Normal Blood Pressure in the Superficial

Venous System of Man at Rest in theSupine Position

BY ALTON OCHSNER, JR., M.D., RALPH COLP, JR., M.D., AND G. E. BURCH, M.D.

The mean and range of venous pressure values in the various body surface areas is presented. Atten-tion is directed to the variability of these values, the constantly decreasing pressure gradient towardsthe heart, and the essentially equal pressures in corresponding veins on opposite sides of the body.The importance of accurately identifying the vein is emphasized. The relation of venous pressureto age, sex, race and other physiologic factors is commented upon.

T HIS study is concerned with measure-ment of the blood pressure in the super-ficial venous system of normal man at

rest in the supine position. Physiologic varia-tions in blood pressure in different parts ofthis system were recorded with the purpose ofestablishing values for reference.Venous pressure was first measured in 1733,

when the English clergyman Stephen Hales'3fixed a glass tube to the left jugular vein of athrown mare. It has been stated that Jacobson,in 1867, outlined the first series of measure-ments in a large number of veins,9 but it wasnot until 1902 that venous pressure was firstmeasured in man by Frey.'0 Although the con-tributions have been voluminous, at presentthere exists no comprehensive picture of theblood pressure in the superficial venous systemof normal man.Such a record is desirable in certain clinical

states, such as bilateral edema and generalizedvenous distention, where symmetric parts can-not be compared. It is also valuable as aphysiologic study in the visualization of thenormal hemodynamic state, i.e., regional varia-tions in pressure and pressure gradients inthe superficial venous system. Many physiciansbelieve that the peripheral venous pressure is

From the Department of Medicine, Tulane Uni-versity School of Medicine and Charity Hospital ofLouisiana at New Orleans, La.

Aided by grants from the Life Insurance MedicalResearch Fund, a War Contract No. W-49-007-MD-389, and a Public Health Service Research Grant(H143).

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uniform and still agree with Eyster and Mid-dleton,8 who in 1924 wrote w.....e are con-vinced that the venous pressure in a peripheralvein in a normal subject who is at rest inbed... rarely, if ever, rises above 11 cm. ofwater."

MATERIALS AND METHODSSubjects. Subjects included 153 physicians, med-

ical students, and ambulatory patients in the CharityHospital of Louisiana at New Orleans. They weredivided about equally between the Negro and whiteraces and between the male and female sexes, andtheir ages ranged from 15 to 70 years. All subjectshad normal cardiovascular and pulmonary systems,although some of the hospital patients had hernias,peptic ulcers, and small benign mammary tumors.

This investigation was carried out in the fall,winter and spring months at sea level. All studieswere performed in a similar type room, in which thetemperature remained about constant. With few ex-ceptions the studies were performed in the afternoon,at least two hours after the noon day meal. All con-stricting clothing was removed. The patient wasplaced in the supine position on a hard flat examiningtable covered by a one-half inch pad and a one inchpillow. In general, the legs were placed together andthe arms were abducted at an angle of 40 to 45 de-grees but were supported on a table, and theshoulders were held in such a way that the head ofthe humerus was never below the suprasternal notch.The subjects were instructed to relax and breathenormally. When the pressure on the posterior sur-face was to be measured, the forearm was pronated,and for measurements on the anterior surface it wassupinated. Slight external rotation of the arm wasnecessary for measurement of the pressure in thebasilic vein. Measurement of the pressure in theshort saphenous vein required internal rotation of theleg and slight elevation of the knee from the table.When the pressure in the jugular vein was measured,

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ALTON OCHSNER, JR., RALPH COLP, JR., AND G. E. BURCH

the head was turned to the opposite side. The patientwas allowed to rest for about 15 minutes whilepreparations were made.

Apparatus and Technic. All measurements of ven-ous pressure were recorded with the Phlebaumano-meter.*, 4Its chief advantage in this study was thatit permitted measurement of pressure in the smallveins. The technic and use of this instrument hasbeen described by Winsor and Burch.3 30 Each veinwas carefully identified. The needle was alwaysinserted in the direction of flow of the blood stream,and the adaptor was generally held so the meniscuswas 2.5 cm. above the site of venipuncture. In thefrontal vein of the face, however, it was necessary tohave the meniscus 2.5 cm. below the horizontallevel. In the jugular vein, dorsal venous arch, andmarginal vein of the foot, the meniscus was about3.5 cm. above the horizontal level.

Reference Level. The theoretic reference point isgenerally regarded as the right atrium, but clinicallythere is no constant topographic reference for this,since it varies somewhat with each individual. Al-though numerous levels have been proposed, theones usually employed, for adults at least, are: (1)10 cm. from the posterior surface of the thoraxO and(2) the phlebostatic axis,30 which in the supine posi-tion corresponds to the earliest proposed referencelevel.28 The latter, which gives a reference point ofone-half the anteroposterior diameter of the chestat the sternum, was chosen for this study. However,had the former been employed, the values wouldnot have varied by more than 0.5 cm., since themean thoracic diameter at the level of the sternumof all the patients studied was 21 cm. A spirit leveland a ruler were employed to locate the phlebostaticlevel accurately.Number of Veins and Measurements. Approxi-

mately 1400 measurements of venous pressure wererecorded in 50 main channels and 60 small tribu-taries of the superficial venous system in 30 differentlocations on the surface of the body. Three to 15determinations were made in each subject.

RESULTS

Results of this study related to the mainvenous channels are summarized in figures 1and 2 and tables 1, 2 and 3. However, certainaspects of the data deserve special attention.

Individual Values. The venous pressure var-ied widely over the surface of the body (figure1, table 1). Although the pressure varied fromvein to vein, the values for corresponding veinson contralateral sides of the body were essen-tially equal. The highest mean pressures wereobtained in the frontal vein (172 mm. of water)

* Phlebaumanometer, W. A. Baum Co., N. Y.

and dorsal venous arch of the foot (188 mm.of water), the latter being higher, even in thesupine position, than the mean venous pressurein the dorsal venous arch of the hand (139mm. of water). In certain areas normal venouspressure was found to be either relatively highor lbw, being lower in a vein of the majorvenous pathway and relatively high in smalltributaries of that vein.Range of Values. Impressive was the wide

variation in the values of the recorded pressuresin all veins studied. Those within any onerange, however, were evenly dispersed.

Pressure Gradient. A general decrease in ve-nous pressure from the periphery towards theheart has been observed in the main venouschannels of the extremities, trunk, and headand neck. However, in five areas (long saphe-nous vein at middle third of leg and knee,superficial epigastric vein at pubis, and cephalicvein at middle third of arm and above axilla)the mean figures in this study show a non-significant rise instead of a fall in venous pres-sure. Persistently low values were also recordedin the small veins on the anterior aspect of thewrist. Attention should be directed to the pre-cipitous drop in venous pressure observed be-tween the veins of the foot and the leg andbetween those of the hand and the forearm andthe steeper gradient of pressure in the upperextremity above the wrist than in the lowerextremity above the ankle (fig. 2). In the distalpart of the limbs the pressure gradient of thelong saphenous vein in the leg was greater thanthat in the veins of the forearm, whereas thepressure gradient of the long saphenous veinin the thigh was equivalent to that of thecephalic vein of the arm. Throughout the lengthof the upper extremity, the pressure in thebasilic vein showed a sharp drop as the heartwas approached.

Transient Elevation of Venous Pressure. Im-mediately after the small veins were punc-tured, a transient rise in venous pressure wasnoted; in all instances, however, it fell fairlyprecipitously rather than slowly, as had beenpreviously observed.30 This elevation of pres-sure is thought to be related to local or generalcontraction of the venous system.

Relation of Venous Pressure to Age, Sex and

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676 NORMAL BLOOD PRESSURE IN SUPERFICIAL VENOUS SYSTEN1

FOuter conthusFrontal -' Posterior external jugular

BasllIc ,, ,, ) '' 172 \ ^ S ,Externol jugular(middle 1 166

Cephallc( ' -. , ,pper 'A thorax (outer4)Basillc(lower'/4)\ Pf70 ephollc (crossing clavicle)Cephallc( * * ' uss \ I jV72 , -- , -----,Upper h thorax (middle

G__-Cephalic (above oxillo)Median cublta,

Baffilc(elow) J1-0- horacosplgastrlc (at nipple)Basilloc(elbow) Is99 >$Q1 1--4>t- -,iLowerA thoraxCephalic( "h eplg lc

AUppesr cephaZl|vr -.-Between xiphold e umbilcusCiphallo (up~g.. 91 /2 // rl A cephalic (middb:4)

Mein()C 1ceseephalic (mp.ddle A)"Basllon (" L i ~ 1 t 105------ { i \,,, ,, BasIlic (middle 5h)9l1 i10c (lower/u)

Cephallo~~~~~~~~~mld.~~ ~ ~~4dIhIi~McledidI( ---i1 -140 Cephallc' ( ) bindlon/ JIB*rg/z//tf-/^\v-\t4o(at wrist)

F " (lo wrf/} \, l-13F-v 9*t j Dorsum of wrist

Ant, wrIst\ \9 139--Dorsal venous arch (hond)Ant 7

(

/\ 1-~ : ^30 Suporficiol opigostric andA \ |t 115 *, 8, J~~~~~l2J} ''-xilio11c circumflex (o111ifiLateral superficIal .. _-120-- of res of iliac)femorol (upper/ ' ''- (midway between iliac crest

- 30 ~~~~~~~~~~~~andpubis)(bw r l \ - - * .. ~~~~~~~~--------Long tophonous (uporYO

Ant. surface (upper/) \ 09 _ (,midowes)t I 103- 0(ower ys)

,, ,,(middleO , ' 142 - (at knee)

(lower/u) ,,, ,,,,13| ta lF00- *=-\,5 (upper

04----- --- (middle)b)Dorsol venous arch of foot 90 ort - (lower

101 ~~~~~~140-----Short (*

---------Saphenous (at ankle)

I88 ) 126----------- 145------Lateral margin7J 152----------- fz^--- --------- Medial margin

FIG. 1.-Mean normal blood pressure (mm. of water) in the superficial veins of man at rest in thesupine position.

190 K

-- - -X Long Saphenous V._-_ Cephalic V170 ' Basilic V

% o 0 Median V.

150vss .. W ~~~~~.....

130 \ \

110

70.

50 I I I I I II l

Dorsal Distal Distol Part of Limb Proximal Proximal Port of LimbVenous Joint Lower'h,Middle' Upper, Joint Lowerh Middle UppersArch (Ankleor (Knee or

Wrist) Elbow)Distance from Heart, Measured by Anatomic Landmarks of the Extremity

FIG. 2.-Comparison of the blood pressure gradient in the large superficial veins of the upperand lower extremities of normal man at rest in the supine position.

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ALTON OCHSNER, JR., RALPH COLP, JR., AND G. E. BURCH

TABLE 1.-Venous Pressure in Main Venous Channels of Normal Man

Site of Venipuncture

Head and NeckVein at outer canthus of

eyeFrontalExternal jugularPosterior external jugular

ShoulderCephalic vein crossing clav-

icleCephalic vein above axilla

Upper Extremity(A) Arm

Upper thirdCephalic veinBasilic vein

Middle thirdCephalic veinBasilic vein

Lower thirdCephalic veinBasilic vein

(B) ElbowCephalic veinBasilic veinMedian cubital vein

(C) ForearmUpper thirdCephalic veinAccessory cephalic veinMedian antibrachial veinBasilic vein

Middle thirdCephalic veinAccessory cephalic veinMedian veinBasilic vein

Lower thirdCephalic veinMedian veinBasilic vein

(D) WristCephalic veinVein on anterior aspectVein on dorsum

(E) HandDorsal venous arch

TrunkUpper half of thoraxOuter thirdMiddle third

Numberof Sub-jects

6

25336

2

3

116

255

1314

179

30

122

I 1011

1031011

1381

7815

41

87

Venous Pressure

Range Meanmm. H20 mm. H20

125-190

135-23040-15035-115

60

90-115

55-14045- 55

55-14045- 65

50-14550-110

65-15570-13560-160

65-15060-11570-13570-155

70-15560-13075-16575-150

90-19065-170140

90-18560-10080-165

75-190

75-14590-140

166

1727270

101

8350

9455

9983

9791103

10687108107

11191113110

118117

13978119

139

120114

Site of Venipuncture

Lower half of thoraxMiddle third

Thoraco-epigastricLevel of nippleLevel of xiphoid tip

Veins between xiphoid andumbilicus

Superficial iliac circumflexand superficial epigastric

At the level of the iliaccrest

Half way between iliaccrest and pubis

Level of pubisPenisDorsal vein at base of penis

Lower Extremity(A) Thigh

Upper thirdLateral superficial fem-

oralLong saphenous

Middle thirdLateral superficial fem-

oralLong saphenous

Lower thirdLong saphenous

(B) KneeLong saphenous

(C) LegUpper thirdAnterior surface veinsLong saphenous

Middle thirdAnterior surface veinsLong saphenousShort saphenous

Lower thirdAnterior surface veinsLong saphenous veinShort saphenous

(D) AnkleLong saphenousShort saphenous

(E) FootMedial marginal veinLateral marginal veinDorsal venous arch

Venous Pressure

oNfumbr Range Meanjects mm. 1m 0

3 135-145 140

9101

22

10

3

19

9

3

3

10

10

4

1025

12132

792

110

97

26

55-13565-150105

85-180

95-180

145-170

75-150

85-145

75-85

115-145

50-150

50-150

90-125

75-18060-130

100-19070-13580-95

105-16075-135110-180

75-195

110-18060-230135-260

96108

135

130

156

115

120

80

130

92

96

103

142100

138104

127101

126

152145188

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NORMAL BLOOD PRESSURE IN SUPERFICIAL VENOUS SYSTEM

Race. These data, summarized in tables 2 and3, suggest that venous pressure does not varywith age except after the fifth decade, when ittends to decline. Most observers have foundno change in venous pressure with age in re-cumbent adults., 8 11 , 17, 19, 21 Hooker 16 on theother hand, observed a progressive increasewith age. Holbrook14 noted the venous pressureto be lower after the age of 30 years, and Criep5found an increase in venous pressure up to 35

lower values for women. No relation to racehas been observed.30

Relation to Miscellaneous Physiologic Factors.These observations agree with others that thereis no consistent relationship between venous andarterial blood pressures" 6, 7, 12, 14, 18, 21,24, 25, 29

or heart rate.5' 15, 17 However, individualswith relatively low systolic and/or diastolicpressures tended, as a group, to have venouspressures slightly higher than the mean. In

TABLE 2.-Variations of Venous Pressure in Relation to Age

Age in Years

Site of Venipuncture 15-30 31-40 41-50 51-70

No. of V.P. No. of V.P. No. of V.P. No. of V.P.Subjects mm. H20 Subjects mm. Hs0 Subjects mm. H20 Subjects mm. H20

Frontal ............................ 4 195 3 193 8 162 10 179Jugular ............................ 11 81 8 73 8 71 6 68Antecubital area ................... 23 104 7 87 15 102 11 101Dorsal venous arch (hand) ......... 18 143 7 144 11 142 5 130Long saphenous (upper third of leg). 4 93 6 108 6 103 9 94Dorsal venous arch (foot) .......... 9 182 7 186 8 198 2 145

TABLE 3.-Variations in Venous Pressure in Relation to Sex and Color

Sex Color

Site of Venipuncture Male Female Negro White

No. of V.P. No. of V.P. No. of V.P. No. of V.P.Subjects mm. H20 Subjects mm. H20 Subjects mm. H20 Subjects mm. H20

Jugular vein ........................ 17 71 16 81 23 72 10 83Antecutibal area .................... 36 99 20 105Median cubital vein ................ 20 99 10 106 18 103 12 103Dorsal venous arch (hand).......... 27 138 14 139 22 141 19 137Long saphenous (upper third of leg) 23 99 2 105 11 105 14 96Dorsal venous arch (foot) ........... 12 182 14 195 14 189 12 185

years, followed by a decrease to the fiftiethyear. Decrease in venous pressure in the agedmay possibly be related to a decline in tissueturgor.

These observations also suggest that venouspressure may be higher in women, althoughthe number of observations is not sufficient tojustify a definite conclusion. Investigators arenot in general agreement about the relation ofvenous pressure to sex. Allen and Hochrein'and Jacques'8 found no relation to sex, althoughmost authors2' 11, 15, 22, 23, 27, 30 report slightly

agreement with previous reports, no constantrelationship was found between venous pres-sure and height and weight' or body surfacearea.5 Subjects in the low weight group (below105 pounds) tended to have low venous pres-sures and those in the high weight group(greater than 200 pounds) had venous pres-sures exceeding the mean. Higher levels havebeen noted in obese individuals.5' 7, 20, 26 In achest with a large anteroposterior diameter(greater than 25 cm.) the mean venous pres-sure was slightly lower than the over-all mean,

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ALTON OCHSNER, JR., RALPH COLP, JR., AND G. E. BURCH

and in chests of small diameter (less than 18cm.) the mean was slightly higher than theover-all mean. As previously reported,'9 noseasonal relationship of the venous pressurewas detected.

DISCUSSION

Because of the wide range in venous pressurein various veins of the body, it would be desir-able to obtain more measurements in certainareas. These wide variations in pressure mustbe fully appreciated when single values areapplied to physiologic or clinical problems.They indicate the need for comparing valuesrecorded at frequent intervals throughout ill-ness and during convalescence and for com-paring measurements on opposite sides. In thisconnection it is well to remember that thepressure in corresponding veins on oppositesides is normally essentially equal.Extreme variations in mean venous pres-

sures have been noted by others. Because ofdifferences in method and reference levels, itis difficult to compare these values or to addthem to the present study. In general, thevalues obtained in this study agree with thosealready reported in the literature. Previousobservers, however, have neglected to studymany of the veins on the surface of the body,which limits the number of veins that can becompared.The importance of identifying the vein in

interpretation of venous pressure should beemphasized. These studies show that the pres-sure in the small tributaries of the large col-lecting veins or main venous channels is defi-nitely higher than that in the larger veins inthe same area. Failure to identify the veinsaccurately in a given area may, therefore, leadto erroneous interpretations of data. It is wellto remember that the level of the venous pres-sure tends to correlate with the "vascular"distance (in a physiologic sense) more thanwith the linear distance from the heart.

Determinations of venous pressure in themany superficial veins of normal man may beof assistance in management of clinical prob-lems involving edematous states and diseasesof the vascular system. These data are es-

pecially valuable in understanding physiologicproblems related to the venous system. It is,however, only with greater interest in the ve-nous system, hemodynamic phenomena and,more especially, in venous pressure that themany remaining gaps in knowledge concerningthe venous system in normal and abnormalstates will be filled. Because of the wide var-iations in venous pressure it is necessary toapply the values recorded in table 1 and figure1 with caution and adequate deliberation.

Finally, it should be mentioned that meas-urement of venous pressure by a direct methodsuch as this is almost devoid of complications.Occasionally a minute vein was lacerated withformation of a small hematoma, but no com-plicating phlebitis or thrombosis occurred.

SUMMARY

A somewhat comprehensive picture of theblood pressure in the superficial venous systemof man at rest in the supine position is pre-sented. The study has indicated the extremevariability of venous pressure over the bodysurface, the wide range of venous pressure inany one area (about 100 mm. of water), theconstantly decreasing pressure gradient fromthe periphery to the heart, the essentially equalpressures in corresponding veins on oppositesides of the body, and the importance of identi-fying the vein accurately during interpretationsof venous pressure values. No correlation ofvenous pressure with age or race was found,but it seemed to be slightly higher in women.

REFERENCES

1 ALLEN, E. V., AND HOCHREIN, M.: Venous pres-sure and vital capacity. Ann. Int. Med. 3:1077, 1930.

2 BRISCOE, G.: Observations on the venous andcapillary pressure with special reference to theRaynaud phenomenon. Heart 7: 35, 1918.

3 BURCH, G. E.: A Primer of Venous Pressure.Philadelphia, Lea & Febiger, 1950.

4_, AND WINSOR, T.: Phlebomanometer. New ap-paratus for direct measurement of venous pres-sure in large and small veins. J. A. M. A. 123:91, 1943.

'CRIEP, L. H.: Studies of venous pressure. Theirclinical application. M. Bull. Vet. Adm. 8:463, 1932.

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6 ERNST, C.: Arterieller Hochdruck und Venen-druck bein Menschen. Deutsche med.Wchnschr. 59: 952, 1933.

7 EVANS, MV. A., JR.: Venous pressure. New Eng-land J. M1ed. 207: 934, 1932.

8 EYSTER, J. A. E., AND MIIDDLETON, WV. S.: Clinicalstudies on venous pressure. Arch. Int. iMed. 34:228, 1924.

9 FRANKLIN, K.: Monograph on Veins. Springfield,Charles C Thomas, 1937.

10 FREY, A.: Uber die Bedeutung der Venendruck-messung bei der diatetisch-physikalischer Be-handlung der Kreislaufstorungen. DeutschesArch. fur klin. MXed. 73: all, 1902.

1 GIBSON, J. G., JR., AND EVANS, WX. A., JR.: Clin-ical studies of the blood volume. Relation ofplasma and total blood volume to venous pres-sure, blood velocity rate, physical measure-ments, age and sex in 90 normal humans. J.Clin. Investigation 16: 317, 1937.

12 GRIFFITH, G. C., CHAMBERLAIN, C. T., ANDKITCHELL, J. R.: Observations on the practicalsignificance of venous pressure in health anddisease with review of the literature. Am. J. M.Sc. 187: 642, 1934.

13 HALES, S.: Statical Essay. London, M`. Innys, R.Manby and T. Woodward, 1733. Vol. 2.

14 HOLBROOK, A. A.: Normal venous pressure as

determined by a direct method. Am. J. MI. Sc.195: 751, 1938.

15 HOOKER, D. R.: Observations on the venous bloodpressure in man. Am. J. Physiol. 35: 73, 1914.

16 -: Influence of age upon the venous pressure inman. Am. J. Physiol. 40: 43, 1916.

17 , and EYSTER, J. A. E.: An instrument for thedetermination of venous pressure in man. Bull.Johns Hopkins Hosp. 19: 274, 1908.

18 JACQUES, L. H.: Venous pressure in children. J.Iowa State M. Soc. 32: 294, 1942.

19 KRINSKY, C. M., AND GOTTLIEB, J. S.: Periph-eral venous blood pressure in schizophrenicand in normal subjects. Arch. Neurol. & Psy-chiat. 35: 304, 1936.

20 KROETZ, C.: Die Koeffizienten des klinische mess-baren Venendrucks. Deutsches Arch. f. klin.Med. 139: 325, 1922.

21 LEAMAN, W. G., JR.: Venous pressure. Penn-sylvania M. J. 38: 244, 1935.

22 LECONTE, AI., AND YACOEL, J.: La tension vein-euse a l'6tat normal et pathologique. J. de m6d.et chir. prat. 93: 171, 1922.

23 LYONS, R. H., KENNEDY, J. A., AND BURWELL,C. S.: Measurement of venous pressure by di-rect method. Am. Heart J. 16: 675, 1938.

24 MAYERSON, H. S., LONG, C. H., AND GILES, E. J.:Venous pressures in patients with varicose veins.Surgery 14: 519, 1943.

25 PLUMIER, L.: Etudes experimentale des varia-tions de la pression veineuse. Arch. internat.de physiol. 8: 1, 1909.

26 ROTKY, H., AND KLEIN, 0.: Studien tiber Venen-druck und Kreislaufsuffizienzprufung und soweiter. Med. Klin. 19: 1542, 1923.

27 VILLARET, M. ST. GIRONS, F., AND JACQUEMIN-GUILLAUME, G.: Contribution a lWtude cliniquede la tension veineuse. Technique et premiers re-sultats. Compt. rend. Soc. de Biol. 84: 80, 1921.

28 VON RECKLINGHAUSEN, F.: Unblutige Blutdruck-messung. MIessung des Blutdrucks in den kleinenArterien, der Venen und Kapillaren des Men-schen und beim Tier. Archiv f. exper. Path. u.Pharmakol. 55: 463, 1906.

29 WARTMAN, W. B.: Venous blood pressure in somecommon diseases. Am. J. AI. Sc. 190: 464, 1935.

30 WINSOR, T., AND BURCH, G. E.: Use of phlebo-manometer. Normal venous pressure values anda study of certain clinical aspects of venoushypertension in man. Am. Heart J. 31: 387,1946.

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Normal Blood Pressure in the Superficial Venous System of Man at Rest in the Supine

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1951 American Heart Association, Inc. All rights reserved.

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