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The Venous and Liver Pulses, and the Arhythmic Contraction of the Cardiac Cavities

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The Venous and Liver Pulses, and the Arhythmic Contraction of the Cardiac Cavities THE VENOUS AND LIVER PULSES, AND THE ARHYTHMIC CONTRACTION OF THE CARDIAC CAVITIES. By JAMES JfACKENZIE, M.D., Holboritmj DIcdical OBcer, Vieloi-iii Hospital, Buriklcy. (Continued from page 154.) THE following case presents iuaiiy features of interest, indicative of the manner in which the various factors influence the venous pulse :- CASE 17.-Female, st. 30; has had rlieuniatic fever at the ages of 11, 16, and 21, and has had heart disease since she TVRS 16 years of age. She had n child 5 years ago, and did not suffer in consequence. She becanie pregnant in July of 1891. She was very sick at first, and be- came very short of breath ; swelling of the legs came on in November. These syniptoms became worse “’ltil Ja’luary 1892, when Fro. 57.-Tracings of carotid and jugular pulse, taketi her in- together. The chief point in this tracing is the de- ‘lncecl premature labour* pression 2, in striking contrast to the wave that She very for a long appears later at this period ; see Fig. 58 (Case 17). time after, and when I first saw her on the 25th May 1892 she had fairly recovered, and was able to get up tind go about. There was only a slight venous pulse, evidently of the auricular form (Fig. 57). She came under my care again on 23rd July 1892, and her condition was then as follows :- She mas very short of breath, and lay propped up in bed. There was considerable swelling of the legs, also puffiness of the face. The pulse was small and quick, 80 per minute. There was niarked pulsation in the veins of the neck (Fig. 58). The area of the heart’s dulness was greatly en- largcd. The apex beat was felt in the mid-axillary line, and in the eighth interspacc. The heart’s duIness extended 2 in. to the right of the middle line. There was a loud systolic murmur heard over the whole prae- corclia and behind over both sides of the chest. The breathing was laboured ; respirations 38 per minute. The base of the right lung was dull as high as the spine of the scapula. There was absence of breath sounds and fremitus over 274 JAMES &fA CKENZIE. this area The liver dulness extended 3 in. below the ribs, and the lirrr conld be felt pulsating distinctly (Fig. 59). FIG. 58.-Tracings of the jngllar and oarotid pnlses taken siInnltaneously. The veiiws waves are ventricular systolic in time, with a notch in the summit separating t.1~ portion due to the ventricular systole before tho closure of tlie l~ul~nonaryvalves n‘ from that which OCCIII’S after a. The depression y is due to the ventricular diastole : the pulse was slightly irregular (Case 17). At the end of the exaniination tlie patient suddenly became very faint, the pulse became rapid and weak, and the veins of the neck greatly dis- tended and crasetl to pulsate. Next day the patient’s condition had materially iiuproved, iLl1tl there was again inarked pulsation in the veins. Tlie tracings- of the venous pulse taken at this time show that the pulse is now of the ventricular type, in which the de- pression in the summit, and the wave produced after the closnre of the pulmonary valves, are well marked. This marked appearance of the latter part of the ventricular wave a is well seen in the tracing of the liver pulse (Fig. 59), where it rises to a considerable height above FIG. 59.-Apcs lieat and liver pulse taken at the same time, and at tlic same visit that the preceding portion a’. Tht~ Fig. 58 was obtained. Tlie highest patient’s condition continued to portion of tlie tracing occurs aftcr the improve, the venous pulse beconling closure of the pulmonary valves a, wliile the effects of tho earliest portion of the less marked until, finally, it again ventricular systole is also nianifestecl by presented the character of the the waves a‘ (Case 17). auricular form, n depression in place of the characteristic rise occurring during the ventricular systole (Fig. 57). I cannot be certain that illy interpretation of this tracing is quite correct. There is no doubt about the timing of the events, and that the great depression is due to the auricular diastole, hut whether b and c represent the aiiricdtw and THE VZNOUS AND LlVZR PULSES 275 arterial waves respectively I cannot positively assert. However, the change from the large wave synchronous with the ventricular systole in Fig. 58 to the depression in Fig. 57 is very striking. The curious point is that the liver pulse retained the rhythm of the ventricular form (Fig. 60). There is, however, a slight depression at the beginning Fm. dO.-Tracings of apex beat and liver pulse, taken together at the same visit that Fig. 57 was made. There isno wave due to the first part of the ventricular systole but rather a slight depression z, corresponding to the depression z in Fig. 57. The liver Iinlse here is, therefore, ventricular, after the olosure of the pulmonary valves (Case If). of the ventricular systole II: which corresponds to that in Fig. 57 ; the niaiii portion of the liver tracing being due to the ventricular systole after closure of the pulmonary valves. The patient’s condition varied R good deal; the pulse in the jugular varied also, sometimes being quite marked, at others, again, disappearing. When it was well marked it gave a tracing very similar to that in Fig. 58. On the 17th of September there was obtained a series of very instructive tracings. The pulsation in the jugular veins had disappeared, but it gradually returned after temporary suspension of the respiration, and a tracing taken showed a sniall wave during inspiration, and two small waves during expiration (Fig. 61). Tracings of the liver pulse were taken, and the patient Fro. GL-Tracings of jugular and carotid pulses taken together at the visit that Figs. 62 and 63 were taken. The venous pulse had in the first instance disappeared. On holding the breath it gradually returned. This figurc was taken immediately after it hegiln to appear. During inspiration the waves a, due to the ventricular systole, after the closure of the pulmonary valves, are alone present, while during expiration the waves a’, due to the ventricular systole, bcfoie the closure of these valves, are liken&. present (Case 17). htaving to hold her breath, the venous pulse became larger and larger until the tracing in Fig. 62 was obtained. In the series of tracings taken at this time the venous pulse gradually became more marked. 376 JAMES MACKENZlE. These two tracings are interesting, inasmuch as they show how the ventricular venous pulse can be brought back in the same manner us the auricular form in Fig. 24. Fig. 61 is also instructive in showing the manner in which the portion of the ventricular wave, following the closure of the pnlmonary valves, is the most prominent feature. During inspiration in fact it is the only feature present. In the inore fully-developed venous pulse (Fig. 62) the whole ventricular wave is FIG. 62.-Ai'ter taking a series of liver traciiigs the holding of the breath necessary thereto devcloped the venous pulse as here given, which was taken at the same time as the apcs beat. Occasionally the aiiricle shom its effect by producing the small wave b (Case 17). present, and it is interesting to note that the auricle has evidently not lost all power, its presence being occasionally distinctly manifested. When the auricular wave is present the venous pulse has a, distinct resemblance to the venous pulse in Case 16 (Figs. 54 arid 55). Except when the patient was very ill there was also a tendency for the auricular wave to show itself. In the liver pulse the auricular wave is iiever present, and the latter part of the ventricular wave is still the most prominent feature (Fig. 63). The patient recovered and was able to FIG. 63.-Tracings of the liver aud jngnlar pnlses taken during the same visit that Wigs. 61 and 62 were obtained. The liver plsc is mainly due tothe ventriculaT systolc after the closure of the pulmonary valves (Case 17). go about, but had a relapse during the month of January of this year. Numerous tracings revealed the same conditions as described above. Often when the pulse had entirely disappeared from the jugular veins THE VENOUS AND LIVER PULSES. 277 its presence was detected in the liver, having the same character as in Figs. 60 and 63. CASE18.-Female, aet. 33 ; examined 22nd Septcniber 1893 ; complains of shortness of breath and swelling of the legs and abdomen. She had rheumatic fcver when 15 years of age, and has been snbject to slight attacks ever since. During the past month the dropsy has increased, and the shortness of breath has become extreme. The pulse is small and feeble but regular, 96 per minute. The heart’s impulse is strong, but the area of the heart’s dulness cannot he accurittely defined on account of the thick parietes and large breasts. There is a loud systolic murniur heard at the apex and propagated into the axilla, and at the base there is a harsh blowing murmur in place of the second sound, and heard best over the second right costal cartilage. There is laboured respiration ; the patient having to be propped up ; the bases of both lungs are dull, arid fine crepitations are heard over the dull areas during a deep inspiration. There is considerable ascites.
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