Pulsation

Pulsation, the perceptible and often visible rhythmic local bulging on the surface of the body in the region of the heart and along the blood vessels, caused by the contractions of the heart and the filling of the vessels. As a direct expression of the heart's contractions, P. can be detected in various intercostal spaces under certain conditions, and it is most often seen and felt in the region of the heart apex. To better see it, the subject should be placed sideways to the light source, and to palpate P. if it is not sufficiently obvious to the naked eye, it is best to apply the whole palm to the indicated area. A tense, heaving apical impulse, even if it is felt to the left of the left nipple line, unambiguously indicates hypertrophy of the left, and sometimes the right, ventricle. Pulsation in the epigastric region is also visible and palpable; it is better seen during inspiration and sometimes during expiration. In many cases, epigastric pulsation is an expression of right ventricular hypertrophy. Along with this, it is particularly sharply expressed when the heart is displaced downward due to a low position of the diaphragm, in particular in pulmonary emphysema, as well as in general visceral ptosis caused by relaxation of the abdominal muscles. Pulsation in the upper part of the chest—in the IV, III, and even II intercostal spaces on the left—can be visible and palpable when the heart is displaced upward due to a high position of the diaphragm caused by sharply increased intra-abdominal pressure, primarily due to the accumulation of a large amount of fluid in the abdominal cavity, or pregnancy in the last months, less frequently due to the presence of large tumors in the abdominal cavity; nevertheless, pulsation in the indicated area is also observed in peritonitis, even without a large accumulation of fluid in the abdominal cavity; this apparently depends on the diaphragmatic paralysis caused by peritonitis, as a result of which its dome rises and displaces the heart. Furthermore, pulsation in the indicated area can be caused by displacement of the heart upward due to pressure from an intrathoracic tumor or a diaphragmatic hernia. Pulsation in the II and III intercostal spaces on the left can also be caused by persistence of the ductus arteriosus, aneurysm of the aortic arch, or dilation of the initial part of the pulmonary artery in the presence of its constriction in the further course. Pulsation in the corresponding intercostal spaces of the right half of the chest can be a consequence of the congenital right-sided position of the heart or its displacement to the right under the pressure of exudate in the pleural cavity or a tumor in the left half of the chest; the same is observed when the heart is displaced to the right under the influence of cicatricial contraction of the right lung in the outcome of pleuropneumonia. Pulsation in the II right intercostal space can be caused by aneurysm of the right half of the aortic arch; if, under the pressure of such an aneurysm, the bone tissue of the upper part of the sternum resorbs, a pulsating tumor is found in its place, directly under the coverings. Pulsation in the suprasternal fossa of the aortic arch occurs with hypertrophy of the left ventricle, especially in cases of aortic valve insufficiency. Even more frequently, increased pulsation is observed in the region of the innominate, subclavian, and common carotid arteries. Pulsation in the region of the thyroid gland, when it is enlarged, is observed primarily in struma basidowiana. True pulsation in the jugular veins, with them filling simultaneously with the carotid arteries, is typical for tricuspid valve insufficiency. However, wavelike fluctuation in the suprasternal fossa and in the jugular veins during the diastole of the ventricles is characteristic of stasis in the lesser circulation, especially with damage to the mitral valve; this fluctuation—the so-called undulation—is much better seen when the patient is in the supine position and especially with lateral illumination. Arterial pulsation in the region of the liver is felt by the hand during its palpation, and sometimes can be caught by the eye, in cases of aortic valve insufficiency; venous pulsation—in cases of tricuspid valve insufficiency. Pulsation of the abdominal aorta, as well as of the common iliac arteries on the posterior abdominal wall, can be detected by deep palpation of the abdomen, mainly in thin and soft abdominal walls and the absence of fat accumulations in the abdominal cavity; with severe emaciation and collapse of the intestinal walls, pulsation of the abdominal aorta can be transmitted to the anterior abdominal wall. Sometimes in the abdominal cavity, in the place of the aorta, a pulsating tumor can be palpated, representing an aneurysm of the abdominal aorta, which is characterized by clearly expressed elasticity; in other cases, a pulsating tumor in the abdominal cavity represents an enlarged organ lying in front of the abdominal aorta, such as the pancreas, mesenteric glands, etc., or some neoplasm also located in front of the abdominal aorta and fused with it. Pulsation of peripheral arteries is expressed the more sharply, the closer they are to the surface of the body and the larger they are; moreover, pulsation in them is greater the more intensely the left ventricle works. It is easiest to notice pulsation of the temporal and lower brachial arteries, especially when they are hardened and tortuous. However, to see pulsation in the brachial arteries, the subject's arm must be bent at the elbow at a right angle and examined with lateral illumination. Sharply expressed pulsation in these arteries has undoubted diagnostic significance, being an expression of arteriosclerosis of large vascular trunks. Pulsation of capillaries is observed in cases of aortic valve insufficiency, best of all in places with thinner skin and increased vascularity, especially after artificially induced hyperemia.

G. Gurievich.