A Clinical Study of the Pulse 
BY 
C. F. Hoover, M. D. 
CLEVELAND 
Professor of Physical Diagnosis in the Medical Depart- 
ment of Western Deserve University 
Reprint from the Cleveland Journal ok Medicine 
May, 1897 A CLINICAL STUDY OF THE PULSE 
BY C. F. HOOVER, M. D. 
Professor of Physical Diagnosis in the Medical Department of Western Reserve University 
TO determine what treatment of the vascular system shall be adopted 
in any given case demands a careful review of all the possible signs 
that can be elicited by physical examination. The heart, its size and the 
relative size of its chambers, the large vessels at the base of the heart, the 
carotid, brachial and femoral arteries, the peripheral vessels, the undulations 
and pulsations in the large cervical veins, and even a study of the retinal 
arteries and veins may often be of service in making an eliminative diagnosis 
of vascular disease. After the clinician has satisfied himself as to the patho- 
logic situation there is no field in medicine (barring, perhaps, syphilis and 
malaria) in which the therapeutist feels himself so sure of his ground, and 
there is no field in which he dare proceed with the administration of thera- 
peutic agents to procure a definite effect with so much assurance as in 
diseases of the vascular system. 
I wish this evening to call special attention to the tactile study of the 
pulse, and what that study may teach us regarding the pathology of the 
central and peripheral vascular organs. I fear this study has been much 
neglected by the modern physician. The medical men of the past century 
made very careful studies of the tactile pulse sensations, but their ignorance 
of the physiology of the circulation led them to apply terms of such mystic 
meaning to pulses of certain qualities, that in the beginning of the 
present century, when the physiology and pathology of cardiac diseases com- 
menced to assume the form of a natural science, the ancient pulse-sensations 
were thrown aside with their misleading terminology. Clinicians since that 
time have been occupied chiefly with the study of the heart-signs, to such 
an extent that even in diseases of the heart's valves the pulse manifestations 
are very lightly treated. Think for a minute of what the pulse is a product, 
and how its various modifications may give us a clue that will lead to the 
Read before the Cleveland Medical Society, April 23, 1897 4 
detection of the pathology of the pulse-factor. I use the term pulse-factor 
in its literal meaning. 
The pulse of the radial artery, as we see and feel it, represents the correla- 
tive action of the myocardium, the four chambers, and valves at the auricular 
and arterial orifices; the elasticity of the aorta, and large and small vessels, and 
the muscular element of the arterial walls and their exquisite vasomotor 
equilibrium. Beyond and besides the vessels, the state of the capillaries and 
the specific gravity of the blood are all factors in modifying the regular 
movements seen in an artery accompanying each cardiac cycle. The quali- 
ties of a pulse, which it is my invariable rule to consider in examining a 
patient, are its rate, rhythm, regularity, volume, relative duration of anacro- 
tus and katacrotus, any interruptions in the anacrotus or katacrotus, the 
compressibility of the pulse and nature of the arterial walls. These pulse' 
elements can be studied far better by the touch and sight than with the 
sphygmograph. What one cannot feel is often plainly visible at the bend 
of the elbow, in the superficialis volac, or a superficially placed radial or ulnar 
artery. A fortunate circumstance is, that in nearly all cases in which there 
is a departure from the normal, these pathologic elements make the pulse 
more plainly visible than in the normal state. A trained finger can palpate 
all of the pulse-phenomena that the sphygmograph can show, and generally 
we can see far more than either touch or instrument can detect. The excur- 
sion of the artery as a whole must be eliminated in purely instrumental studies 
of the pulse. The sphygmograph gives tracings from an artery in a fixed 
position, under a constant pressure, whereas the finger varies the pressure to 
accommodate the arterial excursion, thus enabling us to detect oscillations 
that a given pressure from the sphygmograph may mask completely. In 
feeling the pulse the most frequent error is in using too strong pressure, 
thus masking the fainter oscillations to the tactile sense. 
1 have made it a rule to make a graphic record of the pulse as it can be 
seen and palpated. These records I regard as better pulse-tracings than 
could be made with the sphygmograph. The recent work of William E. 
Ewart on pulse-sensations, or a study in tactile sphygmography is a beautiful 
demonstration of the superiority of the tactile method of studying the pulse. 
Merely a study of the radial pulse is not sufficient. There may be very marked 
changes in the carotid circulation and little to attract our attention in the 
brachial or femoral area. I have seen clinically marked arterial sclerosis of 
the brachial arteries and none in the carotids or femorals, and also advanced 5 
sclerosis of the dorsalis pedis on both sides and no sclerosis elsewhere dem- 
onstrable. The following case shows very well the possibilities of regional 
arterial disease. 
A man 40 years of age complained of severe headaches, lasting for two 
weeks. He was unable to sleep and was forced to remain idle because of 
the persistent pain. The radial artery was of moderate rate, regular, rhythmic, 
moderate volume, monocrotic, easily compressed; the arterial wall showed 
fibrous thickening. The aortic second sound was loud, high-pitched, ringing 
in character and distinctly palpable. Looking for the source of this accentu- 
ation, I found the carotid pulse entirely different in character from the radial; 
at the same time I was struck with the inconsistency between the carotid 
blood-supply and the marked pallor of the man. The carotid pulse showed 
with every cardiac systole a marked excursion, a distinctly visible primary 
ictus followed immediately by an oscillation high in the descending arm, 
so as to give the pulse almost the bisferiens type. The descent of the pulse was 
slow, decidedly that of the tardus type. Here was the key of the situation. 
The accentuation of the aortic second, the high interruption in the katacrotus, 
the long duration of the descending arm of the pulse and the pallor of the 
patient were due to one thing, viz.: increased peripheral resistance in the 
carotid distribution. Trinitrin, 1-100 grain in tablet form, was given every 
four hours. In two days the patient returned, saying he had been directly 
relieved from his headache. After taking the tablets he would be seized 
with a sense of fullness in the head that lasted only a few minutes, followed 
directly by entire relief from the headaches. The aortic second sound was 
no longer accentuated. The carotid pulse was scarcely visible. The peri- 
pheral rebound was gone. The pulse was more nearly monocrotic in char- 
acter. There was a little more color in the patient's face but the change 
was not at all marked. The trinitrin was stopped in four days. Two weeks 
after the administration of trinitrin was stopped there had been no return 
of the headache and the change in the carotid pulse persisted. The radial 
pulse did not change its character at all during the administration of the trin- 
itrin. 
By pulse-rate we mean the number of beats in a given time. Pulse- 
rhythm is the constancy of the pulse with reference to the lapse of time be- 
tween the beats. Pulse-regularity is the constancy of the pulse with refer- 
ence to size. The pulse-volume is difficult to determine; indeed, it can only 
be compared within wide limits. The excursion of the artery is not a faithful 6 
index of the quantity of blood forced into the aortic system with each systole 
of the ventricle. We may have marked excursion of the artery under high 
tension, and at the same time have bloody pulmonary edema from stasis in 
the pulmonary circulation. The actual enlargement of the arterial caliber 
during the systole is so slight that it is only within wide limits that we can 
make any relative observations. Our sense of volume of the pulse is con- 
trolled by the tension of the arterial wall during the heart systole as it is per- 
ceived by the finger. It is true that it is not simply the acme of tension but 
the extent of the oscillations accompanying wall-tension that we appropriate 
for our estimations of pulse-volume. This, too, may be exceedingly mis- 
leading. 
I have on several occasions seen men with arterial sclerosis and increased 
peripheral resistance, suffering from dyspnea on exertion, and showing the 
following signs; slight enlargement of the heart to the left, strong apex 
impulse, loud systolic and loud diastolic tones; the arteries empty between 
the beats; a long anacrotus and strong ictus, followed by a long katacrotus; 
a capillary pulse visible in the finger-nails; the excursion of the entire artery, 
from the inner aspect of the arm to the radial at the wrist being plainly visible; 
the pulse-rate 70-80. Here are no evidences of valvular lesion, but of 
myocardial insufficiency attending physical exertion (that is, dyspnea), and 
at the same time an apparently large amount of blood coursing through the 
aortic system with every heart's systole. I put these same men on trinitrin 
1-100 of a grain. In a few days they returned to the clinic much improved, 
and with no more dyspnea. The systolic and diastolic tones were much 
diminished in their intensity, the apex pulse not so strong. The artery on 
the inner aspect of the arm was scarcely visible during the heart's systole, 
the capillary pulse much diminished; the anacrotus was shorter, the ictus 
much fainter, and the katacrotus of much shorter duration, and still the 
heart's rate exactly the same. If we were left to judge of the relative pump- 
ing power of the left ventricle in these cases with only the character of the 
pulse to guide us, we would have to estimate the pumping power before the 
administration of trinitrin as having been greater, but in reality the pumping 
power must be greater after the effect of trinitrin is apparent. The number 
of heart-beats is the same and there is no dyspnea on exertion, which is suffi- 
cient proof that the left heart is more efficient under the lowered than under 
the high tension. The prevalent habit of describing a pulse as of high or 
low tension is not sufficiently accurate for careful observation; we may 7 
have high tension, as under the circumstances above described, or we may 
have a very small pulse with high tension, as seen in cases of mitral stenosis. 
Here the left ventricle is not suffering, but the left auricle and right ventricle 
are bearing the brunt of the lesion, and there is no necessity for relief of the 
left ventricle by relaxing the arteriole system as in the case of mitral insuffi- 
ciency. The word tension, as generally used, comprises two elements- 
namely, size and compressibility. Extremely low tension, attended with 
relaxed peripheral vessels, may be misleading as to the heart's working 
capacity. Often in the course of typhoid-fever the pulse would indicate an 
extreme impairment of the myocardium. The artery offers very little resist- 
ance to pressure of the finger, but there may be no dilatation of either side 
of the heart and no stasis in the pulmonary circulation. The anacrotus is 
lengthened when there is some peripheral impediment to the work of the 
left ventricle, and in cases of obstruction at the aortic orifice. The pulsus 
bisfericns I have seen only in aortic stenosis. One case which occurred at the 
City Hospital last summer showed, besides evidences of mitral stenosis and 
insufficiency and aortic insufficiency, also evidences of aortic stenosis in the 
form of pulsus bisfericns, which could be felt and plainly seen along the 
carotids and brachials and radials. The autopsy showed a rigid mitral orifice 
from calcareous deposits following old endocarditis. The orifice was much 
stenosed and insufficient. Two of the segments of the aortic valves were 
rigid with united edges projecting as a calcareous plate into the aortic orifice. 
The third segment was much shrunken from old endocarditis. The pulsus 
bisfericns is very unique in its character; once seen it can never again be 
overlooked. With each systole of the heart the pulse in the artery shows 
two sharper elevations at its summit, with a sharp depression between them 
of very short duration. These two elevations are due to the obstructing 
plates at the aortic orifice intercepting the expulsion of blood from the ven- 
tricle. The anacrotic pulse occurs in the so-called button-hole mitral and 
aortic orifices. The hypertrophied left auricle during its contraction throws 
a wave into the aortic system which is under a minimum tension during the 
cardiac diastole. The auricular pulse being directly followed by the stronger 
ventricular pulse gives a further elevation in the anacrotus. The anacrotic 
pulse and pitlsus bisfericns may be strongly simulated in the carotid in high 
arterial tension when the primary ictus from peripheral rebound is met by 
the secondary wave of rebound following the closure of the aortic valves. 
The summation of these waves will sometimes give a second elevation higher 8 
than that of the original wave, but the difference lies in the fact that in the 
anacrotic pulse and pulsus bisfericns the double summit occurs during the 
systole of the left ventricle and before the aortic valves have closed, whereas 
the second elevation under discussion requires the reflected wave from the 
closure of the aortic valves to complete its form. This is in reality dealing 
with the katacrotus. I shall not occupy any time in dealing with the pulse 
of high tension as seen in arterial sclerosis, but will mention only a few of 
the changes in the katacrotus that are apparently inconsistent with the patho- 
logic causes. There are two signs in the arteries associated with aortic in- 
sufficiency which are referred to the low arterial tension as an essential con- 
dition for their occurrence. Their presence is often indeed regarded as a 
safe indication for the administration of digitalis. They are a tone heard 
over the large arteries during the cardiac systole, and the capillary pulse. 
These two signs are of all the more interest to me in view of the fact 
that recently, from Schroeder's clinic in Vienna, there were reported 
several cases described as pseudo-aortic insufficiency having these 
two signs as a basis for the new terminology. I have had two men during 
the last two years who illustrate very well the causes of those two signs. 
The first, a man with dyspnea'and pulmonary edema with marked ausculta- 
tory signs of aortic insufficiency. The pulse was of short duration, but to 
my surprise there was no capillary pulse. The radial artery appeared to be 
contracted on its volume of blood, offering resistance to the sudden arterial 
excursion which occurs in this disease. Under trinitrin the man returned in a 
few days with the dyspnea and cough much improved and a distinct capillary 
pulse. Another man, a dock-laborer, while working in the hold of a vessel, 
was suddenly seized with dyspnea, nausea and extreme weakness; he strug- 
gled with difficulty to the deck and walked to his house, where he remained 
quiet for two weeks, but his strength did not return. He appeared at the 
clinic, a large, well-developed, muscular man. The heart's apex behind the 
sixth rib in the nipple line, very loud, clear systolic tone at the apex and a 
loud diastolic tone over the aortic area, the aortic closure being distinctly 
palpable. The pulsations along the radial and ulnar arteries were distinctly 
visible. The brachial showed a high interruption in the katacrotus, with a 
long descending arm. The arteries were empty between the beats. Taking 
the finger-ends in one's hand a very distinct expansion with every heart-beat 
could be felt. There was a capillary pulse distinctly visible in the finger-nails, 
and a loud systolic tone was heard over the femoral and brachial arteries. 9 
This is a picture of what may be termed pseudo-aortic insufficiency, were 
there any ground for the introduction of such a term into medical literature. 
After taking trinitrin gr. 1/100 every three hours for several days the patient 
returned with an entirely different picture. The heart's impulse and tones 
were greatly diminished in intensity, the pulse was of much shorter duration, 
the ictus was moderate, the brachial pulsation was only slightly visible, 
systolic tone in the large arteries no longer audible and the capillary pulse 
only slightly apparent. 
Here are two cases in which both were benefited by trinitrin; in the one a 
capillary pulse is made to appear when absent, in the other it is made to 
diminish when present, and both by dilating arterioles. The first case is per- 
fectly clear. In the second case we have an increased muscular resistance 
from the arterioles, a moderate selerosis of the large arteries and loss of 
elasticity of the aorta. A strongly contracting left ventricle forces its con- 
tents into an aorta that cannot expand to accommodate the new accession of 
fluid, nor do the smaller arteries, (because of their rigidity) absorb as much 
of the tidal blood-wave as they should, so that the strong myocardium forces 
its wave directly into the capillaries. Relax the arterioles, there is a larger 
reservoir offered for the reception of blood from the heart, and the force of 
the heart's contraction is so much diminished that though the large arteries 
may be as empty between the beats as before the use of trinitrin there is no 
systolic tone audible over them and the capillary pulse is much diminished. 
If the elasticity of the aortic wall be lost, the pulse in the radial artery can have 
only the duration of the heart's systole, thus making the katacrotus very short. 
On the other hand hyper-elasticity of the aorta as it occurs in congenital 
small aorta is attended with a pulse of short duration in the large arteries and 
a loud systolic tone over the femorals, because of the rapid and complete 
emptying of the arteries during the heart's systole and diastole. In severe 
anemia following hemorrhage, (with marked hydremia) there is marked short- 
ening of the katacrotus because of the vasomotor relaxation and the lowered 
specific gravity of the blood. There is an increased peripheral leakage which 
gives the same pulse modifications that a central leakage would give, for 
instance, in aortic insufficiency. 
In septico-pyemia attended with marked dilation of the peripheral ves- 
sels, the capillary pulse was so marked that it could be plainly seen by one 
standing at the bedside as the patient's hands were lying outstretched on the 
coverlet. In this same instance, too, the tone in the carotids, brachials and 10 
femorals, accompanying the heart's systole, was as loud as ever I heard it in 
aortic insufficiency. The tone was like the so-called "pistol-shot" tone of 
aortic insufficiency. The sudden spanning of the arterial wall was distinctly 
palpable. In listening over the heart's apex and base there was a distinct re- 
duplication of the first sound, the second element of which was arterial in 
origin. The autopsy revealed no disease of the heart or arteries. 
In administering drugs to affect the vascular system, this question always 
arises, are we to relieve the heart's work by diminishing its resistance? Are 
we to stimulate the myocardium to renewed efforts? or is there some faulty 
metabolism, the products of which have a toxic effect on the myocardium, 
and should our attempts be directed in the line of inhibition of this faulty 
metabolism? 
Nitroglycerin in tablet form is the most convenient method of dimin- 
ishing the peripheral resistance. In the earlier stages of arterial sclerosis 
when the vasomotor reflexes are exaggerated and the clinical signs are those 
of increased myotatic excitability of the vascular system the results are often 
brilliant and not of short duration. One often sees arterial tension remain 
lowered and the heart's work much relieved for months without any treatment 
whatever. 1/100 grain four times a day is a safe dosage at the start, gradually 
increasing the number of doses until the desired result is obtained, or the 
throbbing headache forbids further use of the drug. If no effect is procured 
from the use of the tablets use the 1% solution in drop doses before abandon- 
ing the trinitrin. One patient I had under observation used five drops of the 
1% solution every half hour for an entire week without any good or evil 
results. Nitrite of amyl however, inhaled in drop doses three times daily 
gave great relief. 
An employee of the City Hospital whom I had occasion to examine 
over a year ago showed no signs of heart or vascular disease at the time, and 
had no illness whatever during the past year. Last fall the patient com- 
plained of severe precordial pain, palpitation and dyspnea. Examination 
revealed a rapid arrhythmic pulse of short duration, moderate volume and 
easily compressed, with no arterial thickening. The left border of the heart 
was nearly two fingers external to the nipple line, and the right border at the 
midsternum, the pulmonic closure distinctly palpable at the second interspace 
to the left of the sterum. There was a loud blowing systolic murmur over 
the apex and over the base of the heart to the left of the sterum. The pul- 
monic second was much accentuated and reduplicated. Digitalis and strych- 11 
nin had no effect. Trinitrin in doses of 1/200 grain caused violent headache 
without affecting the heart. Inhalation of a half a drop of nitrite of amyl gave 
immediate relief. The doses were repeated three times daily. Within a few 
days the pulse became perfectly rhythmic, the murmur disappeared. The 
heart's area of dullness extended from the nipple line to the left border of the 
sternum. The dyspnea disappeared and with it all evidence of increased ten- 
sion in the pulmonary circulation. Since that time the patient has had several 
returns of her difficulty, each time being relieved by the nitrite of amyl. In 
the intervals the patient does her work as a cook, which makes no small 
demand upon her physical powers. 
Another man, 23 years of age, a sailor, suffered for three years from 
severe pain under the left shoulder-blade, which always became more severe 
after exercise. He says his pulse three years ago had a rate of 48-50 a minute 
and was very strong. He has noticed that it has gradually been growing 
weaker and more rapid, and recently he noticed arrhythmia. The pain under 
the shoulder-blade is now constant. There is also severe pain in the pre- 
cordial region and left shoulder and he has been much disturbed by growing 
nervousness. 
The pulse-rate on December 5, 1896, was 100, of fair volume, short dur- 
ation and easily compressed. There was moderate arrhythmia, slight irregu- 
larity and marked thickening of the arterial wall. There was no edema, 
dyspnea nor distention of the cervical veins. The hearts' apex is in the fifth 
interspace in the nipple line. There was no palpable thrill or valve-closure 
over the heart. Over the aortic area, at the second interspace to the right of 
the sternum, there was a low pitched murmur of moderate intensity during 
the systole. The aortic closure was high-pitched, ringing in character. 
There was no retinitis or papillitis, no albumin or sugar in the urine. A 
careful search for all the signs of aortic aneurism other than those above men- 
tioned gave negative results. Trinitrin with strychnin caused considerable 
headache without altering the heart's action. Nitrite of amyl inhaled in drop 
doses three times a day caused the pulse to become rhythmic and regular, the 
pain ceased and the nervousness no longer disturbed the patient; the pulse- 
rate remained the same. Another similar experience with nitrite of amyl after 
trinitrin had been abandoned, occurrred in an old lady with inelastic dilata- 
tion of the aorta, probably of syphilitic orgin, as there were other marked 
symptoms of syphilis. These three cases point to some essential effect of 
nitrite of amyl on the coronary circulation. Although it is the routine practice 12 
to give potassium iodid in arterial sclerosis, I have never been convinced 
in a single case that it modified the arterial circulation in any degree whatever. 
The value of saline cathartics to relieve an embarrassed heart is so well- 
known that it will not bear a discussion at the present time. The use of a direct 
cardiac depressant never seemed indicated in any case I have ever seen. If 
nothing can be gained by diminishing arterial resistance or stimulating the 
myocardium or by the use of alcohol or opiates, I can see little prospect 
of benefiting a patient by depressing the heart's action. 
Digitalis is credited with having the property of contracting the arteri- 
oles. Clinically I never ^^>any evidence of such action. I strongly 
suspect that this idea has originated in insufficient study of the pulse elements. 
Before digitalis is used one should consider the condition of the myocardium, 
the elasticity of the aorta and large vessels and the peripheral arteries. When 
there is no hope of favorably affecting the arterial circulation digitalis should 
be used to strengthen the action of the heart's muscle. Camphor subcutane- 
ously in the form of camphorated oil is much used in Germany whenever there 
is an indication for a direct cardiac stimulant with a quick and temporary 
affect, but with us strchnin takes its place. That alcohol in infectious 
diseases is of great service in supporting the heart's action every clinician 
will concede. But my own clinical experience leads me to agree with deduc- 
tions of the pharmacologists, that alcohol does not stimulate the heart directly 
but conserves its energy by inhibiting the metabolism of the body, thus 
saving the heart from the metabolic products of the tissues of the body in 
diseases which act as intoxicants to the heart's muscle. 
282 Prospect Street