324 Dr. Benson's Case of Pulsation in the

ARW. XIII.--Case of Pulsation in the Veins of the upper Extremities. By Charles Benson, M . D . , M. R. I. A., Member of tim Royal College of Surgeons in Ireland, one of the Surgeons of the City of Dublin Hospital, &c. &e.

MARY OLIVER, ~t. 60, Of middle stature, pale, weak, and ema- ciated, was admitted into the City of Dublin Hospital on the morning of the 14th of August, 1835. She could scarcely give any account of herself, except that " i t was all about her heart." The f(~llowlng notes of her case were taken as soon as she was placed in bed : --She talks incoherently ; is very restless, tossing file clothes about, and seeming ~neasy in every position; pulse 80, soft mid regular; tongue clean; eyes clear; skin natural. (~l placing the fingers lightly over the apex of the heart a sen- sation is communicated to them not unlike that which emphy~ sema of the cellular tissue would occasion, b~t it is lost on the least increase of pressure. Resonance very dull over the whole of the precordial region; impulse considerable, may be felt as high as the clavicles, and peculiarly strong in the epigastrlum a lottd bellows murmur is heard over all the region of the heart, sometimes mingled with a rasping noise; the latter is best heard in the second sound, the former in the first; vesicular respiration every where distinct.

Aug. 15. She became comatose last night, and has not since spoken; face flushed ; some old cicatrices were observed on the scalp, when shaved; pupils moderately contracted; skin natural~

While feeling her pulse, and reflecting on the symptoms be- fore me, I was struck with an appearance of pulsation in a vein on the back of the hand. Further examination showed a dis- tinct pulsation in every superficial vein of the two upper extre- mities. The veins were prominenL and their motion was easily seen, but I could not feel it. Some of the pupils in attendance, however, assured me they felt it. The pulsation was isochronous with that of the radial arterb, ~ but a little later~ following it after

Veins of the upper Extremities. 325

an interval of time, which, when carefully attended to, could be satisfactorily appreciated. I examined the superficial veins of the trunk and lower extremities: riley were small and motion~ less. In the neck tim external jugulars were also small; I could not say they pulsated, for there was a tremulous m0tion communicated to them by file internal jugulars and carotids, which beat vehemently, and prevented accurate observation. The internal jugulars became greatly distended and collapsed during each act of respiration, whilst a confi~sed tremulous pulse incessantly agitated them,

I could learn very little of this woman's previous hlstory, though I sent an intelligent pupil to search it out at her late re- sidence. He cotild only ascertain that for the last six montlm she suffered very much fi'om palpitations and headaches; that she was greatly addicted to the use of ardent spirits, and during intoxication had often r~ceived wounds on the head; that she was able to follow her usual occupation (selling fruit) until a few days before ; and that she was a Scotchwoman.

In the evening of this day I took ten ounces of blood fi'om her arm~ and was surprlzed to find that it did not come per saltum, although pulsation was observed in some of the veiu~ below the bandage. On looking at the veins, after the bleed- ing, they seemed to be much more diminished in size than Icoutd have expected from the quantity of blood drawn oit, and all pul- sation had ceased! This last circumstance disappointed me a good deal, as I had mentioned tile case to some medical friends who intended to visit her next morning. The blood-letting was decidedly useful to her; she was less stupid, and the heart's ac- tion was less tumultuous.

16th. Still comatose; pupils contracted ; she moves all her limbs equally well, or equally ill ; shows no sign of inteUigenc% but is very sensible to stimuli. The veins are collapsed, and r devoid of pulsation. Pulse in the radial artery 80 ; :rises to 90 when she is roused. Physical signs of ~he heart's action as at first report,

326 Dr. Benson's Case o f Pulsation in tile

19th. She continued as on lhe 16th, with very little altera- tion, until this morning, when her left arm and leg were found to be flexed, and somewhat rigid. The veins had resumed their distended appearance, and pulsation was distinctly visible in all as atflrst .

My colleagues and the hospital pupils now joined me in observing file pulsations. The veins were seen to rise and falt with the respiration, becoming turgid towards the end of expi- ration, and flaccid when inspiration was nearly complete. In both states, however, their pulsation went on regularly, beating as often as the artery, 80 in a minute, but a little after it. There was no doubt of this, though the interval was very minute. The stethoscope did not show any change in the cardiac symptoms since the first day's report.

The question as to the cause of tile eurlous phenomena be- fore us was now considered, and as the discussion induced us to note more particularly the circumstances of the case, I may briefly state the substance of it.

Two opinions were supported by opposite sides: ]st, fhat the pulsation was derived from the left side of tile heart, seild- ing on its blood through the capillaries into the veins ; 2d; that it was derived fi'om the right side of the hearts and depended on regurgitation.

In support of the former opinion, it was observed, Ist, that pressure on the brachial or subclavian arteries stopped the pul- sation, but that it was unaffected by pressing on a vein. 2nd. That the valves acted perfectly, as could be seen by emptying a portion of vein just below a valve, and flmrefore that regurgitation was impossible. 3rd. That the venous pulse oc- curred at such an interval after the arterial as was inconsistent with regurgitation, but might be expected if the blood ha'd to travel round by the capillaries. And 4th. That the debilitated condition of the patient might have so relaxed the capillaries as to allow of an unusually free communication between the arteries and veins~

reins of the upper Extremities. 327

]In answer to these arguments, and in favour of regurgitation, it was urged, I st, that pressure on the brachial or subclavian arteries also acted more or less on the principal veins which ac- companied them ; besides by diminishing the quantity of fluid which the veins received, it would render their pulsation less evident, in the same way that the bleeding did ; but that tile free anastomosis would make amends for the slight interruption occasioned by pressing on a superficial vein. 2nd. That though the valves acted well when the vein was emptied behind them, they would not prevent an impulse from being conveyed along a distended vessel ; and that, in fact, if each valve were merely thrown suddenly across the venous tube it would cause a pulse, though ever so perfect in its valvular function. 3rd. That the yielding coats of the veins would serve to retard the rapidity of the returning wave, and thus account for the n~mentary delay in their beat. And 4th. That the arterial pulse was not strong enough to justify us in supposing that it could be contimmd on to the veins ; nor was there any ground for saying that the ca- pillaries were relaxed.

20th. All the phenomena as yesterday. As blood-letting had been attended with some benefit to the patient when prac-

t ised before, it was agreed to take a few ounces more. The blood flowed distinctly per saltum. It was like arterial blood

�9 in colour, but of much thinner consistence. The cephalic vein near the bend of the arm was the one selected for the vene- section, in order that it might not be influenced by any artery. After the removal of eight ounces the pulsation ceased. The arm was bound up in the usual way, and no motion in the veins of either extremity could afterwards be seen. She died the fol- lowing night.

dutopsy, twelve hours after death. On opening the chest the lungs were found almost universally connected to the costal parietes by very old and strong adhesions. There w, as no fluid in the pleura. The lungs were healthy, quite free from disease of any kind ; they were not even congested. The pericardium

328 Dr. Benson's Case of Pulsation in the

was healthy; it contained a little serum~ but not more than is so often seen without disease. The heart was at least twice the usual size. The auricular appendages~ especially the left, were remarkably large. The right auricle was dilate'd, and a little hypertl'ophied. At the posterior margin of the foramen ovale a particle of'osseous matter was observed. Tile right auriculo- ventricular opening was very large and gaping. The right yen. tricle was dilated and hypertrophied. Its cavity was twice as large, and its wails twice as ~hlck as usual. The floating mar- gins of the tricuspid valves were thickened and studded with small cartilaginous nodules. The pulmonary artery was healthy, but its valves appeared somewhat thickened, and their corpora sesamoidea much developed. Tile left auricle was enlarged, its walls thickened, and the lining membrane peculiarly white and opaque. The opening from it into the ventricle was too small to admit the finger ; it was an irregular slit-!ike opening, surrounded with cartilaginous and osseous deposits. The left ventricle was dilated, its walls a little thickened, but softer and paler than those of the right. The mitral valves contained calca~'eous and cartilaginous deposits. The aortic valves were greatly thickened, and filled with osseous matter. The aorta too had osseous deposits~ The superior vena cava, the innomi- natal, jugular and subclavian veins, were slit up, and carefully examined; nothing peculiar was observed in them; their coats were of the usual appearance, and their vanes in the ordinary situations. The abdominal viscera were healthy. The bra#t was pale and bloodless ; it showed no sign of congestion, nor ~f any disease except flint the ventricles contained about half an ounce of clear serum.

I had one of the arms removed from the body, and carefully injected fi'om the brachial artery. Fine wax, largely diluted with oil of turpentine, and coloured with vermilion was used, but not a particle of injection passed into the veins. The valves of the latter al~o resisted the passage of a fiaid from a trunk to its branches.

Veins of the upper Extremities. 329

I think the post mortem decided the question as to tile cause of the venous pulsation. The left ventricle was not at all increased in power; itswalls, though slightly thickened, were pale and soft ; and even if its power were increased, the aorta presented obstacles sufficient to counterbalance that, as was in- deed evident from the weakness of the pulse in the radial artery. Injection, too, showed that there was no relaxation of file ca- pillaries. It could not therefore be maintained that the pulse was transferred through the capillaries on to the veins. Again, the veins could not have received their pulse from the right auricle, for their diastole always followed, though at an ex-

ceedingly short interval, the diastole of the arteries. Neither was there any thing in file coats of the veins to account for it, nor in the neighbouring arteries. It is to the condition of the right ventricle we must look for the e~cient cause. This ven- tricle we find hypertrophied, and the am'iculo-ventricular open- ing dilated ; so that regurgitation into the auricle was inevitable; and as this would occnr with considerable force, it is easy to conceive how the impulse would be communicated along the dilated veins, even to their small ramifications. The valves in- tercepted the shock when the veins were flaccid ; but in the dis- tended state of the vessels the shock was sent from valve t0 valve even by the very force with which they were thrown across their tubes. And this may be supposed to take place without any imperfbction in the valves, which seemed quite sound. The pulsation following that of the arteries may be explained by the more yielding structure of the veins, which would, doubtless, retard the rate at which the impulse was transmitted.

I find that venous pulsation has very rarely been observed to extend beyond the jugulars. It does not appear that Senac, Lancisi, Corvisart, Bertin, Laennec, or Hope, ever met wifll such a case. Laennec refers to a paper on the subject in the Memoires de l'Academie des Sciences, by Hunauld; but on searching for it no such paper could be discovered. I found, however, a case related by Hombert in the Memoires for 1704;

330 Dr. Benson's Case of Pulsation in the

and as Laennec does not mention the volume in which Hu- nauld's case is recorded, I flllnk it probable he quoted from memory, and mistook the writer's name. Hombert states that the pulsation in the veins did not correspond in frequency to that of the arteries ; that it was only to be observed during pa- roxysms of the disease (asthma) with which his patient was afIlicted ; and that the post mortem exhibited great dilatation of all the cavities of the heart, with thinning of their parietes, and large polypi extending from the ventricles into some branches of the aorta and puhnonary arteries. He attributes the pulsa- tion in the veins to reg~,rgitation during the morbid palpitations of the heart ; whilst the arterial pulse was occasioned by the re- gular action of the ventricle.

Dr. Elliotson, in a note in Blumenbach's t)hysiology, says, " In a young lady whom I lately attended for chronic catarrh, accompanied by violent cough, from which she ultimately reco- vered, all the veins of the back of the hands and forearms dis- tinctly pulsated synchronously with the arteries." This is all he says, but h'om the place where he introduces it, I would sup- pose he attributed this pulse to the action of the veins them- selves. It is in a note to tile following paragraph in the text of Blumenbach: " The existence of vital powers in the venous trunks is probable from the example of file liver and placenta, and from experiments instituted on living animals. We fbr- merly mentioned the muscular appearance in the extreme veins near the heart."

In the London Medical Gazette for June, 1832, Dr. Ward relates the case of a woman in whose hands and arms venous pulsation was observed for three days. The patient had lost large quantities of blood for an incipient pneumonia, and was further debilitated by miscarriage. He attributes the pulsation to the " excessive reaction of the heart pushing the thin and impoverished blood through the capillaries straight on into the veins." As the woman recovered there was no opportunity of searching for a more probable cause.

Veins in the upper Extremities. 33t

In the fourth, volume of the Dublin Hospital Reports we have the details of a case which Dr. Davis saw. The only morbid appearance discovered on dissection was, that the left ventricle was somewhat enlarged, and firmer than natural. He thinks there could be "no doubt of the fact that the pulsation had been continued from the heart through the arteries and ca- pillaries to the veins." But the phenomena which led him to this conclusion were all present iu my case, and yet i am sure there can be "no doubt of the fact that the pulsation" depended on a totally different cause.

Dr. Graves mentions incidentally (in the Dublin Journal, Sept. 1834,) two cases of venous pulsation; but he gives no de- tails, nor does he offer any explanation of their cause. From the manner in which they are there brought in, however~ we might suppose he thought they depended on the action of the left ventricle. And yet in one of his lectures, published in tile Loud. Mad. Gaz., Jan. 1831, he seems to advocate the action of the coats of the veins themselves as the more probable cause.

These are almost all the notices I find of general venous pulsation; and on'reviewing them I do not think riley afford any proof that it depended either on the force of the left ven- trlcle transmitted through the capillaries, nor on any indepen- dent action of~the veins themselves. All the arguments in fa~ your of either of these opinions might have been, and : indeed were advanced in the case wl)ich I have related. And yet tire dissection proved, I think, incontestably, that hypertrophy with dilatation of the right ventricle, was the true cause.

This case also goes to confirmthe opinion of Mr. Adams in the fifth volume of the Dublin Hospital Reports. respecting jugular pulsation. I may quote the words o~ this accurate-ob- server. " There is in all cases a little influx into the.right au- ricle during tim contraction of its corresponding ventricle, but the great swelling of the jugular veins i s only seen whenextra- ordinary efforts are made, or where, from any enlargement o[" the right side of the heart, it is capable of containing a larger

yoJ. vnI. NO. 23. 2 X

332 Dr. Kirby on the Treatment Of Cro~cp.

quantity of blood than it can readily transmit through the lungs~ On these occasions it is that the pulsations of the jugular veins become evident. Tlley aresynchronous with the action of the hearG and can more readily take place when the right ventricle has been preternaturally dilated, as it is not likely that the valve will increase in size in proportion as the auricuto-ventricular opening enlarges."

In relating this case I have not given any details of the treatment, because my object was simply to direct attention to the curious phenomena of venous pnlsation, and to the explana- tion which, in this instance, the dissection afforded.

A~T. XIV.--On the Treatment of Croup. By DR. ~IRBY~ Professor of the Practice of Medicine in the Royal College of Surgeons in Ireland.

UNDER the head of Bibliographic Notices in the Iast number of the Dublin Journal of Medical and Chemical Science, the at- tention of the profession is very properly directed to a new method of treating croup, pursued by Dr. Lehman, Staff Surgeon at Torgan, and consisting in nothing more than the application of ho~ water to the region of the larynx at the c0mmehcement of the disease. Tlle plan is announced as simple, easily ap- plied, free from injurious effects to the constitution, arid effica- dons; for Dr. Lehman affirms that it has not yet failed in his hands when seasonably applied, and that it has been used in many cases successfully in several families he attends, before his assistance could be procured.

Tile simplicity of a remedy often opposes its general re- ception, and it especially stands a chance of being wholly put aside, when the disease for which it is proposed is one of known severity, of rapid progress, and most frequently of fatal issue. Mypersonal experience for nearly twenty years i~ the fortunate efficacy of a plan somewhat similar to Dr. Lehman's, gives me the greatest confidence in the report of his successful manage-