Jugular Venous Valves and Physical Signs

_ J

specialcommunications Jugular Jeffrey

fundamental

part

inspection to estimate

Venous Valves and Physical

Fisher,

of the

the

central

veins

venous

examination

of the

neck

pressure,

sided cardiac hemodynamics, rhythmias; however, previously the anatomy and physiology been views3 cardiac

M.D.t

physical

of the jugular

is

predict

right-

and help diagnose acquired knowledge of the jugular veins

of the

subclavian

venous

known modern

bulbs

at the

thoracic

for at least 300 years4 atlases of anatomy.5

information

regarding

the

inlet

arof has

and are Moreover,

physiology

and their role in producing physical in the contemporary cardiovascular

have

been

depicted organized

of these

whether

in

patients

Although drawings teachers

VALVES

aware

the femoral, jugular veins.4

of the valves in the and are so contrived

from

rising

upwards.”6

during

of venous

jugular that

It was

periods

valves

external and wrote in 1628

the

internal jugular venous valves the genesis of an extrathoracic

gradient

been paid to Harvey’s valves, he and his

and Harvey

in

internal that “the

veins hang they prevent

downblood

competence

of the

and their possible role in arteriovenous pressure

of increased

intrathoracic

pressure such as cardiopulmonary resuscitation that led us to review the historic literature; that so much had

been

known

and

forgotten

a great surpnse.7 In the 19th and

early

was

jugular

paid

to

noninvasive ticed by Bamberger ular 8From

the

technique

the

bulb).8 Division

tAssistant Professor cal Center, New Reprint requests:

A fiery

of Cardiology,

veins

much

because

of jugular

of Medicine, York. Dr Fisher, 525

jugular

centuries, veins

Riegel, Friedreich, (whose name was

venous

Baltimore.

about

20th

internal

jugular

this

bulb

capable

of creating

were

subclavian

by

hemo-

valves remain

Shillingford’#{176} and

the

internal

valves

gradients

students

found that regurgitation

venous valves

that in all compewere of more

cough. Chronic elevation was associated in some of these valves, a

previous

dynamics.9 We severe tricuspid

in These

transvalvular

than 100 mm Hg during central venous pressure tients with incompetence

anticipated

present bulbs.

were

question

of venous

only

with were

of pafact

hemo-

long-standing the internal

absent.7 In contrast, subclavian competent in patients with since they are not in direct line stream, a fact noted by MUller by Wood)’

HISTORY

of the presence

subclavian, In fact,

valves

and

tricuspid regurgitation, of the retrograde venous

signs is not present literature.

MEDICAL

much attention has of peripheral venous were

edges wards,

IN

investigated

bicuspid

jugular venous

valves

in the

We

and venographically7 and found normal central venous pressure,

with

tent

valves

jugular

and VENOUS

the

competent.8 dynamically

in order

lost. Modern cardiologic textbooks”2 and restate that faithful transmission of right-sided events occur because of the absence of valves the right atrium and the internal jugular vein neck; however, valves in the internal jugular and

between

Signs*

of

was

the

phlebography

prac-

debate

was

Johns

Hopkins

New

York

Hospital-Cornell

East

68th

Street,

New

era

Hospital, MediYork

10021

BULB

VENOUS

AND

PHYSICAL

Most sources state that the jugular be estimated using the internal jugular contrast

to the external

jugular

vein,

SIGNS

pressure should vein because in the internal

is free

of valves, and, hence, transmission of pressure phasic events will be faithful;’ however, venous are

absent

from

the

internal

patients with long-standing tion7 and account in part seen

in these

patients’

jugular

necks.

Venous

a hydrostatic column from meniscus allows estimation

venous

pressure.

Moreover,

transducer membrane hence, visualization THE The

associated and below sitting,

and

CERVICAL

most with the may

venous

improving of right atrial

of the cervical

etiology

It is present

frequently hyperkinetic clavicles, be ablated

bulb

severe tricuspid for the prominent

prevent whose

new and jug-

the

JUGULAR

attention

Potain, Mackenzie, given to the internal of that

THE

and valves only

in

regurgitapulsations valves

do

not

being of

established the central

valves

may

act as a

transmission and, pressure waves.

VENOUS

HUM

venous

hum

in the

young

states. increases

is unknown. and

may

It is heard in intensity

by applying

pressure

be

above with to the

internal jugular vein above the clavicle.’2 Since the internal jugular bulb with its venous valve lies at the level of the clavicle, I conjecture, as did Potain,’3 that CHEST

/

85 / 5 I

MAY.

1984

685

the

cervical

venous

leaflets

of

cervical be due

hum to the

and,

the

hence,

hum

is created

internal

The

is usually louder in children, smaller radius of the internal

which jugular

may vein

in turbulent

signs

associated

of some Clicks

and

Mackenzie’3 over

attributed

the

“forgotten”

valves

in

signs

the

the

with

to the

presystolic

click

tricuspid

stenosis

sudden

“pistol shots” regurgitation,

in some similar

Bamberger

is credited

with

venous

flow

regurgitant

jugular tricuspid

venous

valves,

exact

veins of patients regurgitation.7’8

walls

shots

of the

may

veins,

be due

to tensing

as Dock

has

acute

rupture

from given the

severe credit face

valvular

the

of the

and

neck

disease

internal

686

valve.

first,

jugular

and

hue)

was

of bluish occurred venous

with

attributed

severe to the

the discoloration or absence of the

in

11

to

heart

disease.

In:

medicine.

Phila-

19 Boston:

Little,

pulse.

in veins:

Brown,

Co,

and

Cardiology.

Primary

1982;

an historical

survey.

Proc

Soc

Med

of anatomy.

St.

J,

Baltimore:

and

Wil-

Williams

543.3) disquisition

in animals. Louis:

of

on the

In: Williams CV

Vaghaiwalla

Mosby and

motion

Keys

of the

TE,

eds.

Brinker

J,

heart

Cardiac

1941:14-79

J,

Levin

clinical

Circulation venous and the

FA,

Co,

F, Tsitlik

H,

Weisfeldt

ofjugular

significance

venous

1982; 65:188-96 liver pulses and the arhythmic

cardiac

P. Buzzi

J

cavities.

12 13

of

Muller

0,

16:195-207

Wood

P. Diseases

Fowler

NO,

1964;

67:135-36

Potain

Pathol

(sic)

Bacteriol

1894;

CV

17

is of

tricuspid combina-

latter

is in part due to internal jugular

18

1891:

Co,

venous

Heart

Association,

Br

Heart

J JB

J

Heart in the

place

Cardiac

classics.

murmurs and

heart,

2nd

sounds

over

J

Am

in the

clinical ed.

St. great

significance.

New

York:

Oxford associ-

the

jugular

veins

Med

1956;

20:853-59

of

venous

palpation

and

heart

(part

II). New

arterial

and York:

American

1972:18

J,

Guzman

abnormal

P, Singer

internal

(abstract).

HN.

Am

that take

eds.

and

pressure. of the

Brinker

sounds

TE,

Pulsations

Inspection

in examination

Hultgren

J

1910:238

pulses

systolic

hum.

sounds

Keys

physiological

presystolic

high

J,

H. their

of the

W. Loud

Fisher

Heart

1941:533-56

1268-70

Press,

NO.

Am

Philadelphia:

venous

and

FA,

Diseases

University

Fowler

circulation.

cervical

1212-14;

J.

with

pulse.

incompetence.

and

movements

neck:

regurgitation: 19

the

Mosby

of the

Dock

heart

In: William

Mackenzie

ated

Tricuspid

R. The

S. Sainsbury

veins

disafter

On

veins.

of the venous

1962:588

Grause

PCE.

Ringer

J.

of the

Co.

Louis: 14

value

Shillingford

1954;

jugular

of

A. Clinical

54:127-137

Lippincott

valves

the

1980;

venous

W. An anatomical

9 Cossio 10

jaundice, and retrograde blood into the neck with Presumably,

Co,

An atlas

blood

classics.

demon-

trauma. Shattuck a greenish discoloration

of patients

which

greenish

case, as in the the incompetence venous

development and neck that

thoracicoabdominal for describing

tion of hepatic congestion, venous flow of desaturated resulting

JCB. 1972:(Fig

6 Harvey

16

head

in

of cardiovascular

cardiology.

KJ. Valves

Lancet

described of the

Saunders

J. The jugular

1957;

Hue

Keith coloration

lost

21:1-17

kins,

15

Facial

This

be returned

2:84-155

these

with long-standIn the absence

findings. should

examination

A textbook

Bedside

contraction

the

of

physical

M, et al. Determinants

is unclear, since my colleagues and I the venous valves were absent in

the pistol

the distended strated.2’

striking

pathogenesis

jugular

70

7 Fisher

a

to reflect

the internal ing severe

J.

The

valve competence. 8 Mackenzie J. The

describing

valves.8”

hemodynamic of medicine

ed.

WB

4 Franklin

patients to the

venous

that

E,

5 Grant

thought

sounds

Braunwald

of the

internal jugular regurgitation,

thrills and demonstrated

E.

1927;

in the tricuspid

The

1 Braunwald

and

prominent palpable pulsation venous bulb in patients with

in the internal

33-47

femoral venous pistol shots reported by Hultgren.’9 Lancisi2#{176} and Mackenzie8 also described a systolic murmur over the clavicles in patients with tricuspid regurgitation.

and

history

2 Constant

heard

closure

valves

at the thoracic inlet has been well presence helps explain several

book.

delphia:

follows.

valves in the internal jugular vein. Dock’6 described a similar sound in patients with high central venous pressure. Fowler’7 and Fisher et al’8 recorded midsystolic jugular venous with severe tricuspid

signs

3 Abrams

a loud

of venous veins Their

in the

MARY

REFERENCES

and A

Murmurs

sound

presence

1976;

in a patient

this

page

SIGNS

with

described

the clavicle

The

and subclavian documented. physical

well known in the past but have been forgotten.

of these

SUM

flow

PHYSICAL

jugular venous bulb were were a topic for review,’4

Jugular

the

valve.

FORCOrrEN

review

across

venous

an increase

Physical

by flow

jugular

Clin

Venous

Res

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shot

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Yin

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valve

1981;

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sounds.

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function

and

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Lancisi

21

Dock

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jugular

PD,

marked

chronic Am

et aneurysmatibus.

sounds.

A. An account of the

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cordis

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of the

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‘NT.

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structures

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concerned

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produc-

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of the deep jugular

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of

Trans

54:199-209

Valves

and Physical

Signs

(Jeffrey Fisher)