(4) Intra-thoracic varicose aneurism, in all its forms, is attended with murmur synchronous with the arterial diastole, sometimes prolonged through its systole.

A certain amount of force in the heart's action is essential to the generation of arterial murmur; increase of that force will convert a soft into a harsh quality instantaneously.

Murmurs heard in the thoracic aorta, single or double, are often merely conducted from the heart. But if a murmur, audible at any part of the arch, be of different pitch, of greater intensity, and of harsher quality than a synchronous murmur at the aortic base, it may be inferred that the cause of intensification exists in the vessel itself. The only source of fallacy would be the chance co-existence of badly conducting materials over the base of the heart, and of excessively good ones over the arch of the aorta. The characters of an arterial murmur will sometimes guide the observer partially to a knowledge of its anatomical cause; but the actual determination of this will mainly turn on the state of other physical signs.

(b) Inorganic arterial murmur is commonly softly blowing, if the vessel be ausculted without pressure. If pressure be used, it rises in pitch, and becomes sharply whiffing or whipping (resembling the sound produced by a quick stroke of a ridingwhip through the air.) It is intermittent, never double, never synchronous with the systole of the vessel, and affects the arterial system extensively, instead of being purely local, as the organic variety. Midway between the organic and inorganic varieties, stands the murmur of an artery, sound in itself, but pressed upon by an adjacent tumour.

The clinical conditions of inorganic arterial murmur are certain of those of cardiac murmur of the blood-class, especially spanæmia. It is said that plethora produces it; a statement I have been unable to verify clinically.

VENOUS SYSTEM.

SECTION 1.-INSPECTION.

CONSIDERABLE distention of any particular portion of the venous system indicates the existence of obstruction in the connected main trunk, or in the right side of the heart itself.* Hence an easy clue to the seat of intra-thoracic tumours.

The internal and external jugular veins are the veins most frequently found enlarged, the right more commonly than the left, when one side only is affected. This obstructive distention, uniform or varicose, even if increasing the size of the external jugular almost to that of the little finger, is unattended either with change in the integuments, hardness or cordiness of the vein, or tenderness under pressure. The common causes of this condition are tricuspid regurgitation, and pressure on the superior cava or innominate veins by intra-thoracic tumour or aneurism; more rarely, simple dilatation of the right cavities of

the heart.

The external jugular vein (oftener the right than the left) is occasionally the seat of visible pulsation, especially at its lower part near the clavicle. Irregular in amount and in rhythm (though obviously connected in the main with the ventricular systole,) jugular pulsation wants the distinctness of an arterial pulse, and is rather an unsteady intermittent tremulousness than a series of well-defined beats. The effect of inspiration and expiration on the blood in these veins partly explains the irregular rhythm; which may also, in part, be traced to the influence of the auricular systole. The impulse producing it comes visibly from below; and when the vein is emptied by pressure from the clavicle in an upward direction, it re-fills immediately from below, while the pressure is sustained above.

Lancisi, the original observer of this phenomenon, supposed that it was produced by eccentric hypertrophy of the right ventricle. Hope, holding to this view, explains the impulse by the "impetuous recoil of the tricuspid valve," which repels the blood about to descend into the ventricle with such force that its impulse is propagated back to the jugular veins. Many

It is not intended here to refer to the signs of local diseases of the veins, such as phlebitis, &c.

persons maintain that jugular pulsation only occurs where the tricuspid orifice is too much dilated to admit of closure by its valve, whence ensues regurgitation in the veins during the ventricular systole. Dr. Parkes teaches that, in addition to tricuspid insufficiency, rupture of the valves at the junction of the internal jugular and subclavian veins is a necessary condition of the phenomenon.

*

I know of no facts positively showing the necessity of such rupture of valves; the vessel may be sufficiently distended to render their valves incompetent, which is all that is required.* The valves, too, may be congenitally absent. Further observation on these points is, however, desirable. But, as concerns the tricuspid orifice? Unquestionably jugular pulsation is most frequently met with in cases of tricuspid insufficiency (though by no means in all of the class;) while, as I have decidedly observed it, where the valve was not demonstrably incompetent, in cases of dilated and hypertrophous right ventricle, I cannot refuse to admit that this condition alone may produce it. the ventricle be hypertrophous, and the valve insufficient, the pulsation reaches its maximum. It is to be remembered, too, that respiration affects jugular pulsation, emptying the vein in inspiration, distending it in expiration. The parts played severally by respiration and heart-action, may be distinguished by causing the patient to suspend his breath for a moment.

If

The right mammary veins under similar circumstances may be knotty and pulsatile, but I have not seen this without disease of the tricuspid valve.

But veins, much more distant from the chest than these,the veins, for instance, of the dorsa of the hands and feet,may be the seat of pulsations either of cardiac or of respiratory rhythm, or of both combined. Dr. Jenner has very kindly favoured me with the particulars of three cases illustrating these various rhythms. When the rhythm is cardiac, pressure on one of the pulsatory veins on the back of the hand, increases the strength and distinctness of the pulsations (equal in number to

e. g. Case of Thomas Denham, U. C. H. Feb. 1851, Males, vol. vi. p. 69. Here notable pulsation, both of the jugular and innominate veins, had existed during life; the valve was perfect, but enlargement of the caliber of the veins had obviously rendered it incompetent.

It is too constantly assumed by observers, that where the tricuspid valve is insufficient to close the orifice at death, it has been so during life also. What proof have we that an instinctive constriction of the orifice does not accommodate the width of the opening to the capabilities of the valve?

the radial pulse) to the distal side of the point pressed on, annuls them to its proximal side; the respiratory movements exercise no influence on the pulsations. When the rhythm is respiratory, the vein collapses in inspiration rapidly, swells in expiration slowly, and, when pressed on, the pulsation ceases to the distal, increases to the proximal, side of the point pressed on. One of Dr. Jenner's cases exhibits the co-existence of the two sorts of pulsation (respiratory,—and cardiac, by vis à tergo through the capillaries, probably) in an infant aged eighteen months, cut off with pneumonia secondary to tubercles. The reason why respiration and cardiac action should exercise this influence on distant veins in some cases of disturbed thoracic action, and not in others, apparently similar, is yet to be discovered.

SECTION II.-APPLICATION OF THE HAND.

Thickening of the walls of the jugular veins sometimes arises in cases of tricuspid regurgitation of long standing. If in such a case those vessels pulsate, it is very probable their diastole will be perceptible to the fingers; but I do not remember ever to have actually observed this.

Visible pulsation is occasionally attended with soft thrill,a minor degree of the arterial phenomenon of the same name.

SECTION III.-AUSCULTATION.

The venous system, as was originally and most ingeniously shown by Dr. Ogier Ward, is the occasional seat of audible murmurs, which possess one invariable character-that of continuousness. Venous murmurs are instantaneously silenced by interrupting the circulation in the veins generating them.

In point of quality, venous murmurs are referrible to four types: the blowing, the whistling, the humming, and the modulated. The blowing varieties may be as soft as the respirationsounds in health, strongly blowing, loudly blowing (as the sound heard on applying a shell to the ear,) or actually roaring. Or, the sound may be cooing or whistling. To the humming type belong various murmurs resembling more or less closely the noise of a humming-top, the buzzing of a fly, the singing of a tea-kettle, &c. Lastly, venous murmurs are sometimes distinctly modulated, consisting of a series of separate tones, ca

pable of musical notation, recurring at tolerably regular intervals, and accompanied by a low hum, which gives the continuous character to the whole.

Inclining rather to softness than roughness, and of moderate intensity (inaudible unless the ear or stethoscope be applied directly to the surface,) generally of low pitch, as the word who, (when modulated, of course, this is variable,) venous murmur is liable to change in intensity and quality from one moment to another. This change sometimes occurs from some intrinsic untraceable agency; more frequently from some one of the following causes. Acceleration of the circulation intensifies venous murmur; and as inspiration favours the rapid flow of blood in the veins adjoining the thorax, in these veins, at least, that act ought to, and does actually, increase the loudness of an existing murmur. But, on the other hand, suspension of the breath at first exercises even more markedly the same effect; the sharp collision of the blood disks inter se, and against the walls in the struggle to move onwards, probably explains this. If the breath be held for any time, the murmur disappears. Any posture which stretches moderately the vein under examination, intensifies its murmurs: if the part be a muscular one,—the thigh, for example, there is a source of fallacy in the rumbling sound of muscular contraction, which must be guarded against by examination in a relaxed posture also. In the neck, murmur is stronger in the erect than in the lying posture; probably from the greater rapidity of flow in the former. Venous murmur attains its maximum under a certain amount of pressure, ascertainable in each instance only by actual experiment. Less or more pressure weakens and finally obliterates all audible sound. Sex exercises no influence on the intensity of venous murmur, nor, directly, on its frequency. No doubt, it is greatly more commonly observed (perhaps five or six times so) in females than in males; but this depends simply on the disproportionate frequency of its physical conditions in the two sexes. dence has ever been adduced, showing that a given state, which fails to generate murmur in a male, will succeed in the case of a female.

No evi

The veins in which murmur occurs may, as far as I have observed, be arranged as follows in order of frequency. The external and internal jugulars, on both sides, or on one side only, in the latter case most frequently the right; the subclavian veins; the femoral (I have never failed to find it in these vessels when well developed in the neck, and it may be caught in them some