia. It follows that the diagnostic value of a systolic
murmur by itself in the aortic area is exceedingly small. A
thrill accompanying the murmur, and due to the coarseness of
its vibrations, adds some degree of diagnostic value to the latter.
In actual stenosis of the aortic orifice the 2nd sound, however,
is usually defective, and may be absent altogether, and when
this is the case, and at the same time the systolic murmur is
very prolonged and accompanied by thrill, while the pulse is

16

Hiiacrotic ivnd slow, a good basis for the diagnosis of aortic
stenosis is afforded. A history of rheumatism in long past
years offers contributory aid in diagnosis, but the lesion is not
always due to rheumatic endo-carditis and may be congenital.
In some cases it is produced by the chronic inflammatory and
degenerative process known as aortitis deformans. In most
cases of aortic stenosis there is some amount of regurgitation,
but the murmur due to the latter is usually feeble. In a few
cases there is neither 2nd sound nor diastolic murmur audible :
a loud prolonged harsh systolic murmur (accompanied by thrill)
being all that is to be heard in the aortic area — a significant
auscultatory condition. In the cases of dilated aorta, above
referred to, the systolic murmur may be of great loudness, and
possibly accompanied by thrill, but the 2nd sound is markedly
accentuated.

(6) The bisferiens pulse is characterised by (1) a well-marked
percussion wave, (2) an elevated but unsustained tidal wave,
and (3) usually an ill-developed dicrotic wave. (Figs. 19, 20, 21.)

17

Fig. -21.

This last is the only character it has in common with the
anacrotic pulse. It often happens that the percussion and
tidal waves can be felt separately with the finger, in the same
way as the percussion and dicrotic waves may become separately
perceptible in certain low tension "dicrotic" pulses. The
impression received through the finger is very similar in the
two cases, so much so that without the sphygmograph one could
not identify the nature of the second beat. In certain cases of
aortic incompetence the sphygmogram may closely resemble
that of an ill-developed bisferiens pulse although there is no
stenosis. (Fig. 22.) A thrill in the aortic region accompanying

Fig. -22,

the systolic murmur is of the same diagnostic value as in Cases
with anacrotic pulse. A very remarkable fact, with reference
to the bisferiens pulse, is its occasional development in one
radial only. I have looked in vain for an anatomical explana-
tion of the fact in fatal cases.

When the two lesions aortic stenosis and aortic incompetence
are present together, and neither is predominant, the effects of

18

the'one le«ioii neutralise those of tlic otiu r on the ]>uhe, so that
the^'pulse curve is not characteristic of cither. Fi<^ 23 was

rig. 23.

taken from a young patient who had a marked systolic thrill
and loud systolic murmur as well as a diastolic murmur in the
aortic region.

With regard to the hisferiens pulse, the cleft of the curve
between the percussion and tidal waves, to be of diagnostic
value, must be very deep. Minor degrees of such character of
the curve must not be allowed diagnostic value in favour of
stenosis, and are common enough in cases of aortic incompe-
tence without stenosis. (Fig. 22.) I have already given a
similar warning concerning the anacrotic pulse, pseudo-anacrotic
curves being only too easily obtainable. The diagnosis of the
case must never be based on the pulse alone.

(B). Aortic lucompefeiice. Incompetence of the aortic valves
may be brought about by several pathological processes which
may be enumerated as follows: — 1. Rheumatic and (rarely)
choreic endocarditis ; 2. Septic endocarditis ; 3. The chronic
inflammatory process that results from excessive strain on the
valves and ends in their shrinking; 4. The chronic inflam-
matory and degenerative process known as " aortitis deformans "
or atheroma. This leads to aortic incompetence in either or
both of two ways : (a) by diminishing the elasticity of the aorta,
whereby the vessel becomes permanently dilated, the dilatation

19

of tlie channel of the vessel being ultimately followed by dilata-
tion of the orifice, so that the valves are rendered incompetent
even though sound in themselves, and (6) direct implication of
the valves in tiie chronic inflammatory pi-ocess of the vessel
■\v<dl. Syphilis produces aortic incompetence by a process
similar to 4.

linpture of an aortic cusp by violence is so rare an event
that we may leave it out of account, and the incompetence that
is associated with aneurysm involving the first part of tlie arch
is of the same nature as that referred to under 4«.

It may be said that rheumatic endocarditis prefers the mitral
to the aortic valves for its attack, and although it frequently
produces aortic incompetence, the mitral lesion usually ovei-
shadows the aortic in the production of symptoms, but the
total number of cases in which aortic incompetence is the
essential lesion is well made up by the cases I term degenerative
in type, inasmuch as they are met with in patients who have
passed the prime of life, or in younger subjects who may be
regarded as prematurely aged as the result of the action of
syphilis on their vascular system. Aortitis not rarely leads to
attacks of angina pectoris and interference with the nutrition
of the heart-muscle by narrowing the coronary orifices. (Fig. 2-5.)

We must keep before our minds, then, the association of aortic
incompetence with disease of the endocardium and with disease
of the aortic wall. It was at one time supposed that the type
of disease which had produced the valve lesion in a given case
could be recognised by the sphygmogram. This is not so, unless
it be.in the early stage of cases referred to under ia, in which,
however the degree of incompetence may be believed to be
small, so small as to fail to impress its special characters on the
tracing (Fig. 24). A valuable sign of dilatation of the arch of the

20

aorta is acceutuatiou of the 2ud Sound, and when such accentu-
ation is pronounced we shoidd listen frequently and carefully
for the faint diastolic nun-nuu' that denotes commencing leakage.
Commonly this nuinnuv, when it first develops, is not jjersistent
but comes and goes, under various circumstances, for a time
before it is permanently established. Then, tiiere is the well
attested fact that even when the lesion is great and tlie i'eg\n-gita-
tion free, the cardiac diastolic murmur may be lost for a time, even
when the diagnosis can be easily made from the visible pulsation
of the larger arteries, and the diastolic murmur elicited ij}^
pressure with the stethoscope over the femoral artery. Tliis
may happen in acute febrile disease or intense disturbance "f
the circulation such as is often present for a day or two after
severe aortic cases have been admitted to hospital. It is easy
in such cases to predict the return of the diastolic murmiu-
provided the patient rallies.

There is no lesion that so rapidly produces dilatation of the
left ventricle as aortic incompetence. Its effects fall directly
upon the ventricle when it is relaxed, and dilatation of the
cavity ensues. Hypertrophy of the heart-muscle can only come
to stay such dilatation and to enable the ventricle to euipt}'
itself of its excessive contents. The first change resulting from
the lesion must be dilatation — that unmixed cardiac evil : till
it has occurred hypertrophy has no place.

Supposing that hypertrophy of the left ventricle lias oc-
curred, and that the ventricle is able to complete its systole,
an abnormally large cpiantity of blood is shot into the arterial
system. Is it surprising that an unusually long upstroke should
be the rule in aortic incompetence ? More than this the blood
jjressure in the arteries during the diastole of the heart has
been running down with most abnormal rapidity, there being a

21

backwanl as well as forward vent during the aittrial systole.
What wonder that the percussion wave should be exaggerated
and the tidal wave uusustained ?

The notch preceding the dicrotic wave is commonly known
as the "aortic" notch, and marks the closure of the semilunar
valves — the end of systole and the beginning of diastole. The
dicrotic wave may be regarded as the result of the rebound
from these valves. But if the valves are incompetent and leak,
such rebound must be deficient. Hence we find that the
dicrotic wave is diminished in aortic incompetence, and in cases
of very free regurgitation, in which the valves are practically
destroyed, the dicrotic wave is with difficulty discerned, or
absent. (B'igs. 27, 28, 29, 33.)

The peculiai'ity of the pulse in aortic incompetence may be
said to consist in the great difference between the maximum
and minimum blood pressure and the rapidity of transition from
the oue to the other. One moment the pulse is full " the
next " empty." This character of the pulse, first described by
Sir Dominic Corrigan, of Dublin, is intensified if the patient's
wrist is raised above his head while the finger is on the radial.
Again, if the forearm is grasped with the hand the pulsation of
the radial and ulnar arteries can be easily felt. For inspection
the larger arteries should be chosen, as the carotids and sub-
clavians, for in them the remarkable jerkiness of the beat is
most characteristic, but the smaller vessels are often seen to
pulsate with extraordinary distinctness, as, for instance, the
palmar arch.

In conclusion : the characters given to the sphygmogram by
aortic incompetence are a long upstroke, an exaggerated per-
cussion wave, an uusustained tidal wave, and a deficient dicrotic
wave.

24

Fig. m.

Fig. 37.

Fig. 38.

Fig. 24. Aortic dilatation, with incompetence of valves. Fig. "25.
Syphilitic Aortitis, slight incompetence of valves, and angina pectoris
from narrowing of coronary orifices. Female a?t. 27. Fig. 26. Exaggerated
percussion wave, small tidal wave, and defective dicrotic wave.
Rheumatic case xt. .35. Figs- 37 and .38. Showing irregularity-inequality
and intermission— in case of " degenerative " type of Aortic Incompetence.

25

Chapter III.
The Pulse in Mitral Stenosis.

Mitiul Stenosis may be regarded as tlie great mitral /esion.
No doubt endocarditis— rheumatic, and especially septic— may
so damage the valve-curtains that they can no longer completely
close the auriculo-niutricular orifice even with the help of a
sound heart-muscle, but in the great majority, if not in all such
cases, it is impossible to guarantee the functional integrity of
the heart-muscle under the circumstances, while we know that
failure of the heart-muscle, quite independently of its cause,
which may be important and permanent or unimportant and
transient, can render the valves, though perfectly healthy in
themselves, incompetent. In the next section I hope to
demonstrate that there is no pulse that has any claim worthy
of consideration to be called the pulse of mitral incompetence,
as was at one time supposed. When the mitral orifice is stenosed
it goes without saying that the valve-curtains are deformed,
and it is only likely that they should, either occasionally or
permanently, leak. And so we find that the murmur most
commonly present in cases of mitral stenosis is the murmur of
mitral incompetence, which directli/ has nothing to do with the
essential morbid condition present, namely, the stenosis.

In the early stages of the case — not of the lesion — the
sphygmogram that is usually found associated with mitral
stenosis is that of a regular pulse of good, one might almost
say high, tension showing a well-developed tidal wave, and in
fact nothing per se abnormal — a pulse compatible with good,
nay, robust health. This is the pulse that is usually associated
with the best development of the most characteristic ausculta-

26

toiy sign of the lesion, namely, the presystolic laurmur, but
there is no necessary association between the two conditions,
and I have found the presystolic murmur present witli a very
low tension pulse.

What may be termed the second stage of the pulse in mitral
stenosis is that most characteristic of the lesion, but one must
rid one's mind of any idea of its being pathounomomc of the
lesion. A precisely similar pulse is commonly present in cases
of simple muscle-failure of the heart. What I term the second
stage pulse of mitral stenosis is characterised by irregularity
and inequality of the curves. We see side by side and in all
degrees of preponderance of one or other, high-tension and low-
tension curves, the latter being generally more or less abortive,
or ill-developed in magnitude at any rate. A series of such
ill-developed curves is often interrupted by a well-developed
curve of the first stage, or the opposite condition may be met
with : that is to say, a long series of regular high-tension curves
is rarely interrupted by an abortive low-tension curve. If any
pulse is entitled to be called the pulse of mitral stenosis, it is
this " second stage," or irregular pulse, but, as I have already
stated, a precisely similar pulse occurs in cases of simple muscle-
failure of the heart, without any valve-lesion whatsoever.

What I term the third stage pulse is simply a low-tension
pulse, and generally regular.

Now it is most important that the three kinds of pulses I
have described as if they were phases in the clinical evolution
of mitral stenosis, should not receive a degree of prognostic
importance to which they have no title. Speaking very
generally, it is the rule for the first and second stages to be
represented, and the same may be said of the third stage if
observations are made up to the end of the case. But a patient

27

quite early in the evolution of tlie case may have a low-tension
—third stage— pulse, and yet be in no danger as far as his
heart is concerned. Often there will be an evident cause for what
we may call the " abnormal " condition, such as the presence of
fever, or there may be disturbed innervation of the heart, such
as produces temporary tachycardia. Again, unfortunately, the
retention of a regular high-tension pulse does not of necessity
justify a good prognosis. Lastly, in some cases the second stage
pulse is never observed. Far better that I should never have
mentioned stages in the description of the pulse in mitral
stenosis than have led — misled — my readers to an erroneous
belief fraught with the risk of erroneous prognosis.
Nevertheless, the three kinds of pulse described are
usually present in the course of cases of mitral stenosis, and in
the sequence indicated, and to a limited extent prognostic value
cannot be denied to them. Prognosis, however, any more than
diagnosis, can never safely be based on one feature of a case. A
comprehensive view of all the features presented is as necessary
in the making of a prognosis as of a diagnosis.

As most of my readers know, towards the end of a case of
mitral stenosis the direct murmurs— the presystolic perhaps
invariably, the diastolic frequently — disappear for a longer or
shorter period before the patient's death, and the only mitral
murmur present is a systolic one, in the majority of cases not
conducted to the back but there replaced by the first sound,
whether or not the first sound is present with the murmur at
the apex. A precisely similar auscultatory condition is met
Avith in that class of case which of all others resembles cases of
mitral stenosis, namely, simple muscle-failure of the heart. A
man may have had rheumatic fever in early manhood, and escaped
severe endocarditis and mitral stenosis, and in the late period

28

nf life hceoiue tlie sul)ject ot ihuwIl'- failure (wliicli luiiy be
regar.lecl as uhn,,.st phj-.sir.logical). may present at the car-
diacapex just sucli ii systolic mui-iimr as I have (li;seribed in eases
of mitral .stenosis, and his ])idse may be typically the second
stage pulse of this lesion, while the usual symptoms of disturbed
circulation— venous stasis— are present. Under such circum-
stances the history of the acute rheinnatic attack is apt to Ije a
stinnbling block for tiie physician, but the rule should be to
regard the case as a simple " muscle " one (senile) unless tiiere
IS a distinct history of cardiac disability in early middle age or
even before this. I have seen the two conditions— mitral
stenosis and muscle-failure — in several instances as it were,
independently condjined, the kidneys at the same time having
undergone ;i certain amount of granular degeneration — so
common in tiie old.

Fig. 39.

30

5

i^ig. 47

Fig. 4! I.

Fig. .")().

32.

Fig. 51.

Fig. 53.

Figs. 39, 40, 41. "First stage" pulses in mitral stenosis.
Figs. 42, 43, 44 " Second stage " pulses in mitral stenosis.
Figs. 45, 46, 47. " Tliird stage " pulses in mitral stenosis.
Figs. 48, 49, 50. Show three stages of pulse occurring in the course
of same ease.

Fig. 51. Bigeminal pulse in mitral stenosis. Heart and vessels at
time under influence of Digitalis.

Figs. 52, 53. Third stage and second (almost first) stage pulses. The
latter (53) taken during convalescence from symptoms of " venous stasis.

('HArTliR 1 \'.

The Pulse in Mitral Incompetence.

Our views with regard to tlio pulse iu cases of mitral regurgi-
tation have undergone considerable modification during the last
quarter of a century. Notwithstanding statements l)y high
authority to the contrary, f attirm witiiout hesitation that there
is no type of pulse entitled to be termed " the pulse of mitral
incompetence." The fact is that incompetence of the mitral
valves is met with nnder a great variety of conditions having
little or nothing in common apart from the mitral inccmipetence.

It mnst be l)orne in mind that mitral incompetence frequently
occurs without there being any disease of the valves ivJiatsoever.
To appreciate tlie fact one has to bear in mind that the mitral
valves, for the perfect fulfilment of their function, require the
co-operation of the contraction of the heart muscle. In two
ways at least the nuiscle of the heart is complemental
in the valve apparatus. Its contraction diminishes the size
of the orifice the valves have to close, and sustains the
curtains in action liy shortening the musculi papillares.
Long ago physiologists were acquainted with what they
termed "the safety valve action of the tricuspid valves " on the
right side of the heart, liy which term was understood the fact
that nnder strain the tricuspid valves permitted a certain
amount of regurgitation of blood, and that the occurrence was
for the immediate benefit of the organism and the temporary
relief of the ventricle. We now know that a similar occurrence
is common on the left side of the heart also, and that under
the influence of high arterial tension the mitral valves
frequently leak, although sound in structure and supported ])ya

33

practically sound — even hypertrophied — heart muscle. There is
a degree of arterial pressure iu face of wlach tlie heart-muscle,
however vigorous, cannot be expected to maintain its perfect
function. Moreover, considering tlie case as a whole, there
seems to be a limit to the continuance of hypertrophy when
established. As we found that it is the heart-muscle that
alone renders possible the full function of the auriculo-
ventricular valves on both sides of the heart, it follows that
muscle-failure of the heart renders incompetence of the valves
likely. Whether we increase the arterial tension or weaken the
heart-muscle — the driving force — the result will naturally be
much the same. We cannot therefore be surprised to find that
a patient with a manifestly strong heart and very high arterial
tension may suffer from most distressing breathlessness — the
first cardinal symptom of heart failure— in the same way as the
patient with a debilitated heart and low arterial tension may
do. In the former case the burden is too grievous even for a
vigorous heart ; in the latter case, though the burden is light
speaking generally, it is no less than in the former case too
sreat for the heart thas has to bear it.

In discussing the subject of mitral incompetence as the result
of muscle-failure, it is impossible to omit reference to that other,
and, in my opinion, more important condition usually involved,
in greater or less degree, in muscle-failure, namely, the no7i-
completion of systole — asystole or systole catalectic. We know now
that this condition, in which the ventricle fails to *empty itself
in the normal manner, is not limited to a short period preceding
the patient's death, but may be a chronic condition lasting for
years, now better, now worse, or a transient one, passing away
with recovered power and energy on the part of the heart-muscle.

* The supra-papillary space contains blood physiologically at the end
of systole.

84

I think I can convince my readers of tlie recoveriil.lciiess of this,
once supposed most lethal, condition l)y reference to a common
type of sphygmogram. A "missed beat" occurs, eitlicr a complete
intermission or a wretched abortive curve utterly nnlike its
fellows, then comes an upstroke of exaggerated length to form
a curve that is a giant among the rest. The obvious explana-
tion of this occurrence in a case of simple muscle-failure without
murmur surely is that the left ventricle has become distended
during the intermission and prolonged diastole even though this
be interrupted by an attempt at systole. The ventricle, how-
ever, is roused to supreme effort by the distension it suffers
and succeeds in completing, or nearly so, its systole, throwing,
at the same time, of course, an abnormally large amount of blood
into the aorta. It is impossible, in considering mitral incom-
petence, to ignore the cases of nniscle-failure of the heart which
are accompanied by all the disturbance of the circulation,
characteristic of heart-failure resulting from or accompanied by
valve defect, but which never develop a murmur, and therefore
presumably mitral incompetence. Such cases are not very rare,
and the obvious explanation of the disturbance of the circulation
in them is that the muscle-failure is manifested alone by the
production of systole catalectic. Why the auriculo-veutricular
valves do not become incompetent in these cases I do not know.
On the other hand, it is probable that in many, if not most of
the cases of mitral incompetence from muscle- failure the in-
competence is associated with systole catalectic in some degree.
Of a silent mitral regurgitation we have no knowledge.
Cases of mitral incompetence fall naturally into groups.
(1) Cases in which the valve-structures are themselves
damaged by rheumatic, choreic, or septic endocojditis in such
degree that their function is impaired.

35

(2) Cases of mitral stenosis, with the necessary deformity in
some degree of the valve curtains. These cases were considered
in last section, and need not be further referred to. Tlie
essential condition is the stenosis.

(3) The great group of cases of simple muscle-failure, in
considering which it is necessary to bear in mind (a) tlie work
to be done by the heart-muscle, and (b) the capability of the
heart-muscle to perform it.

(1) Five-and-twenty years ago rheumatic crippling of the
mitral valves, without stenosis of the orifice, was supposed to
be a common canse of mitral incompetence in such degree as
seriously to interfere with the circulation. The majority of
cases of severe rheumatic endocarditis end in mitral stenosis ; in
the remainder the disturbance of the circulation that may
follow cannot be attributed alone to the damage of the valves,
inasmuch as such damage is associated with other changes quite
as likely to have caused the disturbance of the circulation.
Among these changes are to be found adherent pericardium and
an evidently impaired heart-muscle irrespective of the valve-
lesion. The importance of adherent pericardium has probably
been over-rated, for the condition is not very rarely found with
a sound muscle. Of late, on the other hand, we have been forced
to recognise the fact that rheumatism can exert an injurious
influence upon the myocardium itself, and I am inclined to
think that the evident muscle-failure and dilatation, foimd
post-mortem, have been too often attributed to an associated but
altogether trifling valre-lesion. Many years ago, when I had not
been long Resident Medical Oflicer in the Manchester Royal
Infirmary, my belief in the importance of the changes wrought
by rheumatic endocarditis as the cause of mitral incompetence
and consequent disturbance of the circulation, received a severe

36

sliiike by a P.M. exainiiiiitioii of a rlieuinatic patient wlio had
shown the ordinary clinical signs of mitral incompetence from
valve lesion. 'IMie examination revealed practically sound mitral
curtains, with a, markedly dilated heart, the patient being a
woman in early middle age, in whom the ordinary causes of
simple muscle-failure, such as anajmia, Bright's disease, alcohol-
ism, ike, were absent. Subsequent experience has only served
to emphasise the lesson 1 received from this case. Before
writing this paper, however, I asked Dr. Kelynack to be so good
as to look over his records of P.M. examinations of my cases,
and to state his impressions received therefrom for quotation
here. He M'rites : " At your suggestion I have gone over the
P.M. notes of your cases for the past few years. It is remark-
able that out of the very large number of cardiac cases
examined — -a very considerable number being examples of mitral
stenosis— 1 have hardly been able to select a single case of what
I might call straightforward mitral incomjjetence from mitral
lesion pure and simple. From the list of cases I have sent you,
you will have noticed that several were to a great extent
' muscle ' rather than ' valve ' cases."

It seems quite clear that rheumatic endocarditis can no longer
maintain the high place formerly accorded to it as a cause
of mitral incompetence without stenosis. The latter is, as I
have said, the great rheumatic mitral lesion, although incompe-
tence of the valve in some degree is so often in subordinate
association with it.

Septic endocai'ditis no doubt is abundantly cajjable of so
damaging the mitral curtains that they must become not only
impaired in function but practically useless. Septic endocar-
ditis, however, is a disease so terrible in its other results that
this one becomes of quite minor importance.

37

(3) Our last gvoup of cases owe their mitral iiicompetence to
a great variety of patliological states which have little or
nothing in connnon except the element of muscle-failure of the
heart, and consequent niitrat incompetence. The nutritiou of
the heart-muscle may be interfered with by antcmia— one of
the most commonly met with examples of this group -or by
atheroma of the aorta implicating and narrowing the coronary
orifices— or by excessive work, as in conditions associated
with high arterial tension, such as Bright's disease, gout, and
plumbisra. Severe fever, as typhus, exerts a most debilitating
effect upon the heart-muscle, as was long ago shown by
Stokes, whose classical description of the auscultatory signs
present must be read later, and no doubt the results of
such a degree of weakening of the heart^muscle would
be more permanent were it not that fever is a most potent
reducer of arterial tension, thus lightening the load the heart
has to bear during its debility. In Bright's disease, however,
there may be antemia and high arterial tension in combination
for a time, the result often being rapid dilatation of the heart.
Of course, as the heart fails, the tendency is towards lowering
of the arterial tension.

Fig. 54.

41

Fig. r<3.

Fig. 77.

Fig. .->i. High tension pulse in Briglit's disease : mitral incomiietence.
Male aet. 38.

Fig. 55. High tension pulse in Pernicious Auc-emia : mitral incom-
petence. P.M. Male aet. 43.

Figs. 56 and 57. Low tension pulse in case of Septic Endocarditis :
mitral incompetence- pyrexia and progressive heart failure. 57. Dicrotic
wave nearly as high as percussion wave. P.M.

Figs 58, 59, 60. Alcoholic muscle-failure of heart : mitral incom-
petence—gradual recovery of tension during convalescence.

Figs. 61 and 62. Low tension : alcoholic muscle-failure of heart : mitral
inccmpetence. (62) Lowering of tension towards death.

Fig. 63. Common type of pulse-curve in simple anivmia (Chlorosis).
Mitral incompetence. Well-marked percussion wave ; small tidal wave.

Fig. 64. Low tension pulse of unusual form— in case of rheumatic
valve-lesion with mitral incompetence but without stenosis. Boy aet. 14
pericardium adherent. P.M.

Fig. ft). Showing "missed beat " in case of muscle-failure with systole
catalectic and mitral incompetence. P.M.

42

Fig. 1)6. liigcmiiial pulse. Case of alcoholic; muscle failui e : mitral
ineoinpetence. P.M.

Figs. 67—76. Showing changes in pulse during the course of tiie niusclo-
failure of Bright's Disease (granular kidney P.M.). Patient u as nearly
nine years under observation. When tracing l''ig. 67 (lowest tension) was
taken there was no mitral incompetence, which developed later : no
doubt there was systole catalectic. Figs. 67—73 were taken during
patient's first stay in hospital, and show progressive recovery of tension.
Fig. 74 shows the pidse to be Isigeniinal, probably due to digitalis. Figs.
7') and 76 show irregularity of the pulse, develo])ed only late in the case.
Patient usually came into Manchester Royal Infirmary with mitral
incompetence, the murmur disappearing as his heart regained strengtli.
Towards the end it became persistent.

Fig. 77. Low tension: rheumatic endocarditis without stenosis:
adherent pericardium. Rheumatic fever a year before. P.M. Man
aet. 25.

1

I

43

Chapter V. ■ "

Irregularity and Intermission of the Pulse, &c.

Irregularity of the pulse occurs iu a great many conditions.
It may be met with in cases of pericarditis, myocarditis, and
endocarditis, although these diseases are more usually accom-
panied by a regular pulse. More frequently it occurs in cases
of disturbed innervation of the heart and of degenerative
changes in the heart-muscle, which are often the result of
chronic arteritis of the coronary vessels. As instances of the
first variety may be mentioned, the irregularity often ex-
perienced by excessive smokers, and that observed in cases of
tubercular meningitis. Irregularity of the pulse may be due,
again, to various toxic agents absorbed from the alimentary
canal and the glands of the body generally or to various nervous
impressions received from other organs acting upon the heart
in a reflex manner. In the complicated cnrdiac nervous
system the influence of the pueumogastrio nerves is probably
most often at work in the production of irregular and inter-
mittent pulses. In some animals, as in dogs, the pulse is often
found to be irregular although they are in perfect health and
have excellent "wnnd." Patients who have habitually an
irregular pulse may acquire a regular pulse during jjyrexial
while those with habitually a regular pulse may acquire
an irregular pulse under the same condition. This
latter occurrence is very common in the old and in
those with degenerated vessels and heart-muscle. Lastly,
certain individuals apparently in perfect health have always an
irregular pulse, like most dogs. I know several such individuals
who lead very active lives before the public and who yet have

44

li:il)ilii;LlIy iiTognlai- pul.ses. Figs. SO, 81, and 82 are tracings
from the pulses of such individuals.

'Vhe simplest form of irregularity may be considered to he
occasional intermission. Usually a beat is omitted— the so-called
missed beat — but the sphygmogram may indicate an attempt at
systole on the part of the ventricle which is imperceptil)le by
palpation of the radials. Most healthy individuals at one
time or another have had experience of tiie sensation in the
chest produced by the momentary halt of the heart's beats and
by the throb of the beat that follows such halt. I have
already commented on the state of the left ventricle during
the intermission — a state probably highly dangerous to the
sufferer from aortic incompetence. In one case of the kind, I
was particularly struck by the duration of the intermissions,
and the patient died suddenly a few hours later.

Irregular pulses have been already described as common iu
cases of mitral stenosis and of muscle failure of the heart, and
it has been shown that tracings from such pulses in the two
conditions are indistinguishable. It may be said that the two
elements of the tracing of this type constitute the irregular
pulse in general, but their degree of development and their
grouping vary indefinitely and a tracing often shows both
irregularity and intermission. The term " inequality " is used
by some writers to describe the different size of the curves, but
such difference in size is often associated with a difference in
type as well — the large curves tending towards the high tension
type, the small ones towards the low tension type. There may
be a definite arrangement of the irregular beats, so that the
pulse is " regularly irregular," if one may so say : this has
been called "rhythmic irregularity." The commonest type
is the " bigeminal pulse," the occurrence of which is so

45

COlUlllOU

often promoted by Digitalis, although it is
enough independently oF any drug. It is peculiar to no one
lesion and frequently occurs in simple muscle cases. One of the
examples, Fig. 83, was taken from the pulse of a gentleman,
whom I had passed for assurance at the ordinary rate a few
months previously, his pulse and heart being then apparently
quite normal. Subsequent experience has shown that the
attacks of this peculiar derangement are, in his case, quite
transitory, although they cause him considerable discomfort for
the time. Possibly they are of toxic origin, as the patient is
comparatively young : about 40. Not long ago I took a tracing
of the pulse of a chlorotic girl, that is a perfect specimen of
the bigemmal pulse. In this ease, likewise, the condition was
of short duration, and the muscle-failure of the heart seemed to
be no more than is common in pronounced cases of ansemia.

I have met with the trigeminal pulse in one case only — a
case of simple muscle-failure iti a man over middle-age. (Fig. 84.)

Fig. 85 represents a pulse occurring in groups of four beats
(pulsus quadri-geminus), each group being separated by short
intermissions, but it will be seen that these groups of four
are very different from the bigeminal and trigeminal groups
of two and three, inasmuch as the curves that compose
the groups of four are of equal magnitude, while in
the other cases they diminish onwards. I should regard this
pulse rather as an example of intermission occurring at regular
short intervals.

It is often impossible to recognise any order in the arrange-
ment of the unequal curves of irregular pulses, " arhythmic
irregularity," individual curves of most different type and
magnitude being huddled together in the wildest disorder. For
such condition the fanciful term "delirium cordis" has been
used. (Fig. 89.)

48

The Pulse in Aneurysm. It is common to find one radial
pulse diminished in iutra-thoracic aneurysm. 'IMie usual ex-
planation given is the interposition of the elastic sac between
the henrt and the pulse, but there are obviously other ways in
wliich such an aneurysm may interfere witli the pulse of one
side, as ))y the pressure of the sac on the outside of the
left sub-clavian trunk. Moreover, as already jtointed out,
local disease — atheroma — of the origin of the subclavian
may interfere with the pulse on one side quite indepen-
dently of any aneurysm. In rare cases of intra-thoracic
aneurysm both radial pulses, may be abolished, although
the circulation and nutrition are well maintained in the parts.
Such a case came under my observation a few years ago, and a
similar case is described in Dr. Fagge's "Practice of Medicine."'*
The usual sphygmogram of a radial pulse interfered with by an
intra-thoracic aneurysm is characterised by a sloping up-strolve
and down -stroke and rounded top, the different waves becoming
obliterated, till finally the tracing is represented by a merely
undulating line. (Fig. 101.) It is evident that the attainment
of the maximum height of the curve will be delayed on the
affected side. ' .

Bradycardia, or slow pulse, is sometimes an individual
peculiarity. Napoleon the First, it is recorded, was the subject
of bradycardia. No better evidence of the fact that bradycardia
need exert no injurious effect upon the nutrition of the brain
could be adduced. I think I have read of Napoleon that he
had a singular power of going to sleep again after being aroused
in the night. His brain seemed to spring at once into its normal
marvellous activity, and its function for the time having been
discharged it would pass almost at once into repose again. If

*p. 107, Vol. II, 3rd Edition.

47

this were so, one cannot lielp associating the faculty with the
slow pulse. Fig. 99 represents the bradycardiac pulse in a case
recently in the wards :— pulse 30 to 40. Tliis patient, like
many sufferers from bradycardia, was subject to syncopal attacks
or faints as they are popularly termed, but the relation of such
to epileptic seizures is a close one. Occasionally in severe fever,
as typhus, a bradycardiac pulse is met with, and in diphtheria
it is a very dangerous condition. It is common in jaundice.

Tachiicardia, or frequent pulse, occurs in many circumstances.
An attack of "palpitation" may usually be regarded as an
attack of tachycardia, but they are not equivalent terms. A
patient with tachycardia may be quite unaware of the condition
while a patient with a quite moderate frequency of his pulse
may be distressingly aware of his heart's beats. Fig. 91 repre-
sents the pulse of a patient with diabetes, who experienced a
short attack of tachycardia — rate 200 per minute. His normal
pulse is represented in Fig. 92. In diphtheria a condition of
tachycardia as well as bradycardia may be met with, and the
one is of as bad prognosis as the other.

There is no pulse that is characteristic of Pericarditis. A
great degree of irregularity in severe cases is not rare (Fig. 78)^
while the accompanying fever exerts its usual influence in
lowering tension. Dry pericarditis is common in granular disease
of the kidney with enlarged heart, and under the circumstances
there may be little or no pyrexia, while the pulse shows no
material departure from its normal.

The typical pulse-tracing of pyrexia (Fig. 100) is simply a
low-tension one, often showing well marked dicrotism, the
dicrotic wave being so well developed that it often becomes
perceptible to the finger. As already stated, pyrexia is a
powerful reducer of arterial tension. I think one of the mosl
hyperdicrotic pulses, of which I ever took a sphygmogram,

48

occurred in a man with granular disease of the kidneys wlio
was brouglit into the Infirmary apoplectic from cerebral
luemorrhage. As the coma deepened his temperature rose to a
great height, and he had no doubt paralysis of his vaso-niotor
controlling nerve-centre, resulting in dilatation of the arterioles
throughout the body. In all probability this patient had had
habitual high arterial tension before the cerebral hjemorr-
hage occurred. In such cases heart failure is often the less of two
evils, as it diminishes the risk of apoplexy in the presence of
habitual peripheral resistance in the vessels and high tension.
A great clinicist went so far on this accoiuit as to regard the
failing heart of advanced years as a "conservative lesion."
The irregularity and intermittence and certain rarities of the
pulse in fevers have already been referred to.

When Dr. Bright first described the disease that bears his
name he recognised the cardiac hypertrophy that is so marked
a feature of most chronic cases, but perhaps he hardly dwelt
sufficiently upon the termination of the hypertrophic condition
he described. In most cases the period of hypertrophy is a
limited one, and sooner or later the mass of muscle tends to fail
in vigour, so that all the common indications of muscle-failure
of the heart are apt to arise, and in this relation it is necessary
to bear in mind the vascular tension with which the heart has
to cope. But I have sufiiciently in the foregoing chapter
referred to the matter. Here I wish only to point out that
cases vary greatly as to the duration of the stage in which the
heart-muscle remains vigorous and the sphygmogram one of
high tension, that the state of hypertrophy may never be
established, that dilatation may be rapidly induced with lower-
ing of arterial tension, and lastly that not all cases of Bright's
Disease— not even of the granular form— are associated with
circulatory disturbance.

49

I have already described the pulse of simple auamia — tiie
exaggerated percussion wave, small tidal wave, and well-marked
dicrotic wave of its sphygmogram (Fig. 63) - also the pulse I
have observed in several cases of pernicious aufcmia. (Fig. 55.)
IJiit lest I should lead anyone into error by seeming to imply
that [ regard the latter pulse as pathognomonic, I add in the
present section the tracing of a patient with this grave disease
taken towards the end of the case when the heart had
greatly failed. (Fig. 95.) I had no means of ascertaining the
state of the pulse in the earlier stages of the disease.

Influence of inspiration (especially deep) on certain pulses : —
This occurs in striking development in cases of Mediastinitis
a rare disease that is met with specially in children. My
colleague, Dr. Harris, has kindly permitted me to make use of one
of the sphygmograms contained in his well-known monograph on
the subject. (Fig. 96.) During inspiration it will be noticed that
the pulse-curves become markedly diminished. A less degree of
the same phenomenon may occasionally be seen in cases of
(probably) free mitral regurgitation and Sir Wra. Broadbent
has suggested that in these latter cases the regurgitation is freer
during the act of inspiration so as to diminish the output of the
left ventricle into the arterial system. In the former cases
there is probably intei'ference with the great arteries during
inspiration owing to the adhesions and matting together about
them.

I show illustrations of the pulse in Cheyne-Stokes respiration.
(Figs. 97 and 98.) In these it will be seen that the arterial
tension rises during the dyspnoeal period. The accompanying
phenomena of Cheyne-Stokes respiration seem to vary in detail.
In one case the pulse was slowed in so marked a manner
during the dyspnoeal period that the respiration became more
frequent than it.

50

I have l)ueu iinalile to duinonsti'iite tlu; i-isu u\' bluud-pressnre
tliiit is alleged to Ije tlie deteriiiiniiig cause of attacks of angina
jjectoris. It docs not follow necessarily that liccause vaso-
dilators I'elieve such seizures that rise of pressure is the cause
of the attacks. The heart is undoubtedly embarrassed in action
in seizures of the kind, and any relief afforded to it by vaso-
dilators would no doubt be beneficial. It has always seemed
to me, in discussions on angina pectoris in relation to a rise of
arterial pressure as its immediate cause, that the fact of the
pain itself being capable of acting as a vaso-constrictor has been
too much overlooked. Certainly morphia is the great remedy
that one has usually to fall back upon when vaso-dilators have
spent their powers of aftbrding relief.

There are few conditions of disease in which a sphygmogram
cannot be taken, but it is open to question if the time and
labour" spent on proving the truth of the rule : " there is no
pulse of which a tracing cannot be taken," are fairly compen-
sated seeing that the result is likely to be of only very moderate
value. In such circumstances it may be legitimate to take the
tracing while the radial is compressed below, a proceeding which
does not fundamentally alter the character of the tracing, that is
to say : high-teiision curves remain high-tension curves and
low-tension curves remain low-tension curves.

A few months ago in a case of heart-failure in Bright's
disease with distressing dyspnoea the pulse could only be felt
with difficulty, but a carefully-taken tracing showed a pro-
nounced tidal wave.

Again, the walls of the radial arteries may be so profoundly
changed in structure that the vessel feels like a row of beads
owing to calcareous deposition and in such a case sphygmo-
graphy is inapplicable.

51

r possess a large number of sphj'gmograms from cases of
various diseases not directly associated witli the circulation :
the tracings have often shown characters that one would not
have expected them to show. Tlie subject, however, is too large
a one to enter upon here and it would besides be out of place.
I do not think, however, that many varieties of pulse-curve will
be found to have escaped reference entirely. After all, the
whole subject of sphygmography is composed of simple elements.
These simple elements, their more important modifications and
combinations in the single curve and in the series of curves that
constitutes a pulse-tracing, I have attempted to sketch only.
The study of the subject in detail must be made at the bedside.
" La verite est dans les choses."

Fig. 79.

Fig. 84.

Fig. 85.

53

Fig. 90.

Fig. 91.

55

Fig. 102.

56

Fig. 103. 1.

Figk 105.

Fig. 78. Irregular pulse in case of pericarditis.

Fig. 79. Irregular pulse in case of senile muscle-failure of heart with
slight mitral incompetence.

Figs. 80, 81, and 82. Irregular pulses in apparentli/ quite healthy active
individuals.

Fig. 83. Bigeminal pulse temporary condition in an apparently sound
man. Case referred to in text.

Fig. 84. Trigeminal pulse in man with muscle-failure of his heart.

Fig. 85. Pulse-beats occurring in groups of four. Case of rheumatic
mitral disease in young woman.

Figs. 86, 87, and 88. From case of muscle-failure due to alcoholism,
showing at different times during patient's stay in Hospital, an irregular
j)ulse, a regular pulse of good tension, and a low tension pulse during
tachycardia — 160 per minute. The transition from a condition amounting
to "delirium cordis" to a normal state as in Fig. 87 was often very
abrupt, so that in quarter of an hour Figs. 86 "and 87 might have been
taken.

57

Figs. 89 and 90. From case of " Gouty Kidney " (granular) with heart-
ure. Showing temporary irregular pulse and the normal pulse of the
patient.

Figs. 91 and 92. From a case of Diabetes. Showing transient tachy-
cardia and normal pulse of individual.

Fig. 93. From case of mitral and aortic disease with much enlargement
of heart in a young man. Tracing shows the up-strokes commencing before
the dicrotic wave is completed. Sir William Broadbent has called
attention to this feature.

Fig. 94. Alternating pulse in a case of senile muscle-failure.

Fig. 95. Low tension pulse from case of pernicious anajmia with
advanced lieart-failure.

Fig. 96. Pulse in Mediastinitis. From Dr. Harris's work on that
disease.

Figs. 97 and 98. Tracings taken during the apnceal and dyspnceal
periods of Cheyne-Stokes respiration in a case of " Granular Kidney "
with heart-failure. During the latter period the pulse is slowed and of
higher tension (the upper tracing).

Fig. 99. Tracing of pulse in case of Bradycardia referred to in text.

Fig. 100. Low tension (febrile) pulse in Enteric Fever.

Fig. 101. Aneurysmal pulse.

Fig. 102. Tracing of unaffected radial pulse of same patient.
Fig. 103. Aneurysmal pulse.

Fig. 104. Tracing of unaffected radial of same patient.
Fig. 105. Pulse in Graves' Disease (exophthalmic Goitre),

t

I