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Show SECTION IV._| DISEASES OF THE BLOOD VESSELS. TABLE VII. l Exi)oriii.i~:ni'ris or run Rioii'r MEDIAN View AND i'rs Bimxeiiigs Fiton Ixriic'riotis 'l‘iiumini. l CANE B.-X(r,Her-Young man, twenty-five years old. 1][.sl‘0/']/.-\\l as accidentally shot in the arm. The weap- on was loaded with small buekshot‘, one of which passed through the lower third of the limb; the other slightly deviatcd from its course (antero-posterior) and was lodged under the skin, on the internal surface. The shot was readily extracted and the necessary care given to the patient. The humerus, the principal vessels and nerves of the arm, seemed not at all hurt; everything seemed very favorable, yet on the twenty-fifth day after the wounding, the limb began to swell and suppuration suddenly ceased. Local and general symptoms of phlebitis appeared; visceral iiiflammation spread rapidly; the patient became pyiriiiic. and after six days died of acute septiczeinia. Post m,ortmn.-I‘Iiidoplilebitis of the large ' and smaller veins oftlie arm; multiple metastati ‘ abseesses in the del- blood corpuscles. Shortly afterward the vessel becomes slightly tunic-lied, and is filled up by new blood corpuscles, which develop into connective tissue cells, and with the reformation of vascular net-work, close up the wound produced by the ligature. \Vlien harmless thrombi find their way into the general circulation, they generally locate in small vessels, or at the origin of vascular branches. L'pon such emboli, as the stagnant masses are now called, new coagula are deposited, which may completely close the vessel up; or they may undergo the same changes as the primary thrombi, etc., as described above. (Sc/tall: Drills-cl: Zt'ff-Vt‘ft. f. l'flft'lli‘g, IX Vol.) (Ra/(l), Arc/1.]: [Cl/a. ell/wary, XXIII l'ol., l'frc/i. Arch. LXXV.) Riot l, Dr'i/lsi'll. Zc/t. s f. (‘flf lI‘(/ 1875.) (Bani/Iowan. iS'iif/cnrmlc Orgmzlznt. «his lermnbus, LI'IP 1/: 1877.) (Durante, ll'i'mirr chd. Jalir. [[[, Ill.) (Seal/"Hebert, l/ .11. Arc/r, Vol.77,) (Tilli/imoi, l'frcli..lrclt., Vol.78,) (rlacrbarli,Diss. Bean, 1877,) PHYSICAL DIonosis or Airrizinizs. By means of inspection, auscultation, percussion and spliygmog- rapliy, disturbances of arterial functions and their lesions can be readily ascertained. Pulsation is the visible manifestation of activity in arteries, in the shape of a rhythmical wave movement, more or less synchronous with the systole of the ventricles of the heart. In perfect health, and perfectly at rest, even the larger arteries do not show distinctly visible pulses. But when the activity of the heart is in any way increased, or its movement in any way accelerated, a lively beating in the lateral aspects of the neck, and a rhythmical vibration in the Jtlgul‘dl‘ tosste are plainly visible. liven in such small arteries as the temporal, pulsation then becomes distinctly visible. Capillary pulsation has been noticed by Qtii'iil'c and Lelicrt in in- sufficiency of the aortic valves, in aneurisms and paralysis of the middle coat of the larger arteric. Like the abnormal activity of the heart, which indicates either its own functional disturbances, or t 7 toid and in the muscles situated anteriorly on the forearm; bilateral lobiilarpneumonia; right-sided pleuritis; gratinlar hepatitis. Fig. I shows the biceps perforated by two shots. The cephalic ( 1:0). basilic ( 12/1), ulnar, median and radial veins ( l7. (1., l'. -lfl, 11.13.), and all their branches, are cyliiidri *al, tense, very voluminous, and, in places, very much tumelied. The connective tissue is exceedingly infiltrated, the vasa vasorum injected and plainly visible. Fig. 2 shows the opened veins, their walls are thickened; the cephalic vein is full of pus, likewise the median and radial veins ( 1:11., lift); the basilic presents all stages of plilebitis; a great many purulent cavities were found within the thickness of the deltoid (A.P.). It was very plain that these abscesses were produced by multiple endophlebitis of the smaller veins. The other muscles besides those described were perfectly sonnd. The scapulo-humoral cavity was entirely filled with pits. Fig 3 shows the tortuous course of chronic venous thrombosis, often produced by stagnation of venous eirculaticm. tus Botalli; for tinder such circumstances only collateral circulation can supply the lower half of the body with blood. The collats eral vessels increase enormously in size, and become perceptible as large pulsating cords, There are three ways in which collateral cir- culation can be established in such cases: I. By the subclavian, the internal mammary, superior epigastric. inferior epigastric and external iliac arteries. 2. By the subclavian,internal mammary, anterior intercostalmos terior intercostal arteries and the descending aorta. 3. Snbclavian, transversalis colli, dorsalis scapular, posterior intercostal arteries, and the descending aorta. Pulpu/fm) of Jl)'/Ci‘f("8. The stronger the pulsation the more palpable the artery to the touch. In aortic insufficiency a short fremitus is perceptible in the carotid and subclavian arteries. In very thin people such a fi'emitus may artificially be produced by pressure with the finger or with the stethoscope upon the larger arteries or the abdominal aorta. It differs from a freinitus morbidly produced, by the absence of murmur, which is nearly always present in aortic insufficiency. Aliscullatz'oa of Arteries. In order to auscultate arteries, even the larger ones, great care must be had to keep the person very quiet, for the slightest displacement will very often change the tension of the vests-cl, and with it the sound. An arterial sound is normally short, quick, and eireumscribed to the locality. Presence of murmur. or limits, denote disease. These, may originate in the heart or in the arteries. Mechanical obstructions will sometimes give rise to murmur, without the vessel being alfected; for instance, when the elbow is bent, pres- sure upon the brachial artery will yield a murmur which grows in intensity up to a certain point, which will again decrease and dis- appear when the pressure becomes very gr rat. But when the pressure is at the highest, there will be a quick, sharp sound, but no murmur. Completely closed vessels yield no sound whatever. The subclavian and the carotid arteries in the healthy emit a very dis- anatomical lesions,the arteries, by their abnormal activity,will show tinct sound. In the majority of cases,the common carotid, at its ori- either functional derangements of the circulation, or structural lesionsoftheirown tissues. Dillt'l'c‘iiilill diagnosis of local and general disturbance of the circulation, bythe changed pulse phenomena, can only be made by the aid of percussion, auscultation, etc, of one or more parts of the body. A peculiar pulsatory movement is Often visible in the epigastrium, constitutingarliythmical systolic vibration ot'the abdominal walls, and occupying the space between the xiplioid cartilage and the adjacent costal cartilages. The vibration sometimes extends tothe umbilical region, and even beyond it. This vibration is produced by the heart directly, or by the large‘ arteries. Only when the heart oecupies a very low position, and the diaphragm is very much depressed, can the epigastric pulsation be gin, has two sounds, synchronous with the titling, and subsequent contraction of the artery. It only one is present, it is always during arterial systole,and will then indicate weakness of the vascular wall. In the subclavain artery the same phenomena takes place. In all large vessels sounds may originate in consequence of local changes of its contents or its walls. A sudden contraction or dilatation of an artery usually produces a tone. Murmurs in the pulmonary artery denote constriction or compression of its walls. Chronic intlammation or thickening ofthe left lung, or tumors which com- press that vessel, produce arterial sound. zlufrcrlit describes a case in which he heard a systolic and diastolic murmur in the region of the pulmonary artci'y,which was most intense in the third left intercostal space, about three centimeters from the left edge of the sternum. l'ost mortcni examination showed that the left lung contained no air at all, butwastilled with cartilaginous detritus. The main branch of the left bronchial artery was larger than the trunk at its origin. The other branches of the bronchial artery within the lung were exceedingly reduced in size. The change in the caliber of that vessel caused the sound. Litton describes a case of systolic murmur, overthe region of the pulmonary artery, caused by an embolus in a large branch of the bronchial artery. Murmur in the subclavian artery may be caused by pressure produced upon it, by the scaleni, the subclavian muscles. or by the clavicle, against the first rib. In consumptive pa- ascribed to direct action of the heart. In this case, the apex beat will be foniid very low in the thorax, or, not at all, but auscultation will demonstrate the presence of the 'ardiac pulse in the upper epigastric region, and occ' ‘lOlitllly the ventricular systole may be felt, when the abdominal walls are very thin.-(Eirlmrst.) lipigastric pulsation produced by the aorta, by distention of the stomach or other intestines, carcinoma of the «esophagus, cerebi'o- spinal meningitis. by a nuinbcrof neuroses, produced by direct irritation upon the peripheral nerves, or by reflex action upon the vasa motor centra, will be indicated (besides other coordinate symps toms) by the pulsation taking place after the cardiac systole. The same is the casein extensive aneurismata of the abdominal aorta. Ancurismal enlargements in superficial vessels present them- selves to the eye as pulsating tumors. whereas in deep arteries they do not become perceptible as a pulsating tumor until the overlying tissues have become absorbed or have been displaced bythem. Dilli'rcntialdiz ~nos-isbetween asolidtumorlyingagaiust a large artery, and moving with the pulsating vessel. and an aneu~ rism of an artery can only be properly established by palpation, In case of a solid tumor, only the artery will be felt to really pulsatc, whilst in an aneui‘ism there will l)U(/tl((l'1/I‘/i[('I/f of the sac after each svstole of the heart. Very peculiar changes take place in the artei‘ie.s when the aorta is either t'oilstl'ictctl ol' totally occluded all the opciiilig‘of the Duc- tients subclavian murmur is a very frequent pllctiUlth'IlOI], for, usu- allv in these cast-s, the arterial coats and the pleura are united by adhesion. and the vessel becomes alternately stretched and twisted by breathing, thus continually changing its caliber. These inurniurs are either unilateral or bilateral. An intermittent, blowing sound, synchronous with the carotid pulse, is occasionally heard over the cranial surface of children. from the third month up tothe sixth year. It is loudest over the posti rior i'ontancllc. and reaches sometimes the region of the first cervical vertebra, It is attributed by some authors to the longitudinal sinus, by others it is located in the basal arteries. JOIN/11:, finding that the blowing is synchronous with the carotid sounds, consii'lcrs it a continuation of these. As the carotid canal ls |