It is possible for intermittence of the radial pulse to accompany regularity in the heart-beat. This usually results from narrowing (stenosis) of the aortic valvular outlet from the left ventricle. Only a certain number of impulses fairly reach the more distant arteries. This symptom may result also from fatty degeneration of the heart.
Absence of pulse in one radial vessel, while it is present in the other, shows the presence of an obstacle to the circulation on one side, which may be an aneurism, or an embolus plugging the artery.
Irregularity of the pulse, a total derangement of its rhythm, while not often important in young children, is a serious symptom at other times of life. In one disease most common in childhood, acute hydrocephalus, the pulse in the first stage is apt to be hard and rapid, in the middle stage slow and tolerably full, in the third rapid, feeble, and often irregular. Mitral disease frequently presents considerable irregularity of the pulse; and so does dilatation, even without mitral lesion. Brain trouble, especially late in life, whether structural or functional, may produce the same symptom. B. W. Richardson has pointed this out as one of the effects of the excessive use of tobacco, even in young persons.
The pulse of continued, relapsing, and remittent fevers is, during the febrile exacerbation, rapid (100 to 120); in the earlier part of the attack full, but only moderately hard, or even soft and yielding. As the attack passes its height and critical defervescence occurs, the pulse grows slower, unless great prostration has supervened; in which case it increases in rapidity, while it fails more and more in fulness and resistance.
The pulse of the moribund state is nearly always small, very rapid (130-150), and thready, without force or fulness. It may become imperceptible before death. A pulse of 140 beats in the minute is always alarming; if much beyond that rate the case is desperate. A pulse of more than 150 beats in the minute is very difficult to count accurately.
Exophthalmic goitre is attended characteristically by a full, somewhat rapid, and bounding pulse, the cardiac impulse being also proportionately violent and extended. Exercise much increases this hyper-pulsation.
Pulsation of the jugular veins is ordinarily explained by tricuspid regurgitation, a portion of the blood being sent back to the vena cava with an impulse reaching to the jugulars. In some instances, however, as the writer has repeatedly observed, jugular pulsation takes place without any abnormality in the action or condition of the heart, from a local inflammation (as tonsillitis) causing a marked exaggeration of the muscular contractility resident in the larger veins.
Retardation of the flow of blood through the veins is manifest during the collapse of epidemic cholera. On pressing the blood back in a vein upon the hand, for example, and then lifting the finger, instead of the movement being, as in health, too swift to be seen, it is so slow as to be easily followed.
Capillary movement may be estimated in a similar manner. If it be very sluggish, pressure upon the cheek, forehead, or hand will cause a pallor which remains for some seconds, instead of disappearing at once when the pressure is withdrawn. This is, it may be noticed, entirely different from the pitting upon pressure, without much if any change of color, in local oedema or general anasarcous effusion. The tache méningitique of Trousseau is a pink or rose-red line left for a time after drawing the finger across the forehead or abdomen in cases of acute hydrocephalus (tubercular meningitis).
Respiration must be watched carefully in all cases of disease. Normally, in the adult, while at rest, from 16 to 18 respiratory movements occur in each minute. The number is somewhat greater in women, and is considerably increased in children, at birth being about 40 in the minute. Men breathe most by the diaphragm; in women there is a greater lifting of the ribs. In either sex a disorder attended by pain in breathing may modify this proportion. If pleurisy, for example, be present, the ribs will be but slightly lifted, abdominal breathing taking predominance. When peritonitis makes every movement of the abdomen painful, costal respiration is maintained almost alone. Likewise, a unilateral pleurisy or pneumonia will check the respiration on the affected side, with an increased movement on the sound side. This difference is less manifest to the eye than to the ear in auscultation. In all febrile affections respiration is hurried proportionately with the pulse, unless some complicating local disorder disturbs the relation.