sign in sign up
<<
Home , Cardiac cycle, Central venous pressure, External jugular vein, Heart, Jugular vein, Jugular venous pressure

389 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from

THE JUGULAR VENOUS By D. S. SHORT, M.D., M.R.C.P.* The Institute of Clinical Research and Experimental , the Middlesex Hospital, and the Cardiac Department, the London Hospital

" Study of the still suffers an unfortunate man, but Moritz and Tabora (I9Io) showed that neglect; in these vessels are to be found some-of the the venous pressure could be recorded by inserting most valuable signs we possess in managing a needle into'the median cubital and attaching cases."-Sir Thomas Lewis, I948. it to a manometer filled with citrate. This method has been widely used in the past, but it is Although the neglect ofwhich Sir Thomas Lewis too complicated for routine use; it measures the spoke has since been partially remedied, there is no peripheral rather than the doubt that the value of the jugular pulse is still and an equally accurate estimate can be obtained insufficiently realized. Important information can much more simply. Lewis (I930) showed that the be obtained both from the form of the venous jugular veins could be regarded as natural mano- pulse and the level of venous distension by simple meters connected to the right , and that the observation without the aid of any instrument. central venous pressure could be determined by This paper is based on a careful inspection ofthe observing the height of the venous column above Protected by copyright. jugular pulse in over 3,000 patients with congenital the sternal angle. or acquired heart disease aged between five and 80o years and ioo healthy men aged between 20o and The of the Jugular Veins 6o years. There are three main veins running down- Until recently clinical interest has been focused wards on each side of the : the external, the exclusively on either the wave form or the venous anterior and the internal jugular veins (Fig. I). pressure. It is only in the past decade, due largely The external and anterior jugular veins are to the observations of Wood (I950, 1956), that covered only by skin, superficial fascia and the both have found their proper recognition. thin , so that when distended they Venous pulsation was occasionally recorded in are visible throughout most of their course. The the I8th century, notably by Lancisi (1728), but external runs from the angle of the no important contribution to the subject was made mandible to the middle of the clavicle, where it until the introduction of sphygmography, which enters the . Its size varies in in- permitted the taking of actual tracings (Friedreich, verse proportion to the other veins of the neck. http://pmj.bmj.com/ i866; Potain, 1867). Mackenzie (I893) recorded The begins near the hyoid the jugular and arterial simultaneously and , runs downwards between the anterior border made a systematic analysis of the clinical sig- of the sternomastoid and the midline,'and turns nificance of the venous pulse. He recognized the laterally in the lower part of the neck to enter waves and designated them in accordance with the external jugular or the subclavian vein. The the events in the , which he believed two anterior veins are united above the reflected. At first the chief clinical jugular just they application by a transverse trunk called the jugular on September 24, 2021 by guest. of the venous pulse lay in the diagnosis of arrhyth- arch. mias, but in this it was soon to be superseded by the electrocardiogram. Interest in the venous The lies within the carotid waves then waned until the advent of cardiac sheath, deep to the sternomastoid muscle. It runs catheterization and led to more from the jugular foramen of the to a point precise diagnosis of congenital heart disease and a behind the sternal end of the clavicle, where it consequent reappraisal of physical signs (Wood, unites with the subclavian vein to form the I950). innominate vein. Near its termination it dilates In I733 Hales measured the jugular venous to form the inferior jugular bulb. pressure in a mare by inserting a glass tube into the The has two pairs of vein. This procedure cannot readily be applied to valves, both of which are incompetent; an upper pair situated about 4 cm. above the clavicle, and a * Holding a ILeverhulme Scholarship. lower pair immediately above its termination. The 390 POSTGRADUATE MEDICAL JOURNAL August I957 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from

Sternamastoid m. Trapezius m. External Carotid a. ANTERIOR JUGULAR. V INTERNAL JUGULAR V. EXTERNAL JUGULAR V. Common carotid a. /___ JUGULAR ARCH Clavicle INFERIOR JUGULAR BULB SUBCLAVIAN V. FIG. I.-The anatomy of the jugular veins. Note the position of the valves in the external jugular, internal jugular, and subclavian veins. Those in the external jugular vein are incompetent. Veins running superficially are shown in solid black.

anterior jugular vein has no valves. The internal ably because the top of the column of is too Protected by copyright. jugular vein has a pair of valves immediately above low and lies within the chest, or too high and lies its inferior bulb. The only valves in the subclavian within the head (Fig. 2). Veins that are fully vein lie on the lateral side of the external jugular distended cannot pulsate appreciably, neither can opening. There are no valves in the innominate those that are collapsed. The next step, therefore, veins or in the . Thus there are is to place a lightly over the lower end of the no competent valves between the right atrium and external jugular vein and wait 15 seconds to see if the upper ends of the external and anterior jugular the vein fills. If it does not, the. same procedure veins, or between the heart and the inferiorjugular should be applied to the anterior jugular vein. If bulb. The internal jugular valves readily become either vein fills, it indicates that the venous incompetent in the presence of a raised is too low to be recorded with the patient pressure. in his present position and thejugular pulse may be Keith (i908) believed that during atrial con- assumed to be normal. If the veins are not ren- traction the openings of the caval veins became dered visible by occluding their lower ends, it is occluded by a band of muscle fibres. The experi- possible that they are, in fact, full. The patient http://pmj.bmj.com/ mental evidence is, however, wholly against this should therefore be instructed to sit upright when, view (Wiggers, 1928). The pressure curve unless the venous is extreme, the top recorded from a cannula in the superior vena cava of the column of blood will come into view. corresponds to that recorded in the right atrium A full and tense external jugular vein on one itself, and this still holds true when all the tribu- side only is due to local obstruction and the swell- taries of the superior vena cava are ligated. ing can often be released by a little rotation of the neck. Attention should be directed to the vein in The Normal Jugular Venous Pulse which the pressure is lowest and where free pulsa- on September 24, 2021 by guest. Pulsation in the superficial jugular veins is a tion is visible. Less commonly the veins on both normal phenomenon, and so is pulsation over the sides are full and motionless; they may be made to inferior jugular bulb. Observations of pressure are collapse by a change of position or by sitting the best made in the external jugular vein. The venous patient up. Rarely, in spite of the greatest care, it waves, on the other hand, are most accurately is impossible to demonstrate the venous pulse. reproduced in the internal jugular vein, which is in The jugular pulse consists of three main waves, direct line with the right atrium. In the external named by Mackenzie (I902) a, c and v, the sum- jugular vein the undulations, although visible, are mits of which are presystolic, systolic and diastolic somewhat delayed and flattened. in time, and two troughs, x and y (Fig. 3). The In order to observe the jugular pulse, the a wave is due to atrial ; the c wave, often patient should lie almost flat, and be completely just a notch on the descending portion of the a relaxed. If no pulsation can be seen, this is prob- wave, is caused by the impact of the, underlying August 1957 SHORT: TheJugular Venous Pulse 391 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from NORMA. ABORMA LYNG.ST.TIN CI

NORMAL

VENOUS ,, , I PRESSURE " x I

Vein partly distended Vein collapsed Puilsation visible No pulsatio 5r IAs

RAISED 4;

VENOUS

PRESSURE Car C

Vein fully distended Vein partly distended Protected by copyright. FIG. 3.-Normal and abnormal forms of the jugular No pulsation Pulsation visible pulse: I. Normal dominant a wave 4. Giant a wave FIG. 2.-rThe effect of posture on filling and pulsation of 2. Normal dominant c wave 5. Ventricular pulse of the external jugular vein. The broken lines mark 3. Sinus : tricuspid incom- the level of the sternal angle (after Lewis). summation of v and a petence waves 6. Exaggerated y des- cent of constrictive carotid , and the x trough is due to atrial relaxation. The v wave, which appears towards Note.-This figure depicts the rise and fall of blood the end of the systole, is due to refilling of the in the veins, i.e. volume changes. The broken atrium and its peak coincides with the opening of lines indicate the times of the carotid beats. the . The y trough is caused by the fall in atrial pressure which follows the entry of tion, change of position or abdominal compression; blood into the . or if there are two waves to every heart beat, or a Wiggers (I949) studied phlebograms from 8oo single wave which is slow rather than sudden and http://pmj.bmj.com/ healthy students and classified them into three does not synchronize with the carotid pulse. But groups, which he called the atrial, the modified the distinction is not always easy and venous is impact type and the transitional. In the first, often mistaken for arterial pulsation. which was the most numerous, the a wave was Arterial pulsation is usually maximal in the dominant; in the second there was a large c wave, carotid triangle and it increases when the erect while the third group was intermediate between posture is assumed. Venous pulsation may also be these two. By inspection it is rarely possible to seen in this situation, but when the patient sits up detect more than two waves, since a and c cannot it falls to a lower level in the neck. Pulsation that on September 24, 2021 by guest. usually be separated. In a personal series of Ioo is maximal in the subclavian triangles is almost healthy men two waves could generally be seen in always venous, though the possibility of a kinked the external jugular vein, and in 65 of them the carotid must be considered if the pulsation is con- larger could be measured and timed; in 47 of these fined to the right side in a woman. Arterial pul- the main wave was atrial. sation that is visible is always readily palpable. Venous pulsation is very rarely strongly palpable Differentiation ofVenous from Arterial and only occasionally can be felt. If the jugular Pulsation veins are compressed at the root of the neck, venous It is important to be sure that the pulsation pulsation ceases above this level, whereas the which is observed is venous and not arterial. There carotids continue to beat. When the radial pulses is no difficulty if the external jugular vein is dis- are small, striking pulsation in the neck is almost tended, and the level of filling varies with respira- invariably venous. Conversely, if the radial pulses 392 POSTGRADUATE MEDICAL JOURNAL August I957 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from are large, striking pulsation in the neck is generally sitting position so that the top ofthe venous column arterial. lies approximately halfway up the neck. When, as during congestion, the venous pul- Borst and Molhuysen (I952) have insisted that a sation tends to lose its undulatory character and valid venous pressure can be recorded only during becomes more sustained, and sometimes plainly inspiration and in the part of the cycle during palpable, the direct distinction between it and which the atrial pressure is falling, because then arterial pulsation may be very difficult; but in such the venous valves are knowvn to be open. This cases the remaining signs of a congested venous precaution is, however, unnecessary, since there system are always apparent. are no competent valves in the superficial jugular veins. Measurement of the Jugular Venous Wood (I956) states that the normal jugular Pressure venous pressure ranges between 3 cm. above and The pressure which is recorded in the jugular 7 cm. below the level of the sternal angle when the veins is actually the right atrial pressure and patient is horizontal. In a personal series of Ioo simultaneous measurement of pressures in the healthy men the venous pressure could be right atrium by and in the measured in all but one. The average level was jugular vein by Lewis's method has shown that the -I cm. and 93 fell within the range -3 to +I. two are almost identical. The pressure was a little lower in summer than in Pressure must be measured with reference to a winter. Approximately half the cases were fixed point or level. Various reference points have examined during the months May to September been suggested and there is still no agreement as and the remainder between October and March. to which is the best. The ideal reference point The mean pressure during the warm months was would be the centre of the right atrium, but in -I.5 cm. and in the cold months -0.5 cm. The venous is increased by , but it practice it is impossible to determine this in pressure Protected by copyright. relation to the surface of the chest; moreover, it usually returns to normal or lower within a minute varies with respiration and the heart beat. Bloom- after its cessation (Szekely, I94I). Borst and Mol- field et al. (I946), from a study of lateral chest huysen (i952) observed no measurable change in radiographs, found that the centre of the right pressure under the influence of . atrium in healthy subjects lay on an average 5.8 It is often stated that pressure over the cm. below the sternal angle. When the heart was causes a rise of blood in the jugular veins in heart enlarged the distance was a little less (5.6 cm.) and failure, but not in health. This so-called hepato- in emphysema a little more (6.9 cm.). The distance jugular reflux is, in fact, a normal phenomenon varied with the phase of the respiratory and cardiac and may be produced by pressure on any portion cycles and there was also considerable individual of the abdominal wall (Wood, 1956). variation. Bloomfield et dl. concluded that any attempt to predict the position of the centre of the Jugular Venous Hypertension right atrium in relation to the surface of the chest A raised pressure in the jugular veins is the would only be accurate to within 2 or 3 cm. earliest evidence of general systemic congestion http://pmj.bmj.com/ American and Continental workers commonly and precedes signs in the legs or . Later, take as their zero level a horizontal line 5 cm. below if persists and increases, venous dis- the sternal angle, or o cm. anterior to the back tension will be followed by hepatic engorgement when the patient is recumbent, but in England and the appearance of oedema. Similarly, when the sternal angle is still the most widely used the heart improves, the venous pressure falls to reference point. As Lewis (I930) showed, it normal before the oedema disappears. represents approximately the level of normal A raised venous pressure at rest may be found pressure whether the body is horizontal or vertical in many conditions besides heart failure. Wood on September 24, 2021 by guest. or in any intermediate position. Normally all veins (1956) lists hyperkinetic circulatory states, in- lying higher than the sternal angle are collapsed; creased , , increased intra- all lying below it are distended. pericardial, intrathoracic or intra-abdominal pres- The is expressed in sure, partial obstruction of the superior vena cava, terms of the vertical distance between the top of tricuspid and space-filling lesions affecting the column of blood and the sternal angle during the right side of the heart. The diseases which quiet respiration. It is best to record the highest cause most difficulty in practice are chronic and the lowest points in the cycle; if the excursion anaemia, acute nephritis, emphysema and thyro- is great, this is essential. If the patient cannot lie toxicosis. Congestive heart failure should not be flat, he should be made to lie as low as he can diagnosed in the presence of any of these diseases without distress. If the venous pressure is greatly unless the venous pressure is considerably elevated elevated, he should be propped up in a semi- or the liver is engorged. The possibility of a raised August 1957 SHORT: The Jugular Venous Pulse 393 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from venous pressure being due to constrictive clothing and the abnormal wave disappears. The earliest or bandages around the waist should not be over- sign of tricuspid incompetence is premature looked. appearance of the v wave from accelerated filling Persistent jugular venous engorgement without of the right atrium (Mackenzie, I902). dyspnoea suggests constrictive pericarditis, tri- Another striking and important abnormality of cuspid stenosis or superior vena caval obstruction. the jugular pulse is that described by Friedreich In superior caval obstruction the liver is not con- (i866) in constrictive pericarditis (Fig. 3). The gested. Some jugular pulsation persists while the main feature of this pulse is a steep dip in , obstruction is partial, but once it becomes com- an exaggeration of the normal y descent. This plete all pulsation is lost, anastomotic veins appear recession, which is immediately preceded by a over the chest, and the becomes congested and similar recession in the right ventricular pressure cyanosed. curve, has been shown to be due to a high-pressure gradient between the right auricle and ventricle Abnormal Jugular Pulsation (Mounsey, I955). Although characteristic of con- The commonest and most important abnormality strictive pericarditis, it is not pathognomonic of it, in the form of the venous pulse is an exaggeration and it may be found in other conditions, such as of the normal a wave (Fig. 3). The peak of this cardiac myopathy, in which there is an unusually wave rises until in extreme instances its amplitude high venous filling pressure. may exceed Io cm. It is best seen with the patient In the diagnosis of the electro- sitting upright and usually increases during in- cardiogram is unrivalled. There are, however, spiration. In the internal jugular vein its abrupt emergencies when this instrument is not available, rise and fall resembles the carotid pulsation of and then inspection of the venous pulse may pro- aortic incompetence, for which it is sometimes vide valuable information. It is frequently possible mistaken. The a wave can be distinguished by the to distinguish complete from sinus fact that the carotid pulse is small and follows the bradycardia by observing the position of the a Protected by copyright. onset of the venous wave. Sometimes sudden wave in the cardiac cycle. In systolic collapse of the vein is more striking than it precedes the carotid impulse, as in health, its protrusion. whereas in complete heart block its position is Laubry and Pezzi (1913) first described a large continually changing and periodically, when atrial a wave as a sign of congenital pulmonary stenosis; and ventricular systole coincide, a wave of ex- and Abrahams and Wood (I95I) showed that the ceptional amplitude (the so-called cannon wave) size of this wave broadly reflects the degree of right appears. The jugular pulse may likewise enable ventricular hypertension in this disease. An ex- auricular flutter to be differentiated from fibrilla- aggerated a wave is also found in pulmonary tion. In flutter, rapid regular a waves are seen, but hypertension and in tricuspid stenosis. The a wave in these are absent. is not always abnormally large in pulmonary stenosis or hypertension, but, provided the patient Conclusion is in sinus it is the dominant Inspection of the jugular veins deserves to take rhythm, invariably its place beside of the in http://pmj.bmj.com/ wave. It declines in right heart failure and dis- the clinical examination of a patient suspected of appears with the onset of auricular fibrillation. . The one procedure is as Another common and important abnormality of simple as the other and yields information of the venous pulse is the ventricular form due to equal if not greater value. It tells at once whether tricuspid incompetence (Fig. 3). At the onset of oedema is due to heart failure and when congestive ventricular systole, blood regurgitates into the right failure has developed provides an accurate index atrium and the caval veins and the distension of of its progress. It gives warning of overloading of the jugular veins is maintained until the ventricle on September 24, 2021 by guest. relaxes. This pansystolic or cv wave is even more the circulation during intravenous infusion or striking than the exaggerated a wave because of treatment with salt-retaining and pro- the great distension of all the jugular veins which vides a vital clue to the diagnosis of pulmonary occurs with every heart beat. The start of the cv hypertension, pulmonary stenosis, tricuspid valve wave is a little later than that of the a, synchron- disease, constrictive pericarditis and superior vena izing with the carotid impulse; it is more sustained caval obstruction. and it persists in auricular fibrillation. The cv Acknowledgments wave does not necessarily indicate organic tricuspid I am indebted to Dr. William Evans, Dr. Evan disease; the incompetence is more often tem- Bedford and Professor Kekwick for a number of porary and due to dilatation of the tricuspid valve valuable suggestions and to Dr. Russell Bearn for ring resulting from right ventricular failure. When advice on the anatomical details. failure subsides the competence ofthe valve returns Bibliography continued on next page 394 POSTGRADUATE MEDICAL JOURNAL August I957 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from

BIBLIOGRAPHY LEWIS, T. (I948), Diseases of the Heart,' Macmillan & Co. Ltd., ABRAHAMS, D. G., and WOOD, P. (I95 ), Brit. Heart`Y., I3, 519. London, 4th Edition. BLOOMFIELD, R. A., LAUSON, H. D., COURNAND, A., MACKENZIE, J. (I893), J. Path. Bact., 2, 84 and 273. BREED, E. S., and RICHARDS, D. W., jun. (I946), J. clin. MACKENZIE, J. (1902), 'The Study of the Pulse,' Young J. Invest., 25, 639. Pentland, Edinburgh and London. BORST, J. G. G., and MOLHUYSEN, J. A. (I952), Lancet, ii, 304. MORITZ, F., and VON TABORA, D. (I9Io), Dtsch. Arch. klin. FRIEDREICH, N. (i866), Dtsch. Arch. klin. Med., I, 241. Med., 98, 475. HALES, S. (x733), 'Statical Essays: Containing Haemastaticks; MOUNSEY, J. P. D. (I955)j Brit. Heart J., x7, I43. or, an account of some Hydraulic and Hydrostatical Experi- POTAIN, P. C. E. (I867), Bul . Soc. Mid. Paris, 4, 3. ments, made on the Blood and Blood-Vessels of .' SZEKELY, P. (I94I), Amer. Heart J., 22, 360. W. Innys and R. Manby, London. WIGGERS, C. J. (1928), 'The Pressure Pulses in the Cardio- A. Anat. and I. vascular System,' Longmans Green & Co., London. KEITH, (i908), J. Physiol., 42, WIGGERS, C. J. (1949), ' in Health and Disease,' LAUBRY, CH., and PEZZI, C. (1913), Arch. Mal. Coeur, 6, 433. Henry Kimpton, London, 5th Edition, p. 685. LANCISI, G. M. (1728), 'De Motu Cordis et Aneurysmatibus,' WOOD, P. (I950), Brit. Med. J., 2, 639 and 693. Rome. WOOD, P. (1956), 'Diseases of the Heart and Circulation,' Eyre LEWIS, T. (193o), Brit. med. Y., i, 849. and Spottiswoode, London. Bibliography continued from page 382: Surgical Endocrine Ablation for Advanced Breast Cancer LUFT, R. (1957), Edinburgh University Lecture. PEARSON, O. H., RAY, B. S, HAROLD, C. C., LI, M. C., LUFT, R., and OLIVECRONA, H. (1953), J. Neurosurg., IO, 301. MACLEAN, J. P., and LIPSETT M. B. (t956), J.A.M.A., LUFT, R., OLIVECRONA, H., and SJORGEN, B. (1952). I6I, I7. Nord. med., 47, 35I. PERLIA, C. P., KOFMAN, S., NAGAMANI, D., and TAYLOR, LUFT, R., OLIVECRONA, H., IKKOS, D., NILSSON, L. B., S. G. (I956), Ann. Int. Med., 45, 989. and LJUNGGREN, H. (I956), Amer. J. Med., 2I, 728. RADLEY SMITH, E. T. (I957), Discussion Roy. Soc. Med.. I957. MALLARD, J. R., MCKINNELL, A., and FRANCOIS, P. E. RASMUSSEN, T, HARPER, P. V., and KENNEDY, T., (1956), Nature, 178, I240. Surgical Forum, 1952. Philadelphia, W. B. Saunders Co., MATSON, D. D. (1956), Symposium on Hypophysectomy, Sloan- 1953, p. 68i. Kettering Institute. To be published. RAY, B S. (1956), Symposium on Hypophysectomy, Sloan- MCKENZIE, A. (1955), Lanret, ii, 1129. Kettering Institute. To be published. NATHANSON, I. R., RICE, C., and MEIGS, J. V. (I940), Amer. ROTH, M. (1889), (or-BI. f. s chweitz. Aertze., I9, 146. (Cited by j. Obstet. Gynec., 40, 936. Falls, 1955.) NICKSON, J. J. (1956), Symposium on Hypophysectomy, Sloan- ROTHENBERG, S. F., JAFFE, H. L., PUTNAM, T. J., and Kettering Institute. To be published. SIMKIN, B. (I955), A.M.A. Arch. Neurol. Psych., 73, I93. NORTHFIELD, D. W. C. (I949), Proc. roy. Soc. Med., 42, 845. RUSSELL, D. S. (1956), Lancet. i, 466. D. W. C. Discussion Roy. Soc. Med., SHEEHAN, H. L., and SUMMERS, V. K (1949) Quart. J. Med., NORTHFIELD, ('957), I8, 319 March, 1957. STRONG, J. A, BROWN, J. B., BRUCE, J., DOUGLAS, M., NOTTER, G. (I957), Personal communication. KLOPPER, A. I., and LORAINE, J A. (1956), Lancet, ii, 955. Protected by copyright. PATTI SON, A. R. D., and SWAN, W. G. A. (1938), Lanct, i, 1265. TAYLOR, S. G , LI, M. C., ECKLES, N., SLAUGHTER, D. P., PEARSON, O. H. (i956), Proceedings of the Fourth Conference in and MCDONALD, J. H. (1953), Cancer, 6, 907. Steroid Hormones and Mammary Cancer, Council on Pharmacy TREVES, N. (1956), Proceedings of the Fourth Conference in and Chemistry, Steroid Hormones and Mammary Cancer, Council on Phar- 1956. macy and Chemistry, I956. PEARSON, O. H., RAY, B. S., WEST, C. D., HAROLD, C. C., \VEST, C. D., HOLLANDER, V. P., WHITMORE, W. F., MACLEAN, J. P., and LI, M. C. (I954), . clin. Invest., 33, 956. RANDALI,, H. T., and PEARSON, O. H. (1952), Cancer, 5, PEARSON, O. H, WEST, C. D., LI, M. C., MACLEAN, J. P., 1009. and TREVES, N. (I955a), A.M.A. Arch. Int. Med., 95, 357. YUHL, E. T., HARPER, P. V., RASMUSSEN, T., and BER- PEARSON, O. H., WEST, C. D., MACLEAN, J. P., LI, M. C., GENSTAL, D. M, Surgical Forum, 1955, Chicago, W. B and LIPSETT, M. B. (I955b), Amer. Surgeon, 21, 1075. Saunders C(o.. o5;6, p. 48(0 References from page ?88: in Reconstructive Surgerv REFERENCES 4. MURRAY, D. NIV., and BEST (1938), 'Use of Heparin in i. DEGNI, II., and LANFRANCHI, W. (1954), Heparinizacao ,' Ann. SuIrg., Io8, I63, I77. Regional: Vantagens o Desvantagens-Anais do Segundo Congresso Latino-Americano de Angiologia. 5. MURRAY, D. WV., GORDON, and JAMES, J. M. (I940), 2. FREEMAN, L. E., WYLIE, E. J., and GILFILLAN, R. (I950), Prevention of Acute Failure of Circulation Following Injuries 'Regional Heparinization in Vascular Surgery,' Slrg. Gynec. to Large ,' Brit. med. J., ii, 6, 7. Obst., 90, 406, 412.

3. FREEMAN, N. E., and GILFILLAN, R. (1952), 'Regional 6. WYLIE, E. J., GARDNER, R., JOHANSEN, R:, and http://pmj.bmj.com/ Heparinization after Thromboendarterectomy in the Treatment McCORKLE, H. (I950), 'An Experiment of Regional of Obliterative Arterial Disease,' Surgery, 31, I 15. Heparinization,' Surgery, 28, 29, 35.

zaeA o on September 24, 2021 by guest. SUMMER EXHIBITION of technical and diagnostic interest, practical demonstrations of some of the more unusual tech- July II to August 23, 1957 nical procedures and items of special photographic Although the Ilford Department of Radiography appeal. and Medical Photography is well known as a place Well-known members of the technical staff will of interest to the many visitors who enter its be available for discussions and for the special doors, this year a special effort is being made to demonstration features. add to its technical appeal by holding a summer The exhibition, to be held at Tavistock House exhibition. North, Tavistock Square, will be for all users of The exhibition will include many attractive X-ray and photographic materials and visitors can features embracing a wide range of radiographs anticipate a cordial welcome.