"

THE MEDICAL JOURNAL OF AUSTRAUA

VoL. I.-3-TH YEAn. SYDS EY, SATCRDAY, :JIAY 31, 1947. 22.
Table of Contents.
[The ""'"hole of the Literary MaUer In THE MEDICAL JOURNAL OF AUSTRALIA Is Copyright.]
OR.IGIJ\'AL ARTICLES- Page.
Revision of the V e nous System: The Role of the
Vertebral Veins. by William F. Herlihy . . 661
A Clinico- Pathological Study of Two Cases of
Idiopathic Cardiac Hypertrophy with Con -
ges tive Failure, by Malcolm Fowler 672
REVIE.W S-
Textbook or Gynrecology . . 676
Pulmonary Tuberculosis . . 676
NOTES ON BOOKS, CURRENT JOURNALS AND NEW
APPLIANCES-
Stor ies of a Statesman . . 676
Twice a Pr i soner or War 676
LEADING ARTICLES-
The Next Congr ess . . 677
CURRENT COMMENT-
Activity in the Treatment of Fractures 678
The :11echanism of Healing in Bacterial Endo-
carditis . . . . . . . . 678
Subclinical Poliomyelitis . . 679
AB STRACTS LITERATURE-
Prediatrics . . . . . . 680
Or thopredic Surgery . . 681
BIBLIOGRAPHY OF CIENTIFIC AND INDUSTRIAL
REPORTS-
The Res ult s of War- Time Research 682
BRITISH ASSOCIATION NEWS-
Scientifi c
Medico - Political
!'lotice
684
685
685
REVISION OF THE VENOUS SYSTEM: THE ROLE
OF THE VERTEBRAL VEINS.
By WILLI.ui F. HFJU.IHY,
R esear ch F ell ow in Anatomy, University of
Sydney.
The simple every wcrd; but the prudent man
looketh well tc- his going.
-Proverbs xiv, 15.
THE discovery of t he circulati on is perhaps the most
fascinating in the history of medicine. It is well for us
to reflect on the many stages in th-e acquirement of know
ledge of the circulation over the centuries, for only in
this way can we adopt a proper pers pect ive for our study.
For it is only when we realize that the conc-eptions of
blood flow put forward by various scholars, anatomists
and philosophers thr oughout the centuries had often lasted
several hundred years before being proven false, and that
each conc-eption had been invariably proven incorrect,
with the exception of Harvey's, that we begin to wonder
whether our conception of the circulation today is com-
pletely acceptabl e. As regards the venous part of the
circulation, I beli-eve our present conception is i ncor rect.
HISTOR1CAL REVIEw.
For centuries the circulation remained unknown to man.
Aristot ( 384 to 322 B. c. ) believed that the heart contained
three ities. The right cavity contained the hottest
blood, the left held the least and the coolest blood. This
corr esponded to the belief that the right half of the body
had a greater temperature than the left. The third cavity
was common .
The theories Galen A.ll. 131 to 201) were supreme for
many centuries. ' mistaken ideas were these. Life
consisted of three essentials: th e first was the "natural
spirit", which cam-e to the blood from the liver, the centre
POST-GRAD UATE ' VORK- Page.
:.1e!bourne Permanent Post-Graduate Committee 685
CORRESPONDENCE-
Int e rnational Congress of :.rental Health . . . . 68 5
THE ROYAL At;STRALASIA N COLLEGE OF
SURGEONS-
Gordon Craig Scholarships . . 686
Examinations for Fellowships 686
OBITUARY-
Ralph Charles Brown 686
Albert Edward :.ranin . . 687
Westmore Frank Stephens 687
AUSTRALIA!\" iUEDICAL BOARD PROCEEDINGS-
Ne w South Wales 687
Queensland 687
MEDICAL PRIZES-
The Stawell Prize 687
N0!\11 'ATIO!\"S A-ND ELECTIONS 687
CORRIGE!\'DU'll 688
1\"0TICE 688
){EDI CAL 688
BOOKS RECEIVED 688
DIARY FOR THE 688
) I EDI CAL APPOINTJIENTS: IMPORTANT NOTICE .. ..S88
EDITORIAL NOTICES . . 688
of nutrition and metabolism; the second was the "vital
spirit", which mixed with the blood in the heart, the
centre of the heat regulation of the body; and the t hird
was the "animal s pirit", r es ident in the brain, the centre
of sensation and movement. He believed in the anastomosis
of arteries and veins and the transfer of the blood and
"spi rit" from one to the oth-er by very small passages.
Galen also assumed communication of the two ventricles
by invisible pores in the septum. He realized that arteries
contained blood and experimentally proved pulsation in
v-essels. However, Galen regarded the movement of the
blood as an ebb and flow, the arterial blood conveying vital
spirits from the heart, the venous blood conveying natural
spirits from the liver. Galen also demonstrated the myo-
genic theor eart.
Andrea Vesalius ( 514 to 1564), although still ignorant
of th-e p the circulation, was outstanding in
contradicting many statements of Galen in anatomy i n
gener al, including that of the presence of invisible pores
in the septum. Leonardo da Vinci probabl y indicated to
his pupils the course of further study.
Until the Renaissance, th-e liver was regarded as the
centre of blood flow. In the liver it was believed that the
blood mixed with the chyle which had been . brought there
by the " meseraic" veins and from there spread throughout
the body. The left ventricle of the heart contained air, or
blood mixed with air, which reached the right side of t he
hear t through pores in the ventricular septum. The air
passing th r ough the arter ies carried the vital' spirit
throughout t he body, reaching the hear t from the lungs
by means of the arteria venalis. Only the veins carr ied
blood. Leonardo da Vinci and Vesalius disbelieved the
presence of pores in t he septum, but not unt il Harvey
wer e we to get the true conception of circulation.
The discove e pulmonar y circulation is attributed
to Michael ervetus (1509 to 1553). The following is a
translation ork by Willis.
.. . the first thing to be considered is the substantial
generation of the vital spirit-a compound or the
662 THE }fEDICAL JOURNAL OF AUS'I'RALI.A.. }1.-I.Y 31, 194 7.
inspired air with the most subtle portion of the blood.
The vital spirit has, therefore, its source in the left
ventricle of the heart , the lungs aiding most essentiallY
in its production. It is a fine attenuated spirit,
elaborated by the power of heat, of a crimson colour
and fiery potency-the lucid vapour as it were of the
blood. substantially composed of water, air and tire: for
it is engendered, as said, by the mingling of the inspired
air with the more subtle portion of the blood which the
right ventricle of the heart communicates to the leit.
This communication, however, does not take place
through the septum, partition or midwall of t he heart,
as commonl y believed, but by another admirable con-
trivance, the blood being t ransmitted from the pulmonary
artery to the pulmonary vein, by a lengthened passage
through the lungs, in the course of which it is elaborated
and becomes a crimson colour, mingled with the inspired
air in this passage . . a nd reaches the left ventricle
of the heart. . . . The vital spirit . . . is at length
transfused from the left ventricle of the heart to the
arteries of the body at large, in such a way that the
more attenuated portion tends upwards and undergoes
further elaboration in the retiform plexus of vessels
situated at the base of the brain .. elaborated by the
igneous power of the soul.
a t hat Realdo Colombo f Cremona (1510-?) also
p erved th1 independently and o Servetus.
/ Fabricius 537 to 1619), although not the first to see
t em, de tstrated the valves in veins to his pupils, but
even so, their real significance was unknown to him.
The conception rculation, as we have it, was
known to Andr Cesalpin (1519 to 1603) befor e Harvey's
great work wa camp! He was the first to use t he
word "circulatio , is ent itled to a ri ghtful place with
Servetus and Harvey. Here is an extract from Cesalpino:
The orifices of the heart are made by nature in such
a way that the blood enters the right ventricle of the
heart by the vena cava, from which the exit from the
heart opens into the lungs. From the lungs there is
a nother entrance into the left ventricle, from which,
in turn, opens the orifice of the aorta. Certain mem-
branes placed at the openings of the vessels prevent
the blood from returning, so that the movement is
constant from the vena cava through the heart a nd
through the lungs to the aorta.
Cesalpino altel' the centre of the circulation from liver
to heart.
In 16 8 Harvey's 'De motu. cordis" was published, prob-
ably th milestone in medicine. William Harvey
(1578 to 1657) appreciated the presence and true sig-
nificance of the valves; he discover-ed that they allowed
blood to flow only towards the heart. He demonstrated
the return of blood to the heart by way of the veins, and
also showed that it was a mathematical necessity. He
show-ed that the heart was a muscular pump, and pumped
blood into the arteries, from which it flowed to the veins.
T o quote Harvey:
It has been shown by reason and experiment that
the blood by the beat of the ventricles flows through
the lung and heart a nd is pumped to the whole body.
There it passes through the pores In the flesh into the
veins through which it returns from the periphery
everywhere to the centre, from the smaller veins into
the larger ones, finally coming to the vena cava, and
right auricle. This occurs in such an amount, with
such an outflow through the arteries and such a reflux
through the veins, that it cannot be s upplied by the
food consumed. It is also much more than is needed
for nutrition. It must therefore be concluded that the
blood in the animal body moves a round In a circle
continuously, and that the action or function of the
heart is to accomplish this by pumping. This Is the
only reason fo r the motion and beat of the heart.
So much for the
circulation. It w
to see the capillan"--"-'YU
Hence It was clear to the senses that the blood flowed
along sinuous vessels and was not poured into spaces,
but was always contained within tubules, and that its
dispersion is due to the multiple winding of the vessels.
So it was that the link between arter ies and veins was
uncovered.
In 1664,
which was
blished his "Cerebri Ana-tome", in
ed the a nastomosis of vessels at t he
base of the brain which now bears his name. Raymond de
Vie ussens ( 1641 to 1730) was the first to describe the
coronary vessels
Let me quote fronf Poirier ..eh the portal system.
Se-mblable, co-mparaison de Galien, a
un arbre dont les racines plonoent da.ns le tube dioestif
c t la rat e, et dont les rameaux s'epandent da.ns le foie,
Ia veine porte C071L71Len ce da.ns l'intestin par des reseaux
capillaires et finit dans l'oroane hepatique par d'autre&
ramifications analooues.
I have briefly outlined the history of the circulation,
indi cating but a few of the famous names associated with
the discovery of each system- the general circulation and
the peripheral, pulmonary, portal, coronary, and cerebral
parts of t he circulation.
THE SCOPE OF THE P&ESENT P APEB.
Every reader will be familiar with the present-day
conception of the circulation. But do we ever think that
it may be erroneous, at least in part? Galen was satisfied
with his conception, but nevertheless he was incorrect. Let
us now proceed with the discussion of the flow in the
venous system, bearing in mind that we may still be
short of the truth.
The hub of t he discussion centres on Harvey's statu
ment that "the blood in the animal body moves around i n
a circle continuously". To this we may attribute our
modern theory; but it is incorrect, or rather, it is partly
Incorrect.
Throughout, I shall focus attention upon a great plexus
of veins, the vertebral venous plexus, that has escaped
the just attention of physiologists and anatomists. This
plexus lies within the spinal canal , over the bodies and
laminre of the vertebrre, and partly in the vertebrre them-
selv-es. The plexus has been described in the literature,
but the writer feels that its true significance has been in
great part overlooked. To draw attention to this plexus is
all that the writer desires.
For purpose of discussion, t h e paper is set out as follows:
(i) the venous system, as described in current textbooks;
(i i ) fallacies in this description; (iii) description of the
vertebral venous plexus; (iv) physiological and patho-
logical s ignificance of the vertebral ple.Jeus; (v) morphology
of veins, and the direction of blood flow within them. This
paper is a preliminary report, and for the sake of brevity
t he detailed description of the anastomoses referr-ed to
mus ailed. Reference to the work
of Poirier n Charpy ill supply details of these
ana omo fo he r ested reader. It may also be
mentioned here that experiments are still being carried ou t ,
t he results of which will be published later. The present
paper only presents an hypothesis.
THE VENOUS SYSTEM AS DESClUllED IN CURRENT
TEXTBOOKS.
According to the descriptions in Gray's and Cunning-
ham' s and other textbooks, the veins unite successively
until all the blood is returned to the heart by the superior
vena. cava and the inferior vena. cava (the caval system)
and by the pulmonary veins (the pulmonary system). The
portal system is regarded as entering into the caval
system, and the coronary system opens into the heart
directly. The vertebral veins receive scant attention, and
although anastomoses are mentioned between the azygos
system on the one hand, and the intercostal, lumbar, right
bronchial, pericardia!, mediastinal and phrenic veins on
the other, the significance is not stressed from either the
anatomical or the physiological viewpoint.
The Fallacies escri ption,
1. The statements by unningham that "the superior
vena cava returns blood fro d, neck, upper !!mba,
t horacic wall and upper part of the wall of the abdomen",
and t hat "the inferior vena cava receives all the blood from
the lower limbs, the greater part from the walls and con-
tents of the abdomen and pelvis", are correct only it we
imply that the blood destined to return to the heart from
t hose regions mnst g'o to the heart by the caval system;
lL! Y 31, 1947. THE MEDICAL JOUR AL OF AUSTRALIA. 663
but the presumption that it drains only into this caval
system is incorrect.
2. There is a presumption, i mplied in the above state
meat, that blood returns al most immediately to the heart
via the caval system.
3. Ther-e is inadequate description of venous plexuses
or "stor e houses", which are commonly asserted to be in
existence; apart from capillary storage pools and the
spleen, in common descriptions there is no indication of
anY venous storage.
4. The vertebral veins, to be afterwards described, are
so inadequately treated as almost to be regarded as non-
entit ies.
The above-mentioned so-called "fallacies" apply mostly
to modern British textbooks; but in French and German
books, as w.eil as in old British books, there are good
descriptions of veins and their anastomoses. However,
the following exposition of the venous system is not
applied, let alone stressed, even t hough evidence is pr-esent.
An attempt will be made to prove the following

1. That venous drainage is not wholly into the caval
sys em, but t hat by plentiful anastomoses a not insig-
nificant portion goes into the vertebral veins from hearl,
neck and limbs, thoraco-abdominal wails and pelvis; and
also, that various viscera are directly drained into the
veins ; the significance of t his will be seen later.
2. That the venous system is much greater in volume
th n the arterial system, for often two veins occur with
each artery, v-eins occur in regions where there are no
arteries, and veins are on the whole larger than arteries.
Therefore, all the blood may not necessaril y go straight
back to the heart to maintain the circulation.
(3.) That the v-ertebral system is a very large system
contains a great volume of blood exceeding that of
most venous stores. An amount of 200 millilitres of dye
was found by Batson to be comfortably accommodated in
it, even though the cadaver was small. Besides storage,
this system anastomoses with all other parts of the
circulatory system, except the coronary circulation, and
it is a means of regulation of the cerebro-spinal fluid
pressure.
I shall now discuss points in the r eturn of blood from
(a) the head, (b) t he pelvis, and (c) the body walls.
I The Head. \
The following data indicate that the statement that all
the blood returns from the head and neck to the superior
-> ve?W. cava is not absolutely correct. Professor hellsh r
has thrown some light on the subj.ect. He points out t at
in our own day cadavera are preserved in formalin, which
produces hardening and contraction of the veins, and
this is partly the reason why adv e description
-""":> of veins have not occurred since Quain' ti me 1 th-e
_.., middle of the last century. He quote t Hilton:
There is a tendency which is not on y prevalent
amongst students but even amongst others, to ascribe
to the internal jugular veins a more important part
than they really perform, or to attribute to them a
greater share in the return of venous blood from the
brain than they really take, and to regard in a less
important light than they really deserve those
accessory systems which escape in various points
through the osseous walls of the skull. Not only do
these accessory systems convey from the braln a
considerable portion of blood under the normal, but
also under the abnormal cond1tions of lite. For when
there exists a temporary venous obstruction in the
lungs and heart , they contribute the chief and almost
only means o! escape o! venous blood !rom within the
cranial cavity. H. for example, !rom a voluntary etrort
or from some other cause. the process or respiration
be arrested, we know as a matter o! observation, the
eyes start and that the !ace becomes exceedingly red
and turgid.
This paragraph appears to have been left unnoticed by
ph ogists.
-> !It realized the value of accessory pathways,
ally in obstruction o! the internal jugular vein.
most well known these accessory pathways ar e
grouped together as emissary veins; but as the function
and importance of t hese are so well understood, they will
not be described in detail. Rather, attention will be
drawn t o another accessory pathway, less well known, but
probably of much greater physiological i mpor tance. This
accessory pathway is the vertebral venous system. The
superior extremity of the internal vertebral venous plexus
lies on t he clivus of the skull around the margins of the
foramen magnum and in the region or the atlas. Thus,
at the base of the skull, this plexus anastomoses with the
great venous trunks of the cranium. and is therefore
admirably situated to perform its role as an accessory
pathway. From its commencement on the inside of the
base of the skull, and throughout it.s whole length, this
mternal vertebral plexus is encased in bone and is therefore
free of the effects of external pressure. In the neck, the
vertebral veins make anastomoses with the deep cervical
veins.
In the presence of obstruction to the internal jugularl
vein, this accessory pathway will probably exceed in
importance the pathways via the emissary veins, for the
latter only change th-e position of the blood within the
same venous drainage area (t hat of the internal jugular),
whereas the former carries the blood out of the dralnage
area of the internal jugular into a new drainage area,
the vertebral system. This change of venous drainage area
provides a real escape for the blood dammed up in the
internal jugular drainage area.
In other words, the internal vertebral plexus provides the
only tr ue alternative pathway of venous return from the
cranium, and therefore overshadows the emissary v-enous
system in importance. In fact the writer believes that the
emissary veins have been credited with too much, and
hav.e gained a distinction that more truly belongs to the
vertebral veins. For on comparing the size of the two
pathways and the situation of these two alternative routes,
and on considering the problem of drainage areas (s.ee
above), one is forced to believe that the emissary veins
have been credited with much more than they really
deserve, and what is more, they have been credited with a
function that is largely carri-ed out by t he vertebral veins,
and only to a lesser extent by t hem. It is the eclipse of
the vertebral veins in modern descriptions that is to blame.
Therefore, the writer believes, we are correct in regarding
the vertebral veins as the largest and by far the most
important accessory pathway for venous return from the
cranium.
Morphologically, the cranial sinuses and internal
vertebral pl-exus are in the one pl!lne; but at the base of
the skull the venous blood in the sinuses gains the plane
of the "active stratum" or plane of the viscera, and is
carried directly to the heart via the internal jugular vein.
Thus, although th.e blood does not normally continue in
the same morphological plane, yet, in the presence of
obstruction to flow in the internal jugular vein, it is only
natural that the ll.ow will be diverted into the vertebral
veins which are in the sam.e morphological plane as the
sinuses. Thus, morphologically, the internal vertebral
plexus is the ideal alternative pathway.
Also we must remember that the emissary foramina
decreas-e in size with age; in other words, the importance
of the emissary system decreases with age.
Thrombosis of the superior vena cava does not mean loss
or life from venous obstruction in the head and neck. The
operation of ligation of the internal jugular vein in
transverse sinus thrombosis does not mean venous obstruc-
tion in the head. The Queckenstedt test would not be so
freely applied in wards if obstruction of the internal
jugular vein was so serious. Thus th.e following statement
of Morris is not correct: .
All veins, whether superficial or deep, sooner or later
terminate in the internal jugular, external jugular,
vertebral or deep cervical--chiefly the two former, and
these veins open d1rectly or Indirectly into the in-
nominate veins in the root of the neck through which
all the blood !rom the head and neck passes to the
heart.
There appears to be another pathway for the dralnage of
the blood of the head, and this functions t o great etrect
in caval obstruction. This pathway )s the vertebral veins.
1{
664
THE MEDICAL JOURNAL OF AUSTRALIA. lLu 31, 1947.
I The Pelvis. 1
The following observations disprove the statement that
all the blood returns directly from the ower part of the
body to the inferior vena cava. Batson approaches the
subject from the viewpoint of cancer spread, being dis-
satisfied with t he view that spread of prostatic cancer is
by way of lymphatics. He inj ected cadavera, using Weber's
"king's yellow" (an artists' tube water colour), which is
radio-opaque and is readily followed by fluoroscopy, When
the dye was injected into the dorsal vein of the penis,
which is virtually the same as t he prostatic plexus, it
was noticed that it went partly into the inferior vena cava
and partly into the vertebral veins. But when a dye
especially for fine vessels was used (Weber's artists' water
colour vermilion, because it casts a good shadow in small
dilutions ), it was found that the dye did not go into the
caval system, but into the pelvic veins, the sacral body
and the wings of the ilia (v-ertebral veins) . This illustrates
remarkedly well t he distribution of spread from prostatic
cancer which is found clinically, and it is noted that the
distribution does not correspond with the lymph drainage
pattern. On injection, the dye travell ed up the epidural
and vertebral veins, freely anastomosing with those of the
thoraco-abdomi nal cavity to the skull. Even when 200
millilitres of injected fluid wer-e used, the dye did not go
into the caval system. When live monkeys were used (the
experiment was repeated under anresthesia), the dye found
its way into the inferior vena cava, but when a towel was
placed around the abdomen, the flow was into the vertebral
veins. This shows that the valvel ess and low pressure
system of vertebral veins is important. The caval system
' is t he usual way of return during activity, but the vertebral
system is the way when pressure is increased in any cavity.
Injection into the vein of the breas t of a monkey shows
that the dye t ravels to the clavicle, t he intercostal veins,
the head of the humerus and the cervical vertebrre. It
even finds its way into the transverse sinus and superior
longilWLi.._nal sinus.
Hatson 'continues: "There is a pathway up and down
the spine which does not involve the heart and lungs
and it has many connections. It provides a vehicle for
tumor metastases and removes the stumbling block of t he
lung capillary bed." He considers that there are four
systems or veins : ( i) pulmonary, ( ii) caval, (iii) portal,
(iv) vertebral- with significant physiological a nd patho-
logical aspects.
In coughing, in straining, and in Valsalva's experiment ,
blood is not only prevented from returning to the lungs,
but is squeezed into the vert ebral vein system. Under the
subheading "Vertebral Veins and Their Connections",
Batson continues to the effect that they are t hin-walled
and when empty of blood are barely recognizabl e. There
are rich anastomoses in the head (the brain, t he meninges,
and the bone of t he skull, which are storage places for
blood, and are a cause of stagnation). Batson considers
the vertebral system as a lake or blood store. The
longitudinal veins, he points out, are duplicated in size
and pattern from segment to segment, and have connexions
with veins of body cavities at each intervertebral space.
They also have rich connexions with the veins of the
spinal column and spinal cord. The system communicates
with segmental veins-for exampl e, the intercostals, those
o[ the breast and the azygos veins- and via these, it com-
municates with pleural and bronchial veins. Rich con-
nexions occur with pelvic viscera, and occasionally it
commun icates with the renal veins. In a mal e cadaver
only five feet four inches in length and weighing 65 pounds
( a small person), 200 millilitres of medi um were put int o
the vertebral venous system. This illustrates its capacity.
The testes and ovaries have no connexion with the system.
Batson states that pelvic veins have varying valves. Veins
accompanying spinal nerves are described as having valves,
but are known to be no resistant barrier.
This probably explains the occurrence of metastases in
the brain in cases of lung cancer (or abscess). Cancer
causes cough, this causes increased intrathoracic pressure,
blood from the bronchial veins is squeezed into the
vertebral system, whence it is carried into the brain.
Batson concludes by stating that it is a venous pool and
also a "by-pass". His statement is accompanied by a
diagram illustrating his "fourth" system.
1 The Body Wall. f
From the foregoing observations, and from our know
ledge of anatomical anastomoses, we know that the inter-
costal and lumbar veins connect with this vertebral
system as well as with the caval system. By the arrange-
ment of the valves in the posterior segment of the
intercostal veins, it seems that the direction of flow is
back into the azygos and vertebral system.
Comment.
J.
Therefore, we see that it is a fact beyond doubt that the
blood from the head, pelvis and body wall can and does
flow, in part, into the vertebral veins. Even though a
degree of obstruction in the caval system is requi red to
cause t his flow to occur to any extent, it is immensely
important to realize that these obstructions are being
caused every few minutes of our lives from coughing,
sneezing, straining, micturition, defrecation, parturition et
cetera. That is, there is a steady but intermittent flow
into and out of the vertebral veins.
J '

FIGURE I.
Diagram representing the
basic architectural design ot
the arterial system (shown
as radii radiating !rom a
central heart) and venous
'system (shown as con-
centric circles). The veno:1s
strata are : (I) cerebro-
spinal stratum, (ii) epidural
stratum (i nternal vertebral
plexus), (iii) bony stratum
(diploic veins), (iv) " active"
stratum, ( v) subcutaneous
st ratum. The diagram is ot
a horizontal section or the
body.


/----+--3
FIGURE II.
Diagram illustrating a more
correct interpretat ion ot the
basic architectural design of
the arterial and venous
system. The heart is shown
in its correct stratum, the
fourth. and not in the centre.
The venous strata are: (I)
cerebro-spinal stratum, (ii)
epidural stratum (internal
vertebral plexus). (iii) bony
stratum (diploic veins), (tv)
"active" stratum, (v) sub-
cutaneous stratum. The
diagram is o( a horizontal
section or the body.
t
well with what we have now formulated in our mind_
It is a "store-house" of blood, and this we see in the
itecture of its dilatations and in its very magnitude.
It is a pool for receiving "backt!ow" from adjacent
s, hence its many anastomoses. m It redistributes
the blood from other adjacent parts, anYt-tbe bacldlow !rom
other regions is soon accommodated in its very immensity;
it reminds us of the " invaders" of China, are absorbed
until they themselves become Chinese. ct. Any unequal
pressure in the adjacent veins is quick! equalized, and
this follows as a result of the greatness of the system's
extent, its low pressure, the shortness of its component
vessels, and the dilatations in each segment. te\ It itself
has no pressur-e, arrihence is more suitable 1'5' act as a. \
pressure absorber. (f It has no direction of flow, and this
makes possible a qu adjustment and accommodation to
a sudden inrush of blood; this is shown in its consisting
of a network instead of longitudinal channels.
'i'ch following statement is from the works of John
tHunte :
\..,__/ The vessels carrying blood from any part ot the bodY
to the heart are called veins. They are more passive

1
0
31, 19-!1. THE MEDICAL JOURNAL OF AUSTRALIA.
665
than arteries and see m to be fro m their beginning to
their termination in the heart little more than con-
ductors of blood to the heart, that it may receive its
sal utary influe nce from the lungs. However, this is not
uni versally the case, for the Vena Portee would seem
to assume the office of an artery to the liver and there -
fore a n active part: and we have many veins formed
into plexuses so as to a nswe r some purpose not at all
subservient to the circulation, but still in this respect
they are not to be reckoned act ive. They differ from
the a rteries in many of t heir properties, although in
some ways they a re very similar. They do not compose
so uniform or regular a syst em of vessels as the
arteries either in their form or use, being subject to
consi derable variety in their uses (which a re, however,
passive a nd not active) a nd often answeri ng from their
cons t ruction collateral purposes.
This last sentence shows that Hunter thought that v-eins
wer e built for many purposes and that t heir structure was
in conformity with their function.
. ve t h e following clear description of these veins
Jn uam
he vei ns which return the blood f rom the spine
a nd parts cont ai ned within the cavity, present some
pec uliarit ies which distinguish them from those in ot her
sit uations. Proceeding f r om the posterior surface of
the spine to the anterior aspect, we fi nd firs t a series
of tortuous vei n s deeply placed in the vert ebral g r ooves
bet ween the extensor muscles; in the next place a
complete network of vei ns surrounds the spinal canal
on its interior surface and two venous reservoi rs
extend along its enti re length not resembling si nuses
(for they are not formed in dura m.a.ter ) nor ordinar y
veins, for they do not present a continuous canal: they
resemble rather a chain of short veins linked together
receivi ng blood from the other rachidian veins and
t r a ns mi t ting it to some part of the general venous
system. The great spinal vei ns lie along the interval
at each s ide between the bodies of the vertebra and t he
intervertebral foramina. In some parts, the links of
the chain they form are double or even triple, a nd
occasionally det ached from any connection with the
li nk above or that below which shows that each portion
is, as it were, a separate trunk itself receiving the
blood on the on e hand a nd pr opelli ng it on the other
hand, and that it does not the r efor e ascend or descend
along the column which the series of vei ns fo rm. Each
rl of these venous links is as long as the interval between
\l.... t wo intervert ebral foramina: fo r it is found constric ted
at both extremities which communicate by shan narrow
canals with the vein s a t the fo repart of t he s pine. In
the thoracic region they open into the azygos a nd into
the intercostal veins ; in the neck for t he most part
into the vertebrals. A complex interlacing of tortuous
veins is established along the inne r surface of the
arches of the vertebrre. In the lower part of the
canal the interlacement is not so close as in the upper
portion where it usually conceals (if t he injection has
run minutely) the whole surface of the dura m.a.ter.
These veins a lso converge to the interver tebral foramina
a nd ope n by rather narrow channels into the inter-
costal vei ns. The numerous foramina observable in
the bodies of the vertebra find exit to veins which open
into the great spinal vei ns. Another group of vei ns-
vena: dorsispinales- arise amongst the extensor muscles
a nd pass in a tortuous course forwards to reach the
spaces between the arches of the vertebrre a nd open
into the mesh of the spinal veins after having pierced
the lioamenta S1Lb- flava. Some, however, accompany
the posterior branches of lumbar a nd intercostal arteries
and pass through the spaces between the transverse
processes of the vertebrre, to open into lumbar or inter-
costal veins. These veins liter ally encircle the root of
the transverse process . . in other parts of the ve nous
system, the blood flows in vessels, forming continuous
tubes which diminish in n umber, as t hey increase in
size, in t hei r progress forwards towards the hear t, each
tributar y curre nt going in most instances at a n acute
a ngle with the larger one into which it flows: but here
the blood f r om the muscles a nd the interior or the
s pine is conveyed into the great spinal vei ns whic h a r e
wider in the middle than at their extremities and there-
fore resemble so many reservoi r s from which it flows
off lets or minor veins terminating in the general
stem. What is the propelling force? ... M.
conceives that the circul ation in the great
rach' a n veins presents sever al points of similitude with
in some ani mals that occupy the lower g rades in
the scale of being and t hat it is performed with a degree
I ot slowness. proportionate to the impediments of its
I course.
I
The anastomoses of this vert-ebral venous a are
and they have been described by oirie a nd
1
and by many oth er writers. Although ce does
ow me to enumerate a ll these anastomos-es, yet I
must point them out in a general manner.
The s u perior termination of the internal vertebral pl exus
lies, as a l ready described, on t h e clivus of the skull and
in the region of the foramen magnum. Thus it anastomoses
with the other venous channels inside the skull. In the
neck there a r e anastomoses with t he deep cervical veins,
a nd i n the thorax and abdomen the anastomoses with the
intercostal and lumbar veins are well known. Infer iorly,
F!GURR III.
Diagram illustrating the
various venous strata o! the
body ; ( i) cer ebr o-spina-l
stratum, ( ii) epidural
stratum (cranial sinuses.
internal vertebral ple::rus),
(ii i) bony stratum (diploic
veins of the skull, intra-
vertebr al veins), (iv)
"active" stratum (plane ot.
soft tissues, viscera, muscles
et cetera) , (v) subcutaneous
stratum. H-heart; S. V.C. ,
I. V.C.-superior and infer ior
vena cava respectively. The
diagram represents a longi -
tudinal sect ion of the body.
the internal vertebra l plexus
has communi cation with t he
large pelvic pl exuses, by
vessels passing through the
a n terior sacral foramina; and
also, by channels passing
backwards thr ough t he
posterior sacral foramina,
anastomoses occu r with the
gl uteal veins. Exte nding
a lmost the length of the
tr unk, the vertebral system is
able to anastomose with veins
in the superior and inferior
poles of the body, and wi th
the veins on both s ides of the
trunk ; so advantageously
is t his plexus that it
anastomoses with all portions
of t he venous
ing t he coronary ci rculation,
and it is therefore able to
exert a profound influence on
venous flew and ve nous pres-
sure, for in the firs t instance,
it provides an a lternative
route for venous blood, and
in the second, it has a
presumably lower pressure
t han t h e caval system.
But these are not t h e only
anastomoses of this
system, for various viscera-
for example, the lungs, the
left s uprarenal and t he left
kidney-have a direct anasto-
mosis with t h e vertebral
veins. T hese communications
a r e li sted below and are of
great pathological impor-
tance, for at a ll times a
great portion of the venous
blood from these organs flows
into the azygos and verte bral
veins, whereas in the case
of most other or gans-for
example, the pelvic viscera..:_a
change in thoraco-abdomi na1
pr essure is necessary to direct t h e venous fl ow i nto the
ver tebral syst em.
Bronchial Ve ins.
There are two bronch ial veins on each side, which are
not quite satellites of t he bronchial arteries, and which
not onl y drain the small and larger bronchi, but also
recei ve the drainage of the lymph nodes of the hilum,
which is of great i mportance in cancer spread. The right
empties into the arch of the azygos, t he left into the
s uperior hemi-azygos.
The Infer ior Hemi-Azygos.
The inferior h emi-azygos commences by the union of the
lef t ascending lumbar vein and an anastomosis with the
left renal vein and enters the vena azygos. It o!ten com-
municates with tne spermatic and lett suprarenal veins
(see bel ow, Hutchison's syndrome). We must remember

->
666 THE ::tlEDICll JOUR1 AL OF ADSTRll:U.
..\Lu: 31, 19 n.
that the azygos veins u e inti mately r el ated to t h e
vertebral plexuses.
Anastomoses with the Portal Ve in.
The <ESophageal and phrenic veins drain into the azygos
s ystem, and the system of Retzius allows anastomosis
with the vessels of t h e post e rior abdominal wall and with
t he veins around t h e s p inal col umn.
The " Reno-Azygo-Lombaire" Anastomosis-
The "ren mbaire" anastomosis of Lejars,
according to estu opens by one end into t he renal vein,
and after bifur ing n ear its other end, empties into the
inferior hemi-azygos and first I umbar vein. Testut states
that it is present in 88% of cases, and Poiri er and Charpy
found it present in 62 of 70 cases on the left side and in
six only on the right side. On the ri ght it is usually
r eplaced by an anastomosis between the renal vein and
first lumbar vein. Therefore, this vital renal a nastomosis
is usually on the left side.
Comment.
By th is t ime we have now
a clear concept ion of the
vertebral veins. A glance at
the bra! veins in the atlas
of Told gives us a striking
illu ion. They are a distinct
system, warranting e ve ry bit
of . Batson's enthusiasm-they
have wide anastomoses with
the rest of the v eins of the H.
trunk, yet the whole system is
one that deserves r ecognition
as an entity. Apart from be ing
an anatomical fact, it will now
be shown that it is a system
of physiological and patho- B.
logical importance, as it holds
within itself many secrets of
as yet unknown physiological
phenomena. It is with this
that I shall now deal. From
its widespread anastomoses it
A
Ftouru: IV.
may explain some of those
facts of cancer spread of which
the explanation is as yet so
far from ou r grasp. As a
surgical probklm, its very mas-
siveness is of interest in spinal
Diagram illustrating the
development ot channels
( B) in the venous plexus
( A). H. hearL
surgery, not only in t h e attack on t h e s pine i tself, but in
the posturing of the patient, as it has long been known
t hat hremorrhage occurs more readily when the patient
i s prone (compression of abdomen) .
The Phys iological and Patholog ical Significance of the
Vertebral Venous Plexus-
The relation of the ve rtebral venous plexus to cerebro-
s pinal fluid pressure illustrates well the physiology of
the veins themselves. Thus, this section will deal at length
with the problem of maintenance of and of variations in
the cerebro-spinal fluid pressure, as far as it t hrows light
on the plexus under discussion_ As I have no experi me ntal
evidence to offer as yet, and as my work is put forward
only as an hypothesis, no attempt is made to discredit
t heor ies based on ex11._erimental_jact.
Hamilton, Woodbury and Harper have written an article
on lne "ll hYsiological relationshiPs between intrathoracic
pressure, intraspinal pressure and arterial pressure. They
make the following statement:
Evidence to be presented elsewhere shows conclusively
that quick changes in intrathoracic pressure are trans-
mitted directly and Immediately to the cranio-spinal
canal. These pressure changes are NOT propagated
to the c.s.f. by the Internal jugular vei n, because they
are slower a nd less extensive in that vessel than in the
canal itself. They are NOT propagated over the arterial
tree. , An ordin ary systemic rise o! arterial pressure
causes a rise o! Intraspinal pressure o! only 1-2 mm.. Hg.
A s imilar rise In arterial pressure caused by a cough
is accompanied by a rise In intraspinal pressure as great
or_ even a bit greater than the arterial rise !tselt. Thl.s
evidence leads us to regard the cranio-spinal cavity
a sort of f unctional extension of the thoracic
a nd to think of the cerebrospi nal arteries as
fro m the sudden stress that results from straining and
coughmg m the same fashion that the Intrathoracic
a rte nes a re protected. Thus m Fig. 5 [o! these autho
work] the rises in systemic B.P. that occur lUI a
of coughing do not appear in t he nett lnt.rasplnal
pressure. They a re cancelled by stmilar rises In c..a..t
pr essure. The nett intracranial B.P. falls to r1ae
does the systemic B.P., but just as In the thorax It d
rise after strain is over. Moreover, the
pressure pulsatwns are much more extensive atter a
s train puts t he greatest st ress on the cerebral arteries
The nett intraspinal B.P: which Is analogous to the nett
Intrathoracic B.P. IS, or course, the force that burn.
the arteries a nd ca.uses apoplexy. One cannot tail to be
struck by the admirable way In which the vital arteries
within the cranio- spinal, within the thoracic, and to a
great extent wnhm the a bdominal cavities are pro-
a gainst t hese sudden a nd enormous physiologic
mcreases m pr essure. Admlttmg the existence of theee
pressure relationships and their usefulnesa, what 111
there to say about the mechanism that results In the
prompt and opportune rise in intracranial pressure? A.e
we have seen, the pressure cannot be propagated from
the thoracic to the craniospinal canal by the arteries
or by the inte rnal jugular vein. How then do theee
sudden and large pressure changes occur In such a
rigid box as the craniospinal canal? These are the
hypotheses. We would suggest that the presauree
which a rise during coughing and stralnl ng ln the
thoracic and a bdominal cavities a re transmitted through
the soft tissues between these cavities Into the splna.J
foramina_ Because o! the rigidity o! the cerebrosl)lnal
canal, and because of the temporarily Increased v8.8Cular
pressure no very large tissue or ftuld volume would need
to be squeezed into the canal in order to raise the lll:'ee
sure e ve n to the extent it does during cough. The material
e ntering the canal under s tress may be: (1) C.B-F. trom
under evaginations of the dura around spinal nerve._
(2) Spinal ne r ves themselves and the looae &reai&l'
tissue surrounding them. ( 3) Venous blood In the p&nL-
vertebral plexus, and in the veins at the ba.ck of t.be
thorax and a bdomen in close co=unication with t.be
veins. . . . The pressure Increases that are,
to our notion, pr oduced In the spinal canal muat
na turally be propagated up through the fora-
magnum and Into the cranial cavity. Even t-hough. t.be
volume movement up through the base 111 small, the
pressure thrust is considerable. A similar and opposite
thrust occurs as intraspinal pressure goes down_ The
fact that these stresses are localis;xl at the base o! the
brain may have some bearing on the frequency o!
hremorrhage in this region.
With that, Hamilton, Woodbury and Harper concluded
their paper_
From this I developed the notion that in increa..sed
intrathoracic pressure, it was most likely a squeezing of
the blood vessels in t he thoracic walls that increased the
volume of the verte bral veins. How, then, was th111
transmitted to the cerebro-spinal fluid? It would not be
s urpri si ng if t he internal vertebral plexus i s larger than
what we expect. In the days when alcohol and not formalin
was used for embalming, the veins were found In a better
state, and their size struck the earlier anatomists. It is not
far from the imagination, when we consider that in every
part of the body no gaps are left between adjacent tissues,
if we postulate that most probably the veins within the
spinal canal nicely fill up the space in the canal left by
the spinal cord and membranes. That Is, a mutual pressure
may exist between the venous pressure in the veins and
t he cerebro-spinal fluid pressure_ Rise in pressure in the
one means displacement of fluid in the other to allow
accommodation (however temporary) of the increased
quantity of fluid in the one in question.
Clinically, we may take the Queckenstedt test as an
example. Pressure on the internal jugular vein causes an
i mmediate rise of cerebro-spinal fluid pressure, and release
of the hand causes almost as sudden a falL Secretion of
cerebro-spinal fluid due to the back pressure in the internal
jugular vein is no longer feasible' as the cause ot raiaed
pressure. Events are too rapid for this. From whAt h&a been
said before, pressure on one internal jugular vein e&UMIJ
the opening up of anastomoses, most likely the nrtebral
31, 19-!7. THE MEDICAL JOURNAL OF AUSTRALIA. 66T
veins. This swelling of the vertebral veins causes mutual
pressure on the subarachnoid space with consequent r ise
or cerebro-spinal fluid pressure. Release of the hand allows
blood to flow quickly onwards in the internal jugular vein,
and the stream into the spinal canal diminishes and thus
cerebro-spinal fluid pressure becomes normal.
In Frein's syndrome the block in. the subarachnoid space
is itsel f of such a nature as to exert pressure on the spinal
>eins, so that in performing the Queckenstedt reaction we
have a column of blood running down only to t he site of
the lesion-the collapse of the veins at this site prevents
the flow going down to the region of the lumbar puncture
needle. Thus there is no alteration in this region of the
"mutual pressur e" r elationship, and the column of cerebro-
spinal fluid does not rise. It may be more accurate to
postulate that it is not the increased flow that is prevented
from passing the site of the lesion, but probably the tumour
in the subarachnoid space prevents the distribution of the
rise in cerebro-spinal flufd pressure above the lesion to the
region below. Thus the response to the Queckenstedt test
is "negative".
In point of fact, the supposition or this "mutual essure
is borne out by the observations or o and
uri . Th-ese authors describe a new techniqu or the
removal of "Pantopaque" in the spinal subarachnoid space.
With the lumbar puncture needle in situ, the patien.t
performs the Valsalva manreuvre, which raises intraspinal
pressure.
During Valsalva's manceuvre, two things happen to
the column of opaque oil: first. the whole column tends
to move craniad a dista nce or !rom 05 em. to as much
as 5-8 em.; second, the column becomes narrowed.
These changes are the result of engorgement of the
venous plexus that surround the dura and can be
demonstrated by taking spot films.
During the raised press ure, the lighter cerebro-spinal fluid
is displaced and the oi l is in more mutual contact with
the needle and can be expelled.
Therefore, from the evidence at hand, we see that in
such drastic exercises as Valsalva's manreuvre an actual
blood shift occurs into the vertebral veins, and this shift
of blood with consequent engorgement of the plexus causes
compression of the spinal subarachnoid space and raised
cerebro-spinal fluid pressure. Thus it appears that in such
drastic manceuvres the raised intrathoracic and intra-
a bdominal pressures are responsible for raised cerebro-
spi nal fluid pressure.
But what of the effects of the constant, normal r espira-
tory variations on er o-spinal fluid pressure? I refer
the r eader to O'Connel work. This writer sets forth
the cer ebro-spinal fluid pressure and
cerebro-spinal fluid circulation. These are as follows, as
O'Connell has set them out :
1. The normal posi tive intracranial pressure is due to
the balance existing between the process of production and
absorption of cerebro-spinal fluid.
2. Most observers believe that during a given time of
observation, the cerebro-spinal fluid pressure is relatively
constant and subject to but slight and unimportant varia-
tic with cardiac and respiratory activity. 1.. Smitl:\. and
Kub e (according to O' Connell) point out that tli'l;pressure
variations with cardiac activit y amount to two to four
millimetres of cerebro-spinal fluid, and with respiratory
activity to five to ten millimetres of cerebro-spinal fluid
at lumbar puncture. Frenfield and Carmichael (according
to O'Connell) point t o the waves superimposed by this
activity upon the tide of the circulation between the
points of product ion and absorption. They believe that
the replacement of fluid in the spinal canal is due to the
pulsations of cardiac and respiratory activity.
3. The ci rculation of cerebro-spinal fluid is accepted as
being a movement from its point o! production towaros
the villi; also the circulation is believed to be slow.
O'Connell disagrees in great part with the above state-
ments. Let us consider each in turn.
1. O'Connell came to the conclusion that vascular !actors
were of great importance in the maintenance of cerebro-
spinal fluid pressure. For he found, in cadavera obtained
soon after death, that on lumbar Puncture no fluid dripped
!rom the needle, and no manometric record was possible.
Rightly he asks why the cerebro-spmal fluid pressnre drops
t o atmospheric pressure after death. With death the
production and absorption of cerebro-spinal flnid cease,
so that the fall in pressure must be due to increase in
volume of the subarachnoid space. O'Connell attributes
this to post-mortem decrease in volume of the arterial
tree, and to collapse of the intracranial veins when blood
fails t o reach them from the arteries. Thus vascular
factors are important, according to him, in the maintenance
ot cerebro-spinal fluid pressure.
We have seen the effect of engorgement of the vertebral
veins on t he cerebro-spinal fluid pressure, and when we
compare the size of to the size of the intracranial
veins, it is more probable t hat the collapse of the former
will contribute more to t he enlargement o! t he sub-
arachnoid space than the col-
lapse of the latter. So it
may be feasible to state that
the vertebral p!extLS plays a
major role in the maintenance
of cerebro-spinal flnid pres-
sure.
l!. When the subject is in
S.V. C. the horizontal position, only
H
small variations are round
with cardiac and respiratory
activity at lumbar puncture
and cisternal p u n c t u r e .
Cardiac variations are usually
05 to 10 millimetre or
I.V. c. cerebro-spinal flnid, and
respiratory variations are
slower and amount to two
millimetres. But, on the other
hand, in intraventricular
"tap", cardiac variations are
5 to 50 millimetres 0! cerebro-
FIGURE V.
Diagram illustrating the ef'fect
o! the development o! the
thor aco-abdomi oal cavity on
the production ot great vessels
a nd obliteration of the plexus
in the area o! its development.
The pol es of the body, into
which the cavity does not
extend. r emain plexiform and
are shown as the superior (A)
<nd inferior (B) polar plexuses.
The great vessels ( S.V. C. ,
I.V.C.-superior a nd infer ior
vena cav a respectively) and
heart (H) are shown. The
plexuses of the viscera remain
despite the body cavi ty (V) .
fluid (a>erage 15
millirnetres) and respiratory
variations are 15 to 60 mtli!-
metres (average 35 milli-
metres) . Thus, according to
O'Ccnnell, intranmtricular
pressures are far trom con-
stant and range between 20
and 110 millimetres o!
cereMo-spinal fluid (avera!!=t:
50 rnillimetres). O'Connell
sought the reason for t!Jis
difference. By experiment, !Je
has shown that the difference
in the readings is due to the
differ ence in bore of the
lumbar puncture needle and
intraventricular cannula. The
forme>r are much narrower in
bore, and t his smallness of bore prevents the recording o!
rapid changes in pressure, and even when the changes are
recorded, the amplitude is recorded at a mnc.h smal!er
figure than what it really is. Therefore the intra-rentricular
cannll.la gives the true r esult. Thus cardiac and respiratory
activity, contrary to previous opinion, causes great and
important changes in cerebro-spinal fluid pressnre. When
the subject is in the horizontal position, according to
O'Connell, cerebro-spinal fluid pressure varies rhythmically
every thr ee or four through a range of eighty milli-
metres. This accounts !or t he pulsation o! the cerebrum
at operations, and !or the jet o! cerebro-spinal fluid that
leaves the cannula periodically in cranial operations.
Back.fl.ow into the vertebral veins with respiratory
activity is therefore probably considerable, and it is no
doubt owing to the engorgement of this plerns and its
collapse with respiratory activity that we have this great
variation in cerebro-spinal fluid pressure. Other !actors
associated with cardiac and respiratory activity, as sug-
gested by O'Connell, play their part. But in Tiew o! the
amount or blood flowing back into the plexus, and o! its
much more intimate relation with the thorax when com-
pared with the cerebral veins, it must be recognized that
668 THE MEDICAL JOURNAL OF AUSTRA.LIA. "MAY 31, 1947.
the vertebral plexus is probably the chief factor in these
variations.
O'Connell gives us another interesting example of
cerebro-spinal fluid mechanics. I! a rigid cylinder full of
fluid is connected to a manometer and its level is variw,
no variation in fluid l-evel occurs. If now the cylinder is
provided with a vent, open to atmospheric pressure, then
alteration in fluid level occurs with similar alteration of
t he level of t he cylinder, a nd is recorded on the mano-
meter. In lumbar punctu re, if the head is lower ed out of
the horizontal, t he cer ebro-spinal fluid pressure falls; but
if the head is raised or the sitting posture is assumed, the
cerebro-spinal fluid pressure rises. That is, t he sub-
arachnoid spac-e is "ventw". O'Connell believes that in
the raising of t he head (or in sitting), cerebro-spinal fluid
passes into the spinal theca, raising t he pressure there,
and at t he same t ime, venous blood is retained in the
intracranial cavity to replace t he cerebro-spinal fluid.
The r everse occurs on lowering of the head, t he cerebro-
spinal fluid being re;->laced by an influx into the extradural
vei ns ( O'Connell). Thus, t he so-called "venting" of th-e
subarachnoid space is largely due to the vertebral veins.
Before closing the discussion on cerebro-spinal fluid
pressure, I wi sh to r efer t o thos-e cases of lumbar puncture
in which t he patient is postured so t hat his thighs press
on his abdomen, and also to the restless, non-cooperative
patient who makes it necessary for the assistant t o place
his fist firmly in the abdom-en t o obtain fl exi on of the
spine, fo r in these cases an undue a mount of blood will
probably pass into the vertebral plexus with proportionate
rise in cerebro-spinal fluid pressure. This may give a mis-
leading figure.
3. Lastly, O'Connell discusses th-e circulation of t he
cer ebro-s pinal fluid. To the large variations of cer ebro-
spinal fluid pressure caused by cardiac and respirator y
activity, he attributes the displacement of t he cer ebro-
spinal fluid into the spinal th-eca and t he region of t he
villi ( where pressure is lowest ). Also to t he same cause
he attributes t he formation of arachnoi d granulations
from the microscopic villi, for O' Connell believes that the
intermittent rise and fall of c-e rebro-spinal fluid pressure
give rise to hypertrophy of t hese villi. Again, in post-
t raumatic hernia. cerebri, the contused and weakened region
of the brain is bulged by th-e intermittent rise and fall of
pressure, a nd this factor is also t he cause of its progressi ve
bulging until it becomes a "hernia".
O'Connell attributes all this t o the r ise and fall of
cerebro-spinal fluid pressure, cons-equent on cardiac and
respiratory activity. But whereas he believes t hat t he
mechanism is the change of volume in t he intracranial
veins and arteries, I believe that the factor of the
vertebral veins is just as great or even greater.
The work of an ark would seem to
support the theory that th-e engorgement and collapse of
the ver te bral veins have a profound influence on cerebro-
spinal fluid pressure. They have shown a striking relation
between t he dislocation of cerebro-spinal fluid and its
pr-E!.'lsu re. According to these workers, t he physiological
mechanisms involved can be considered elastic systems.
These mechanisms a pparently concern the elasticity not
only of t he anatomical coverings of the nervous system
(the cer-eb ro-spinal fluid channels), but also of the blood
vascular system. Weed et alii state t hat the elasticity or
the dura against outward distension seems t o be very
small indeed, for it is closely applied to the bony skull
and constitutes a m-embrane of great rigidity, of much
greater rigidity t han t he spinal dura, suspended in the
epidural space, with its areolar tissue and th!n-wallw
veins. The fact that in most animals a constant relation-
ship exists between the fluid dislocated and th-e resultant
pressure of the cerebro-spinal fluid indicates a consider-
able elasticity which permits a certain dislocation ot fluid
even in the intact animal. This dislocation o! fluid may
be du-e to the el asticity ( collapse inward) of the spinal
dura on the vertical head-down tiltings, but it also seems
related fundament ally t o the possible compression or
dilatation of blood vessels. Weed et alii continue as
follows. Because of the high pr-essure existing in the
arteries of the central nervous system in comparison to
that of the veins, it would seem important to emphasize
the elasticity of the venous system as a factor in the
establishment of the relation between the dislocation of
the fluid and its pressure rather t han the elasticity of
the arterial channels. We have, t hen, in the central nervous
system, a mechanism which r elates the dislocation or
cerebro-spinal fluid t o t he resultant pressure. It indicates,
Weed et alii state, that the whole central nervous system
may be looked upon as enclosed within elastic membranes,
whose func tion is modifiw by t he rigid character oC the
bony encasement. Once again we have evidence of the
A
svc
H
+-:-:": - ----- - -:
B
FIGURE YI.
Diagramma tic repr esenta-
tion of the two most impor-
tant venous systems in the
body. The caval system
is shown in stipple, the
xertebrai system in black.
The superior polar ( A)
a nd infer ior pol ar (B)
plexuses are Ulustrated.
and the thoraco-abdominal
anastomoses are s hown.
The usual venous flow is
indicated by black arrows,
and the flow in raised
cavity pressure by dotted
arrows. H-heart, V-
viscera, S.V.C. and I.V.C. -
superior and interior vena
cava respectively.
great part played by the Inter-
mittent engorgement and col-
lapse or the vertebral veins
in the variations of cerebro-
s pinal fluid
Many !actors of cerebro-
spinal fluid physiology have
oee:J. discussed. I d n:lt
discount the prPsent theories
altoget her, but rather I have
discussed them with a view
to opening new !ields of
research. Also it is not my
intention to discuss the
merits of the pap-ers dis-
cussed, nor do of!er a
soluti on for all points raised.
HoweYer, it does appear that
a major factor, the vert-ebral
ple::tus, has been much over-
looked.
Not only is this blood shift
in and out of the spinal canal
with changes in respiration
important in cerebro-spinal
fluid pressure, but it proves
that Haney's statement that
the blood moves in a circle
is not absolut-ely true. This
is the most significant inter-
pretation of this phenomenon
and will be discussed In
greater .detail in tLe last
section.
In pathology this plexus Is
no less important. In
fracture-dislocations or the
s pine, in traumatic spinal
lllJUnes in general, and
esp-ecially in spinal surgery,
the v::rtebral venous system
is of immense importance. In
t he case of emboli, it pro-
vides a means of spread
which, as Batson has stated,
allows the lung capillary bed
to be by-passed. In cancer
spread it provides no doubt
the cl ue to many metastases
as yet unexplained. In cancer
of the prostate, the constant straining on micturition and
consequent raised abdominal pressure carry the metastases
by the blood to the spine. In cancer and abscess of the
lung, cough causes raised intrathoracic pressure, and
metastases are carried to the vertebral veins; this may
account for metastases in the brain. W-e may rememb-er
that the bronchial veins, draining the bronchi and lymph
nodes, travel to the vertebral system. In connexion with
neuroblastoma of the suprarenals in children, we may
note that Hutchison's syndrome involves metastases In
the cranium, and thus, in contradistinction to Pepper's
syndrome associatoo with the right suprarenal, occurs
classically on the left side. Poirier's description shows
that the anastomoses between the renal and azygos systems
occur only on the lett side.
It seems, then, that just as
or two cavities, abdomen and
going constant alterations of
the trunk consi.sts mostlY
thorax, which are under
pre.ssure, so the pressure
r :n, 197. THE :.IEDICAL JOURKAL OF AUSTRALIA.
669
relationships in the veins of t he walls of those cavities
likewise undergo sever e alterat ion of pressure. When
we remember that the pressure in the vertebral vein
svstem is zero, and that the systemic vein pressure,
reinforced by raised cavity pressure, is so much greater,
we can realize that intermittently blood will flow into
the internal vertebral plexus. We have al r eady seen
that, by the nature of the plexus of veins, it is their
function t o carry
vertebral vein system have not been described in detail
i n this paper, as it is only an outline of some ideas on
the circulation. But a study of the valves i n t he inter
costal and lumbar veins may thr ow some light on t he
subject. Poirier mentions that Baume maintains that
the intercostals at thei r opening into the azygos adhere
intimately to the pleura, attached firmly between the
ribs, so that their lumen is constantly gaping. The
distribution of
out the duty of
equalizing t he
pressure of the
,enous sys tem.
so, when we
consi der that the
venous blood is
so much greater
in volume than
che arterial blood,
it appears that
the circulat ion is
capable of carrY
ing out the task.
Thus, when the
venous system is
aken as a wholP.
--:: ----:;--. ..... .. --::- .... - _,. - .. ;
(' .. __ .. .. :.e:,0=E ;-.> .:.,.
valves in the
intercos tals is
-
. 11:-oTv ." : ____
remar kable. The
vein in respect
of valves is
divided into thr ee
segments. The
anterior segment
contains valves
which look for-
;.- ; G
ward, the pos
ter ior segment
cont:;. ins valves
which look back;
the middle seg-
ment has neutral
valves, or is
devoid of t hem.
Thus blood is not
able to circulate
for the length of
the vein. The
blood in the middle
segments is sub-
ject to two cur
r ents, one sweep
ing it forward to
the internal mam-
mary veins, and
the oth er back to
t he azygos veins.
The for ce drawing
the blood on,
Poirie r and
Cbarpy state, Is
inspiration and
expiration. They
th-emselves state
that nothing is
so variable as the
ostial valves of
the int ercostals.
They are often
paired, s i n g I e ,
a t r o p h i e d , or
absent. They a r e
probably on I y
50% e ffi c i e n t ,
especially below,
in contradistinc
tion t o those in
the superior inter-
costals, which are
better and more
efficient.
Poirier states
that the valves in
the lumbar veins
a r e incompetent.
ex c e p t for the
largest v e s s e 1 s
w h i c h contain
valves to direct
flow to the hear t,
the blood is in
constant move
ment back and
forth and in and
out of the
vertebral veins in
accordance with
the pressures in
those r e g i o n s .
The r e l at i o n
w i t h cerebro-
spinal fluid pres
sure has been
dealt with, and
a full r ealization
of the problems
of the drainage of
the head and its
various strata of
veins is a much
differPnt s to r y
from that dis
played in current
tPxtbooks. \Ve
can imagine t hat
in any activity
associated with
increased breath
ing or holding of
the breath, in
acts of defreca-
tion. micturition
and parturition,
the archaic ideas
ot venous circula-
tion are unten-
able. The vertebral
vein system is
a provision of
F IGURE VII. Thus the veins of
the walls 'Jf the
ature to equalize
The frontispiece of Harvey' s epic work on the movements of the heart and blood.
Pr-essure, to r edistribute blood, and in pathological con
ditions of either of the two v enre cava', to act as an
alternate path for the continuation of the circulation. It
is important physiologically and pathologically. The portal
system via the system of Retzius may have an outlet in
pathol ogical conditions of the portal vein.
It is interesting to observe that in thrombosis of the
inferior vena cava no ascites occurs, but cedema of the
back and legs is frequent. The anastomoses of the
abdomen contain incompetent valves
mouths. This fits in nicely with
postulated.
horax and
and have wide open
the theory I have
My last reference is t o the monograph on the veins
by Franklin. Some inter esting facts are quoted. He
states that all the blood may not necessarily be in
circulation, or in rapid ci rculation, but part may be in
reserve. In exer cise the minute volume increase is
eight times normal, which shows tha t there must be an
Supplement to T1-rc: :\Ir:n
1
c.,L .J
1
w
1
c,_\L or- TR.\LL\ . :vlay 31, 1947.
ILLl-STI:_\TIO:\' TO THE ARTICLE BY DR. \\'ILL!A:\1 F. HERLIHY.

. I \
FIGuRE VIII.
Illustration oi lilt' inrerna l vertebral plexus and its anastomoses. The huninao of the ver tebrae
and the of he skull have been removed, along with Ihe bram. spinal cord
and <'X<'<'I't the dura of that portion of the skull remaining and Ihat pan of the
spinal dura that ,,,., opposite the vertebral bodies. The spinal dura has been removed below
the four:h nni,al ,-e.- ebra o Ehow the plexus in detaiL The internal ,ert cbral plexus with
its dilatfd i!" and also its extension onto the cliYus where it with
the 5<nu,es at the hase of the skulL The two a nterior longitudinal channels and the t r ansverse
annular oppo<ite the bodies and into which the basivertebral ,-ens of t h e \'ertebr al body
substance drain. are depicted. \Vhen engorged, the plexus completely hides the vertebral bodies.
_.\nnst ontotk passing through the inter\ertebral foramina tn anastomose with the
deep cen i<-al ,-,ns (depicted) a nd vertebral veins, are shown_ On the laminae is seen the
posterior cxternal vertebral plexus (the anter ior external vertebral plexus lies on the front
of the bo<ii<':'l. The left deep cerv ica l vein is drawn later ally for pic torial purposes. The
r igh t ,-enebral ,-,."' is shown only in i s lower part. passing in irom or the two lower
transverse pr ocesses.
lfa,...t6
cl

,, _
THi: .JOCl-{XAL Ol

J. Shellshear for his invaluable suggestions, and I wis:1
to accord my thanks to Miss Hunter, librarian of the
Department of Anatomy, Universi ty of Sydney, and to
my colleague, Dr. Wyke, for his invaluable help. .-\II
diagrams were drawn by Mr. D. Farrell. and I here
record my appr eciation of them.

0. Batson : "The Function of the Ver tebral Veins and their
RAie in the Spr ead of Annal of Surgery. Volume
CXII, 1940, page 138.
A. Castiglioni: "A History or Medicine", 1941.
D. J . Cunni ngham: "Text-Book of Anatomy", Seventh
Edition, 1937.
K. Frankli n: "A on Veins", 1937.
J. Fulton: "Selected Readings in the History of Physiology",
1930.
H. Gray: " Anatomy Descriptive and Applied", Seventeenth
Edition. 1909.
\V. Hamilton. R. Woodbury and H. Harper: "Physiological
Relat ionships between Intrathoracic, Intraspinal and Arter ial
Pressures". The Journal of the American .l:[edical .4.>sociation.
Volume CVII, September. 1936, page 853.
\V. Harvey: " Anatomical Studies on the :M:otion of the
Heart and Blood", translated by C. D. Leake, Third Edition.
J . Henle: "Ha?tdbuch der systemati>chen Anatomie des
Jftntsche"" Volume III. 186 .
.J. Hilton: "Developmental a nd Functional Relations of
Certain Portions of the Cranium", 1855.
J. Hunter: "The Works of John Hunter'', edited by J.
Palmer, 1837.
F . A. Mettler : "Neur oanatomy", 1942.
"Human Anatomy" , Seventh Edition, 1923.
J. O'Connell: "The Vascular Factor in Intracranial Pressure
and the Maintenance of the Cer ebrospinal Fluid Circulation",
Brain, Volume LXV1, Part III. 1943. page 204.
P. Poirier and A . Charpy: .rTraitB d'anatomie h1,maineu,
Volume II, 1899,
J. Quain: " Elements of DescriptiYe and Pract ical Anatomy",
1 28.
\V. Scot t and L. Furlow: ";.lfyelography with Pantopaque and
a New Technic for its Removal", Radiolcgy, Volume XLIII,
July-December. 1944, page 241.
J. Shellshear: "The Venous Drainage of the Head and Neck",
Dossier 35, Corres pondence Course in Anatomy, Post-Gr aduate
Committee in in t he University of Sydney.
W. Spalteholz: " Hand-Atlas of Human Anatomy", Volume
II. Seventh Edition, 1923 ( translated by Bar ker).
L. Testut: ' Trait 8 d'anatontie h"main en, Volume I, Third
Edition. 1 96.
C. Toldt: "An Atlas of Human Anatomy", Volume II, 1941.
L. Weed, L. Flexner and J. Clark: "The Effect of Dis
location of Cer ebr ospinal Fluid upon its Pressure", The
A111erican Journal of Physiology, Volume C, Number 2, 1932,
page 246.
A CLINICO-PATHOLOGICAL STUDY OF TWO CASES
OF IDIOPATHIC CARDIAC HYPERTROPHY
WITH CO. GESTIVE FAILURE.
By MALCOL:II FOWLER,
Prom the Department ot Pathology of the Univer sity
of Adelaide.
THE disease known as idiopathic cardiac hypertrophy
W!lS first described by Josserand and Gallavardin u> in
1901. Within recent years numerous examples of the con-
dition have been descr ibed i n adults, includi ng a series of
ten cas es by Levy and von Glahn, "' five cases by R eisinger
a nd Blumen thal.'" and eleven cases by Kaplan, Clarke and
de Ia Chapelle. ''' In addition, Kugel m and Kugel and
S toloff<> and othersm<s> have repor ted a similar but not
necessarily identical disease in infants.
During t he past year two young men llave died f r om the
condi t i on a t the Royal Adelaide Hospital. The cli n ical and
pathological find i ngs are here recorded.
Repo rts of Cases.
CASE I.-J.B., aged twenty years, single, an engineer's
apprentice, was admitted to the Royal Adelaide Hospital on
August 29. 1946. under the care of Dr. A. R . Southwood. For
two months he had suffered from dizzy turns, and for one
month from pain in the left side of the chest. During the
week before his admission to hospital this pai n had been
con tinuous. Breathlessness on exertion had been present for
an indefinite period. His sleep had been undisturbed. He
had coughed up a quarter of a pint of blood the night before
e ntering hospi tal.
On
i n sorr
per m
was l

in the
the m
the us
out.
The
days s
Aut<
carrie<
Clelan
Mac
thi n y
30 gr
dilated
#l"ftJ,...



til
/ckJK
formea on tne anlenor wau a.uu apex or tne tett ve ntriCle.
At the apex the myocardium was considerably thi nned.
:>'either valvular defects nor coronary disease were present.
The endocardium was milky in colour in all chambers. In
F:Gt;RE l.
Case I; fibro-elastic pr oliferation in endocardium ( hre ma -
toxyli n and eosi n, x 540) .
the lungs were two small ,i nfarcts , one measuring two a nd
a half inches in diameter, t he ot he r on e a nd a half inches.
The l ungs, spleen, kidney and liver wer e congested, the
last - mentioned having a typical nutmeg appearance. The
thyreoid, pit uitary and suprarenal glands were normal. The
thymus weighed 23 grammes.
Micr oscopic Examination.- The endocardium throughout
was much thickened. Immediately subjacent to it there
was a great increase in fibro-elast ic tissue, extending Into
bundles of degenerating muscle (Figure I ) . In the myo-
cardium were found patchy areas of necrosis which appeared
as pale granular material mixed with disintegrating muscle
fibres. Various stages of fibrosis were pr esent throughout
the muscle. Somettmes the fib r ous tissue penetrated between
individual necrotic muscle fibres. There was no evidence
of inflammat ory reaction. Other muscle fibres were less
affected. but their cytoplasm con tained deepl y staining
granular material. The majo rity of the muscle ftbres had
large hyperchr oma ti c nuclei, distorted Into many bizarre
shapes. Often the nuclei were lobed or spider- li ke, and
invariably they had one concave edge. Many of the muscle
cell s were separated f r om their s heaths by a clear s pace,
the appear a nce suggesting cedema. The muscle fibres.
measured from l 71J. to 331J.. For the most part the blood
r -1
"-
THi: .li:O]('.\L .JOC}{X..-\.L OF .\C.' Tl\.\LL\.
----------
J . Shellshear for his invaluable suggestions, and I wi:; :l
to accord my thanks to :\1iss Hunter, librarian of the
Department of Anatomy, University of Sydney, and to
my colleague, Dr. Wyke, for his invaluable help. All
diagrams were drawn by :\Ir. D. Farrell, a nd I here
record my appreciation of them.
BIBLIOGR..\PHY.
0. Batson: " The Function of t he Vertebr al Veins and t heir
R<>le in the Spread of )1etastases", .-l.lmals of Surgery. Volume
CXII, 1940, page 138.
A. Castigliom: "A History ot Medicine", 1941.
D. J. Cunningham: "Text -Book ot Anatomy", Seventh
Edition, 1937.
K. Franklin : "A )1onograph on Veins". 1937.
J. Fulton: "Selected Readings in the History ot Physiology" ,
!930.
H. Gray : " Anatomy Descriptive and Applied", Seventeenth
Edition. 1909.
\V. Hamilton, R. Woodbury and H. Harper: "Physiological
Relati onships between Intrathoracic, Intraspinal and Arterial
Pressures", The Journal oj the American .lfedical A.ssociation.
Volume CVII, September. 1936. page 853.
\Y. Harvey : " Anatomical Studies on the Motion of the
Heart and Blood", translated by C. D. Leake, Third Edition.
J. Henle: "Handbuch der systemacischen Anatomie des
.Yfe"Kschen", Volume III. 1868 .
.J. Hilton: " Developmental and Functional Relations of
Certain Portions or the Cranium", 1855.
J. Hunter: "The Works of John Hunter", edited by J.
Palmer , 1837.
F. A. :l<Iettler : "Neuroanatomy", 1942.
)!orr is: "Human Anatomy" , Seventh Edition, 1923.
J. O'Connell: "The Vascular F actor in Intracr anial Pressure
and the )!aintenance of the Cer ebrospinal Fluid Circulation",
Brain, Volume LXVI, Part III, 1943, page 204.
P . Poi rier and A. Charpy : 'Traite d'anatom;e humaine",
Volume II, 1899,
J. Quain: "Elements of Descriptive and Practical Anatomy",
1 28.
\V. Scot t and L. Furlow: with Pantopaque and
a ew Technic for its Removal", Radiology, Volume XLIII,
Jul y-December , 1944, page 241.
J . Shellshear: "The Venous Drainage of the Head and ::-<eck",
Dossier 35, Correspondence Course in Anatomy, Post-Graduate
Committee in )!edicine in the University of Sydney.
W . Spalteholz: "Hand- Atlas of Human Anatomy", Volume
II, eventh Edition. 1923 ( translated by Barker ).
L. Testut: 'Traite d'anatonr.ie humaine"", Volume I, Third
Edition. 1 96.
C. Toldt : " An Atlas of Human Anatomy", Volume II, 1941.
L. Weed, L. Flexner and J. Clark: "The Effect of Dis-
location of Cerebrospinal Fluid upon its Pressure", The
American Jounal of Physiology, Volume C, :-lumber 2, 1932,
page 246.
A CLINICO-PATHOLOGICAL STUDY OF TWO CASES
OF IDIOPATHIC CARDIAC HYPERTROPHY
WITH CONGESTIVE FAILURE.
By M.A.LCOUI FOWLER,
Frorn the Departrnent of Pathology of the University
of Adelaide.
THE disease known as idiopathic cardiac hypertrophy
w;.ts first descr i bed by Josserand and Gallavardin m in
1901. Within recent years numerous examples of t h e con-
dition have been described in adults, including a series of
ten cases by Levy and von Glahn, <:> five cases by R eisinger
and Blumenthal, '" and eleven cases by Kaplan, Clarke and
de Ia Chapelle.<'' In addition, Kugel <> and Kugel and
S toloff'"' and oth ers""
8
' have reported a similar but not
necessarily identical disease in infants.
During t he past year two young men have d ied from the
condition at the Royal Adelaide HospitaL The cl inical and
pathological findings are here recorded.
Reports of Cases.
CASE L-J.B., aged twenty years, single, an engineer's
apprentice. was admitted to the Royal Adelaide Hospital on
August 29, 1946. under the care of Dr. A. R . Southwood. For
two months he had suffered from dizzy turns, and for one
month from pain in the left side of the chest. During the
week before his admission to hospital this pai n had been
con tinuous. Breathlessness on exertion had been present for
a n indefinite pel'iod. His sleep had been undisturbed. He
had coughed up a quarter of a pint of blood the night before
entering hospitaL
On examination, the patien t was seen to be a pale yout h
i n some slight respiratory distress, with a pulse rate ot 112
per mmute and a normal temperature. The blood pressure
was 115 millimetres of mercury (systolic ) a nd 90 milll -
mette,; (diastolic). The maximal impulse of the heart was
in the sixth intercostal space fou r and a half inches from
the mid-sternal line. The urine was normal accord ing to
the usual ward t ests. ::-<o special investigations were carried
out.
The pat ient died after a sudden increase in dyspnrea three
days subsequent to his admission to hospitaL
Post - Jiortem Examination.
Autopsy (Post -Mortem Examination ::-<umber 212/46 ) was
carried out fifteen hours after death by Professor J . B.
Cleland.
Jfacroscopic Examinati on. - The body was that or a fairly
thi n young man of normal appearance. The heart weighed
30 g-rammes and was great ly hypertrophied a nd somewhat
dilated in all chambers. Large ante-mortem thtombi had
formed on the a nterior wall and apex or the left ventricle.
At the apex the myocardium was consider ably thinned.
::-<either valvular defects no r corona r y disease were present.
The endocardium was milky in colour in all chambers . I n
F.Gt.;RE l.
Case I; fib r o-elastic pr oliferation in endocardium ( h..,ma-
toxylin and eosin. x 54 0).
the lungs were two small infarcts, one measuring two and
a half inches in diameter, the other one a nd a halt inches.
The lungs, spleen, kidney and liver were congested, the
last - mentioned having a typical nutmeg appearance. The
thyreoid, pituitary and supr a r ena l glands were normaL The
thymus weighed 23 grammes.
Microscopic Examination.-The endocardium throughout
was much thickened. Immediately subjacent to it there
was a great increa s e in fib r o-e lastic tissue, ext e nding i nto
bundles of degenerating muscle (Figure I ). In t he myo-
cardium were found patchy areas of necrosis which appeared
as pale granular material mixed with disintegrating muscle
fib res. Various stages of fibrosis were present throughout
the muscle. Sometimes the fib rous tissue penetrated between
individual necrotic muscle fibres. There was no evidence
of inflammatory reaction. Other muscle fib r es were less
1
affected. but their cytoplasm contained deeply staining
granular materiaL The majority of the muscle fibres had
large hyperchr omatic nuclei, distorted into many bizarre
s hapes. Often the nuclei were lobed or spider-like, and
i nvariably they had one concave edge. Many of the muscle
cells were separated from their sheaths by a clear space,
the appear a nce suggestin g redema. The muscle fibres_
' measured from 171L to 33/L. For the most part the blood