194 THE VENOUS PULSE. 



II. Regurgitant Murmurs. On making a sudden effort, a murmur may be 

 heard in the crural vein during expiration, which is caused by a centrifugal current 

 of blood, owing to the incompetence or absence of the valves in this region. If the 

 valves at the jugular bulb are not tight, there may be a bruit with expiration (ex- 

 piratory jugular vein bruit Hamernjk), or during the cardiac systole (systolic 

 jugular vein bruit v. Bamberger). 



III. Valvular Sounds in Veins. When the tricuspid valve is incompetent, 

 during the ventricular systole, a large volume of blood is propelled backwards into 

 the venae cavas. The venous valves are closed suddenly thereby and a sound pro- 

 duced. This occurs at the bulb or dilatation on the jugular vein (v. Bamberger), 

 and in the crural vein at the groin (N. Friedreich), i.e., only as long as the valves 

 are competent. Forced expiration may cause a valvular sound in the crural vein. 

 No sound is heard in the veins under perfectly normal circumstances. 



99. The Venous Pulse Phlebogram. 



Methods. A tracing of the movements of a vein, taken with a lightly weighted 

 sphygmograph, has a characteristic form and is called a phlebogram (Fig. 86). In 

 order to interpret the various events of the phlebogram it is most important to 

 record simultaneously the events that take place in the heart. The auricular con- 

 traction (compare Fig. 29, p. 88), is synchronous with ab; be, with the ven- 

 tricular systole, during which time the first sound occurs, whilst a, b is a 

 presystolic movement. The carotid pulse coincides nearly with the apex of the 

 cardiogram, i.e., almost simultaneously with the descending limb of the phlebogram 

 (Riegel). 



Occasionally in healthy individuals a pulsatile movement, synchronous 

 with the action of the heart, may be observed in the common jugular 

 vein. It is either confined to the lower part of the vein, the so- 

 called bulb, or extends farther up along the trunk of the vein. In 

 the latter case, the valves above the bulb are insufficient, which is by no 

 means rare, even in health. The wave-motion passes from below up- 

 wards, and is most obvious when the person is in the passive horizontal 

 position, and it is more frequent on the right side, because the right 

 vein lies nearer the heart than the left. 



The venous pulse resembles very closely the tracing of the cardiac 

 impulse (Landois). Compare Fig. 86, 1, with Fig. 25a, A, p. 82. 



It is obvious that, as the jugular vein is in direct communication 

 with the right auricle, and as the pressure within it is low, the systole of 

 the right auricle must cause a positive wave to be propagated towards 

 the peripheral end of the jugular vein. Fig. 86, 9 and 10, are venous 

 pulses of a healthy person with insufficiency of the valves of the jugular 

 vein. In these curves, the part a, b, corresponds to the contraction of 

 the auricle. Occasionally this part consists of two elevations, corre- 

 sponding to the contraction of the atrium and auricle respectively. As 

 the blood in the right auricle receives an impulse from the sudden 

 tension of the tricuspid valve, isochronous with the systole of the right 

 ventricle, there is a positive wave in the jugular vein in Fig. 86, 9 and 



