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Show DISEASES OF TIIE BLOOD YESSELS. TABLE VIII. MULTIPLE CAVIZKNOI's‘ A xoioiix'rA. Sizxitm (‘rxxomzxn Figs. 1. ‘2. the dorsal surface of the right ltand of an individual affected with cavernoustumors over a great part of the body. Those on the body resembled fibronta inolluscum; on the haiid their cavernous character was distinctly marked. The tumors on the hand. Fig. I, are small and spheroid; the fingers are extremely deformed. Fig. 2 shows the palmar surface of tlte same hand. the skin (lissected away; the tumors are seen to be occupying every tisstte of the member. 3efore removal of the skin. they looked bluish and purplish. nearly spherical: the skin over them was very fine. but healthy. and could freely be moved over them. backward and forward; some looked like ripe niulberrics; after the skin was removed, the tumors presented a racemose appearance. were freely movable. bttt held to their places by a very tine connective tissue. constantly undergoingr a change of growth, etc, during infancy, there is great plausibility for the theory.tltat the murtnur is due to change of caliberof theartcries. espm-ially as in the middle mening: ‘al and in the temporal murmurs are ofteti enough found to exist at that period of infancy. In anettrism. the sottnds and murmurs: are so constant in different portions of the enlargements and constrictions, arid synchronous with the diastole of the artery. that no other cause can be ascribed to them, than the eddies. formed in the sac. Aneurismal bra/'15 are often exceedingly loud. and audible atadistance. When the interior of the tumor is so filled with clots as to absorb all sound and to leave but a very narrow passage for the blood. no bruit or murmur will be heard. In extensive dilatations and tortuousness ofarteries,as is often found in such diseases as that ofBas- edow, etc..murmurs will be found over the region oftln; erookml vessels. Congenital stone. is of the aorta. near the origin ofthe ductns. Botalli is liable to prodttcc flttctuatiou in the arteries. and render them tortuous. I‘lreinitus.murmur." etc, may be looked forin s veral regions of the body in such cas is, Leopold lately discovered an arterial murmur in a case ofcanecr ofthe liver. There was also a cotistatit sound. which became louder duringr every arterial diastole. He ascribed them to excessive dilatation of the hepatic vessels. In excessive inflammations of the uterus and ovaries. murmurs and sounds are very frequentamd are owing to the existence of dilatations and contractions of the vessels of those ore-ans. When two opposite blood currents mectd'or instance. when an arteryl ireaks into a vein, eddi :s are produced. and with them there will always be murmurs of g ‘zttet‘ or lesser intensity. (,‘ossy cites a case of ruptttre of an aortic aneurism into the. vena cava superior, prodttcing fremitus and [rt/its- in the jugulars, In general amemie and cachcctic condition of the body, arterial bl'llffé' and murmurs are a very common occurrences. [SECTION IV. The" all constituted an erectile. cavernous or spongy tissue. iii different stages of morbid alteration. In some of the tumors the blood was litptid. and appeared to have had free circulation: some contained coagttla of differettt colors: some contained small phleboliths of different sizes. in the thrombi; the larger phleboliths were surroundedbythin clots. which were mostly colorless: these calcareous secretions were of different degrees of hardness. This pcrsott was affected with a weak heart. and general serof‘ulous habit. (\I. l'., vascular tumors.) (1'. La mul- I / tiple tumors.) Figs. 3. I show the dorsal and plantar surfaces of the foot of a woman of eighty-five years. affected for years with excessive varicosities on both legs. The gangrene. which developed on the right foot. began at the little toe, / and slowly spread upward. She died front Itlt‘lll‘t)-1)ll['ll1110nia and pachymeningitis. Most ofthc arteries of the body were found atheromatons. trom any cause there is Ili>illl‘lizlli('t' in the pulmonic. or in the coronary circulation. etc. then the latckward wave becomes visible. The external jugular becomes very prominent during the pre: 'rstolic phase of the heart's action. ()ccasionally a double venous pulse is found, one presystolic and the other simultaneous with the ventricular systole, but ordinarily the internal jugular, and afterward the external. pulsate. Gerhardt and Scidel found, under the above described circumstances. pulsation of many cutaneous veins, \Valsh found a pulsating mammary vein: liaridan. in a case of cirrhosis of the liver. a pulsating cpigastric vein: (jeigcl a pulsating: inferior vena cava: Scidel and Marcy. pulsating vctuc saphena-. l'ulsatiou of the internal jugular will denote insutli» eiency of its valves. and may be produced very suddenly. Such instttlicicncy may be caused by insufficiency of the trieuspid valves. when there is at the time hypertrophy of the right heart. Iicisch and ltosenbaum found such venous insufficiency iii incompetency of the tnitral valve and lack of closure ofthc foramcn ovale. Stokes and I"I'lt‘ill‘t'lt.'ll met the same iii exudative pcricarditis. lt is al» ways presvstolic, and as a rttle cannot be rccomiizcd by the spliygmm graph. fieidel‘s researches have shown thc great symptomatic importance of pulsatingy hepatic veins. It is hardly ever present except in insulticiency of the tricuspid valves, aiid is really more valuable as a symptom than jugular vein pulsation. for it appears long,. before the neck veins continence to pulsate. since the interior vcna cava has no valves. and any regurgitation ot the auricle toward the venous system will nec ‘arily affect this: vessel first. This pulsation is most perceptible over the right lobe of the liver. The cause of the hepatic vein pulse was thought to be the raising up of the liver by the over-filled vcna cava. bttt. firstof all, the organ is too voluminous to be liftedby that vessel. and secondly.as Taylor atid Thamni have shown that the pulsation is to be felt as a vibration below that gland (the Imp/([27: (MM/N). it can only be ascribed to a tur- DonXOsis or DisLxsEs or THE VEixs. git‘tity ofthe hepatic veins. caused by the backward wave in the inferior vena cava. The pulse of the hepatic vein, sometimes, sud- Inspection of the veins must be carried on upon the largersuperficial veins of the body, to ascertain their characteristic state of tcn- dcnly disappearsto reappear. \Veakness of the heart rcinle it imperceptible, Aneurismal enlargements of the abdominal aorta, or. especially, of the hepatic artery. often cause the liver to pulsate. or rather undulatc: it differs from the hepatic vein pulse in not causincr any temporary cnlargcment of voltttne of the liver,which finds place in the venous pulsation. l'ulsation in the inferior vcna cava and in the veins of the lower extremities are of very rare occurrence. sion, fullness. and the mode of movement of the blood in theircav- ities. especially during~ respiration. Venous plethora may be local or general. and in .either case a greater or lesser obstacle to circulation will exist. Thrombi in the veins. or tumors adjacent to them.usually form such obstacles. The distal end of an occluded vein is generally found distended and very tortuous in itsown course (Sec. IV. Tab. llI) as well as in that of its branches. Diseases, of the portal circulation, as well as in the liver.very frequently produce such phenomena in the veins of the abdominal wall. In pregnancy. or when there is much pressure upon the vena eava. similar venous conditions are found in the low- er extremities and in the abdomen. Mediastinal tumors and aneurismata of the abdominal aorta likewise produce such effects upon thealnlominal walls. Dilatationsand thrombosis of the transverse and superior petrosal sinuses dilate the internal jugular, while the external jugularbecomes much reduced in caliber.#( Gt r/oo'dl.) Diseases of the lungs. the heart. and abdominal viscera produce enormous modifications in the tension and caliber of all veins. very often visible 111 the surface Veins. Venous stasis is most perceptible iii the veins ofthc neek.especially when the patient occupies a supine position. The external jugular may assume an extraordinary width. and the internal may even become wider than the external. and appear from above downward. as a large ttttnor. behind the SLL‘l'llUL'lCltltl-Iilzl>lt)ltl muscle. and its sterno clavieular attachment. when the person is coughing. or when any pressure is brought to bear Upon it. lvl's/h/I‘ i"(-"1H‘l‘flf"/'kl/ worm/Ho's of flu" Hilts". Inspiration assists the flow of venous blood toward the thorax. expiration.to somcextcnt.cln-cksit. In healthy persons tclrrcs» piratory movementsof the veins are bttt very seldom pct't't‘pltldt'. ‘lnsr'o/t'o/fo/t of 1'! 2.118. Rounds, or tones and murmurs. are audible in the veins. When the blood current becomes suddenly widened or narrowcd. murmurs arise. Venous sounds are usually characterich by not being ryhths mical like the arterial. Now and then a rhythmical venous inur- mur is to be heard. then it is: gcncrally due to some pressure brought to bear upon the vessel. As; a rule. venous sounds are due to vibration oftht-ir valves by the retrograde wave of the blood. It must be stronger wln re the force actine' upon the valvular membrane is strongest. and necessarily absent where there are no valves. Ti 1 a number of very conscientious obst rvers have perceived tones and murmurs in valve- lt ss veins. Such sounds must, of courst-if they really do exist-- be ascribed to the blood current acting directly upon the vascular wall. Normally a murmur is heard in the bulb of the jugular vein. Lacnec. who first described it.thoneht it was due to a continuation of sound in the t‘ul'otlds. ll is cltal‘acterim d by H fir/1'. coiiI/oI/o/ts LII/u. which varies in intc sity every few ininutcs. so as to produce tptite a scale of murmurs. When it is very intense. it will annoy the person as a disagreeable, buzzing sound iii the car. it is usu- ally ascribed to increased velocity of the blood toward the heart. as it is mostly audible when [lit person stands upriehtmr by deep inspiration. whilst by deep expiration. and in rccuml ent posture 1t But when veins are overtillcd. from any cause whatever. or when becontt s very, wt ak or disappears altogether. respiration goes on irregularly. then each inspiration will decrease. each expiration incre se the volume of the veins of the neck. l'ulsatioti of veins is usually connected with venous plethora. Such pulsation must be dillcrentiatcd front simple undulation. preduced bv an overlyingr vein upon all artery. \\'hen there is a mods ified functional or anatomical state of thc right heart. venous pul» sation. can be looked for. especially when the heart-force is much reduced. Normally there 1 >lllell retroor ion of the venous blood into the veine (‘ithL‘ during the auricular systolcs: but when with a pathological backward wave. and is synchronous with car» diac diastole. ‘This Illlll'lltlll' used to be dis. it has nothing to do rated as low/l 1/, l)/- t/Hi. [j/V'lf I/v Are/luvs. ainl Was considered it \‘nltltlldc symptom of chlorotic and kindred dist ascs. but is really of no value whatever. as it isa vcrv norinal ph- noun-run. and simply indicatcsthe frictional condition of the blood. according as it moves fastcror slower toward the heart. Well and l'riwlrcicb havi found similar murmursin the subclavtan and other luge veins, but \\'h;ch were all devoid of clinical interest. |