THE VENOUS PULSE. THE PHLEBOGRAM. 187 



the veins, by which a marked wave may be produced. As a rule, the common 

 jugular vein pulsates quite strongly in cases of tricuspid insufficiency; but when 

 the valves at the bulb of the jugular vein are still competent, the pulse is not 

 propagated into the vein itself. The jugular pulse is, therefore, not a necessary 

 sign .of tricuspid insufficiency, but only a sign of insufficiency of the valves of 

 the jugular vein. The ventricular systole, however, is always propagated into 

 the inferior vena cava, which is without valves, and there it produces especially 

 the so-called liver-pulse. Each ventricular contraction throws a large quantity of 

 blood as far as the hepatic veins and thus the liver undergoes systolic swelling 

 and distention due to injection. 



The figures from 2 to 8 represent tracings from the common jugular vein. 

 In all the curves, a b indicates the auricular contraction; the contracting auricle 

 throws a positive wave into the veins. This portion of the curve appears at times 

 as a simple anacrotic basal elevation (3). Not infrequently (as particularly in i, 

 representing a curve from one of the thyroid veins) two or three small notches 

 make their appearance at this point, and these may be compared with the analo- 

 gous elevations in the cardiogram. 



In accordance with the tension of the vein, as well as with the freedom of 

 the flow of blood from the vein to the heart, and also with the respiratory position 

 of the thorax, the auricular notch may appear in the descending portion of the 

 foregoing curve, as in 5 and 8; at times alternately as in 3 and 8 (see 7) ; at other 

 times, a portion of the auricular wave may be in the descending portion of the 

 foregoing curve, while the remainder is found in the ascending portion of the 

 same curve, as in 6, 2 and 4. When the action of the auricle is exceedingly feeble, 

 the auricular wave may even be entirely abortive as in 7 at f . 



The ventricular elevation is caused by the large blood-wave thrown back into 

 the vein by the evacuation of the ventricle. The apex of this wave (c) is at times 

 higher, at other times lower, in accordance with the tension in the vein and the 

 pressure of the sphygmograph. It is usually followed by at least one notch (4, 

 5, 6 e), produced by the sudden closure of the semilunar valves of the pulmonary 

 artery. It is not surprising that the closure of these valves produces an undulatory 

 movement in the ventricle that is propagated through the constantly open tricuspid 

 valve into the auricle and the veins. The adjacent aorta may even produce a 

 small wave next to e by the closure of its valves (as in i and 2 d) . When the 

 valve-closure becomes feebler in consequence of diminished tension in the large 

 arteries, the aortic-valve wave d is the first to disappear (as in 4 and 5) ; later 

 also the elevation due to closure of the pulmonary valves e disappears (as in 3 

 and 7). After the closure of the valves the curve falls, in correspondence with 

 the diastole of the heart, as far as f. 



An especially distinct venous pulse may be produced also when the right 

 auricle is greatly overdistended, as in cases of mitral insufficiency or stenosis. 

 In rare instances other veins pulsate in addition to the common jugular, such as 

 the external jugular, some of the facial veins, the anterior jugular vein, the thyroid, 

 the external thoracic, and the veins of the upper and lower extremities. Landois 

 on one occasion saw extensive venous pulsation in a moribund woman without 

 any cardiac lesion, in whom the autopsy revealed an enormous, white, fibrinous 

 clot extending from the right ventricle into the auricle and making closure of 

 the tricuspid valves impossible; even the cutaneous veins on the anterior surface 

 of the thorax could be seen pulsating strongly. 



It is evident that pulsations similar to those produced in the veins of the 

 greater circulation in cases of tricuspid insufficiency must also be produced in 

 the pulmonary veins in cases of mitral insufficiency. Such pulsations are, however, 

 not directly visible; although it may be possible to demonstrate their presence by 

 observing the cardiopulmonary movement. 



In rare cases the veins on the backs of the hands and the feet are seen to 

 pulsate, because the arterial pulse is propagated to the veins through the capillaries, 

 or possibly through some direct communication between the arterial branches 

 and the veins. This phenomenon may occur even under normal conditions, espe- 

 ciallv when the peripheral extremities of the arteries are dilated and relaxed, or 

 when the pressure within them becomes high and falls rapidly again, as in cases 

 of aortic insufficiency. 



Diastolic collapse of the veins of the neck is observed in association with heart- 

 disease at the instant when the tricuspid valve opens. It is due to deficiem 

 traction of the right auricle. In cases in which the interior of an artery c 

 municates directly with the interior of a vein as a result of traumatism or rupture, 

 the arterial pulse is propagated into the venous channels. 



