389 Postgrad Med J: first published as 10.1136/pgmj.33.382.389 on 1 August 1957. Downloaded from THE JUGULAR VENOUS PULSE By D. S. SHORT, M.D., M.R.C.P.* The Institute of Clinical Research and Experimental Medicine, the Middlesex Hospital, and the Cardiac Department, the London Hospital " Study of the veins 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 heart a needle into'the median cubital vein and attaching cases."-Sir Thomas Lewis, I948. it to a manometer filled with sodium 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 central venous pressure 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 atrium, 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 Anatomy 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 neck: 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 platysma muscle, 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 jugular vein 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 subclavian vein. 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 anterior jugular vein begins near the hyoid the jugular and arterial pulses simultaneously and bone, 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 cardiac cycle, which he believed two anterior veins are united above the reflected. At first the chief clinical jugular just they application sternum 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 internal jugular vein lies within the carotid waves then waned until the advent of cardiac sheath, deep to the sternomastoid muscle. It runs catheterization and cardiac surgery led to more from the jugular foramen of the skull 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 external jugular vein 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 blood 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 superior vena cava. Thus there are is to place a finger 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 right atrial pressure 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 hypertension 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 systole; 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 tachycardia: 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 artery, and the x trough is due to atrial pericarditis relaxation.