Download Name That Murmur — Eponyms for the Astute

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Name That Murmur — Eponyms for the Astute Auscultician
Iris Ma, M.D., and Lawrence M. Tierney, Jr., M.D.
After the introduction of the stethoscope by René
Laennec in 1819, the art of auscultation gained
traction as a group of early adopters described
the heart murmurs they were now able to hear.
A race to discover and define ensued. Leading
physicians published their new observations, and
a robust crop of eponyms was born for use by
future generations of physicians and medical
trainees. This list of eponymous heart murmurs
includes a number of particularly esoteric selections that should satisfy novices and seasoned
clinicians alike.
Aus tin Flint Murmur
Videos and audio
recordings are
available at
NEJM.org
2164
Austin Flint was an American physician practicing in the early and middle 19th century and a
true pioneer in medical education. He cofounded
two medical schools, Buffalo Medical College
(now State University of New York at Buffalo)
and Bellevue Medical College (which later joined
the New York University College of Medicine),
and taught at six medical schools. A prolific writer, he is credited on more than 200 published
articles and wrote one of the major textbooks of
his time, A Treatise on the Principles and Practice of
Medicine, which persisted through six editions.1
The Austin Flint murmur is a mid-diastolic rumbling sound present in selected cases of nonrheumatic aortic regurgitation. The sound is
indistinguishable from mitral stenosis. Flint postulated that the murmur was due to regurgitant
flow onto the mitral valve that pushed back the
mitral leaflets, decreasing the size of the mitral
orifice and impairing flow from the left atrium
to the left ventricle.2 Multiple theories regarding
the cause of the Austin Flint murmur persist,
including regurgitant flow causing vibration of
the anterior mitral-valve leaflet, the turbulent
flow of the regurgitant jet colliding with incoming blood from the left atrium, and the regurgi-
tant jet hitting the left ventricle myocardium, or
a combination of these.3-5
B arlow ’s S yndr ome
South African physician John Barlow first submitted his work on mitral-valve prolapse to the
journal Circulation, but the manuscript was refused
for its “overstated conclusion.”6,7 After considerable abbreviation of the paper on Barlow’s part, it
was finally accepted and published in 1968 by the
British Heart Journal. Despite the initial rejection,
this paper would generate substantial interest.
According to a search of the ISI Web of Knowledge, Barlow’s work is the 13th most cited paper
in the 101-year history of the journal (which became Heart in 1996), with nearly 400 citations.6
In his paper, Barlow described the features
of mitral-valve prolapse in 90 patients with nonejection clicks, late systolic murmurs, or a combination of the two. The click corresponds to the
point at which the voluminous mitral-valve leaflets reach maximal stretch. The musical late systolic murmur arises from mitral incompetence,
a result of the prolapse of the leaflets (Video 1,
an audio recording of the murmur, is available
with the full text of this article at NEJM.org).8
The murmur is loudest at the apex or left sternal
border. The click and murmur may occur concurrently, but more commonly the click initiates the
murmur. There may even be multiple consecutive clicks. The click or murmur of mitral-valve
prolapse moves closer to S1 with standing, and
closer to S2 with squatting.8,9 Barlow was able
to supplement his auditory observations with corresponding phonocardiographic tracings that confirmed his findings.8 Barlow’s syndrome refers
to the spectrum of symptoms caused by mitralvalve prolapse.10 Patients’ experiences range from
the click or murmur alone to palpitations, chest
pain, or syncope.11,12
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occasional notes
Richard Cabot was an American physician and a
trailblazing educator (Fig. 1). Recognized by his
peers and medical trainees as an expert diagnostician, he introduced case analysis at Harvard
Medical School and founded Case Histories of the
Massachusetts General Hospital, the case series
that continues to be published regularly in the
Journal. Cabot was a vocal agitator for increased
social services and a patient-centered approach
to patient care and history taking. He was instrumental in establishing the first in-hospital
social service department in the United States, at
Massachusetts General Hospital in 1905.13 Collaborating with his colleague Frank Locke, Cabot
published a series describing three cases of severe anemia with diastolic murmur in patients
who had been given a diagnosis of valvular disFigure 1. Dr. Richard Cabot Auscultates a Patient’s Chest before an Audiease but were found to have normal heart valves
ence of Physicians in Boston, 1926.
on autopsy.14 The Cabot–Locke murmur is a diastolic murmur that sounds similar to aortic inRETAKE
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C are y Co omb s Murmur
Please check carefully.
lead to clogged arteries. He also popularized
36322 Willie Sutton’s
11-25-10
ISSUE: explaThe Englishman Carey Coombs was a rheumatic Sutton’s law: bankJOB:robber
fever specialist whose book, Rheumatic Heart Dis- nation that he robbed banks because “that’s
eases (1924), was based on more than 600 of his where the money is.” Dock taught that if “the
cases.16 The Carey Coombs murmur is a short money” resided in a specific diagnostic test, that
mid-diastolic murmur caused by active rheumat- test should be conducted immediately instead of
ic carditis with mitral-valve inflammation. The several steps into a general algorithm.20
murmur is soft and low pitched, heard best at
Dock described the murmur that bears his
the apex.16,17 The murmur is frequently tran- name in a 1967 case report of a patient with
sient, with onset during acute rheumatic mitral heart failure resulting from hypertension; the
valvulitis and improvement or resolution with patient had no apparent valvular disease. But a
recovery from the acute illness.18 It is thought continuous diastolic murmur with early and late
that the murmur is the result of turbulence accentuation was in fact present, in a sharply
caused by thickened mitral-valve leaflets.19 Al- localized area, 4 cm left of the sternum in the
though similar to the diastolic rumble of mitral third intercostal space, detectable only when the
stenosis, the Carey Coombs murmur does not patient was sitting upright. The murmur was
have an opening snap, presystolic accentuation, measured with the use of phonocardiography
or a loud first sound, but may follow an S3 gal- and found to be distinguishable in morphology
lop.17 The latter may be superficially confused from existing murmurs. The patient’s autopsy rewith an opening snap.
vealed that the descending branch of the left
coronary artery was markedly stenosed, whereas
the heart valves, great vessels, and coronary artery
D o ck ’s Murmur
orifices were normal. Dock’s murmur is greatest
In his New York Times obituary, American doctor in diastole, with a presystolic peak, a pattern
William Dock was remembered as a devoted ca- consistent with blood flow through the coronary
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november 25, 2010
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Copyright Bettman/CORBIS.
C a b ot– Lo cke Murmur
The
n e w e ng l a n d j o u r na l
arteries. Dock concluded that this murmur was
due to stenosis of the left anterior descending
artery, and likened its cause to that of the bruits
heard over stenosed renal and hepatic arteries.21
Gib son’s Murmur
George Gibson was a committed teacher and
academic who practiced in London at the turn of
the 20th century. In his most significant work,
Diseases of the Heart and Aorta, he described his
namesake murmur as being caused by a persistent patent ductus arteriosus. The murmur was
also featured in his subsequent lectures.22,23 The
Gibson murmur is continuous, beginning after
the first heart sound and extending through the
second heart sound, which is distinctly audible
over the unbroken rushing of the murmur (Video
2, echocardiogram, and Video 3, audio recording).
The murmur may diminish during diastole. Although the murmur is audible over the entire
base of the heart, Gibson noted that it is best
heard at the left upper sternal border.23 The Gibson murmur may make a humming, purring, or
clanging sound or may sound like machinery or
rolling thunder, depending on its severity. The
continuous murmur may even be audible from
the back, at the left interscapular region, or cranial to the scapular spine. The murmur grows
louder as the child ages and arterial dilation increases, and the area of maximal intensity may
migrate farther left.22,24
of
m e dic i n e
echocardiogram). The Graham Steell murmur is
a soft, blowing, decrescendo diastolic murmur
running off of an accentuated second sound that
mimics the murmur of aortic insufficiency. The
Graham Steell murmur is best heard in a localized area at the left upper sternal border.28,29
Ke y– Hod gkin Murmur
Charles Aston Key was one of the most prominent surgeons of the early 19th century. Key operated in London, the undisputed pinnacle of
surgical activity during his time, and was a contemporary of Thomas Hodgkin, the physician for
whom Hodgkin’s lymphoma is named.30 Hodgkin lectured intermittently at Guy’s Hospital,
where Key was a staff surgeon.31 Key is credited
with first drawing Hodgkin’s attention to the
problem of aortic incompetence. Subsequently,
Hodgkin wrote the first case series that both
described aortic incompetence and included a
postulation of its pathophysiology.32 Syphilitic
aortitis was the leading cause of aortic regurgitation at the time, causing dilatation of the ascending aorta, aortic valve ring, and occasionally
leaflet retroversion. The Key–Hodgkin murmur
is a diastolic murmur of aortic regurgitation; it
has a raspy quality, similar to the sound of a saw
cutting through wood. Hodgkin correlated the
murmur with retroversion of the aortic valve
leaflets seen post mortem.33
R o ger ’s Murmur
Gr aham S teell Murmur
Scottish cardiologist Graham Steell was an avid
horseman and iconoclast. He was known for his
illegible notes, brevity of speech, and excellent
bedside teaching. For his more robust patients,
he was said to recommend horseback riding as
the best form of exercise.25 Although this murmur
of pulmonary insufficiency bears Graham Steell’s
name, it was first described by others — notably, George Balfour, for whom Steell worked as
a house officer at the Edinburgh Royal Infirmary in 1873.26 Steell nevertheless published numerous articles describing the murmur clearly
and in depth.27 He posited that the pulmonary
regurgitation was usually the result of chronically elevated blood pressure in the pulmonary
artery, resulting from mitral stenosis (Video 4,
2166
The French physician Henri-Louis Roger was a
pediatrician who developed a special interest in
auscultation while working in Paris at the children’s hospital, Hôpital des Enfants-Malades,
during the mid-late 1800s.34 Comparing autopsy
findings of interventricular defects with murmurs previously documented in the medical record, Roger recognized that holes in the interventricular wall were associated with murmurs
(Video 5, echocardiogram). Roger’s murmur of
ventricular septal defects is holosystolic and
heard best at the left upper sternal border. The
murmur is loud, and its sound has been compared with that of a rushing waterfall. It is accompanied by a harsh thrill. The smaller the
ventricular septal defect, the louder the murmur.
Roger emphasized the benign nature of congen-
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occasional notes
ital ventricular septal defects, having observed
that many of the patients who had the defect
were acyanotic and had normal life spans. But
his observations were hampered by the times he
lived in — a normal life span in the 1800s was
much shorter than it is today.35,36 It is now well
understood that ventricular septal defects can
become problematic, causing pulmonary hypertension, right heart failure, and endocarditis.
Maladie de Roger describes patients with asymptomatic ventricular septal defects. Patients with
symptomatic ventricular septal defects, which
cause cyanosis and progressive pulmonary hypertension, have Eisenmenger’s syndrome.37-39
benefit in the application of the stethoscope to
the chest. We hope the description of these murmurs will stimulate renewed interest in the bedside exam.
S till’s Murmur
2. Flint A. On cardiac murmurs. Am J Med Sci 1862;44:29-54.
3. Fortuin NJ, Craige E. On the mechanism of the Austin Flint
English physician George Frederic Still, the father of British pediatrics, is best known for his
eponymous rheumatic disorders: a juvenile febrile arthritis and a more typhoidal illness in
adults, both called Still’s disease.40,41 During his
long career, Still published several textbooks and
articles, most significantly, the book Common
Disorders and Diseases of Childhood.42 In the twilight
of his career, he even became physician to Princess Elizabeth (who would become Queen Elizabeth II of the United Kingdom), and her sister,
Princess Margaret. He was knighted in 1937.43
Most often seen in children, Still’s murmur is a
medium-to-long systolic ejection murmur with a
musical quality; it is heard at the left lower sternal border and apex. Still emphasized that his
murmur was completely benign and described
its sound as “twangy,” similar to that of a string
being plucked.42,44 The murmur increases in intensity with fever, anxiety, or exercise.42 Its cause
is unknown, although it has been suggested that
the source may be vibration of the chordae tendineae in the left ventricle or the sound of blood
gushing into the aorta.44
4. Oshinski J, Franch R, Baron M, Pettigrew R. Austin Flint
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Nelson B. Schiller and Melvin D. Cheitlin for their
assistance in preparing the audio and visual materials and an
earlier version of the manuscript.
From the Department of Medicine, University of California, San
Francisco School of Medicine (I.M.); and the Department of
Medicine, Veterans Affairs Medical Center, University of California, San Francisco — both in San Francisco.
1. Mehta NJ, Mehta RN, Khan IA. Austin Flint: clinician, teacher
and visionary. Tex Heart Inst J 2000;27:386-9.
Conclusions
The modern era of diagnostic cardiology is focused on costly technologies, with regular use of
electrocardiography, echocardiography, and coronary angiography. However, it is the authors’
opinion that physicians continue to enjoy and
value the bedside exam. In addition to its diagnostic function, there is considerable therapeutic
murmur. Circulation 1972;45:558-70.
murmur. Circulation 1998;98:2782-3.
5. Landzberg JS, Pflugfelder PW, Cassidy MM, Schiller NB,
Higgins CB, Cheitlin MD. Etiology of the Austin Flint murmur.
J Am Coll Cardiol 1992;20:408-13.
6. Barlow JB. This week’s citation classic. Curr Contents
1983;26:18.
7. Cheng TO. John B. Barlow: master clinician and compleat
cardiologist. Clin Cardiol 2000;23:66-7.
8. Barlow JB, Bosman CK, Pocock WA, Marchand P. Late systolic murmurs and non-ejection (“mid-late”) systolic clicks: an
analysis of 90 patients. Br Heart J 1968;30:203-18.
9. Chizner MA. Cardiac auscultation: rediscovering the lost art.
Curr Probl Cardiol 2008;33:326-408.
10. Whonamedit.com. Barlow’s syndrome. (http://www
.whonamedit.com/synd.cfm/823.html.)
11. Wigle ED, Rakowski H, Ranganathan N, Silver MC. Mitral
valve prolapse. Annu Rev Med 1976;27:165-80.
12. O’Rourke RA, Bailey SR. Mitral valve prolapse syndrome. In:
Fuster V, Alexander RW, O’Rourke RA, eds. Hurst’s the heart.
11th ed. New York: McGraw-Hill, 2004:1695-706.
13. Dodds TA. Richard Cabot: medical reformer during the Progressive Era (1890-1920). Ann Intern Med 1993;119:417-22.
14. Cabot RC, Locke EA. On the occurrence of diastolic murmurs without lesions of the aortic or pulmonary valves. Bull
Johns Hopkins Hosp 1903;14:115-20.
15. Cabot RC. Physical diagnosis. 5th ed. New York: William
Wood, 1912.
16. Coombs CF. Rheumatic heart disease. New York: William
Wood, 1924.
17. O’Rourke RA, Silverman ME, Shaver JA. The history, physical examination, and cardiac auscultation. In: Fuster V, Alexander RW, O’Rourke RA, eds. Hurst’s the heart. 11th ed. New York:
McGraw-Hill, 2004:217-94.
18. Besterman EMM. Phonocardiography in acute rheumatic
carditis. Br Heart J 1955;17:360-72.
19. Wood P. Discussion of the management of rheumatic fever
and its early complications. Proc R Soc Med 1950;43:195-9.
20. Fowler G. Dr. William Dock, 91, innovator who questioned
medical beliefs. New York Times. October 23, 1990.
21. Dock W, Zoneraich S. A diastolic murmur arising in a stenosed coronary artery. Am J Med 1967;42:617-9.
22. Tynan M. The murmur of the persistently patent arterial
duct, or “The Colonel is going to a dance.” Cardiol Young 2003;
13:559-62.
n engl j med 363;22 nejm.org november 25, 2010
2167
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occasional notes
23. Gibson GA. A clinical lecture on persistent ductus arterio-
sus. Med Press Circular 1906;132:572-4.
24. Gilchrist AR. Patent ductus arteriosus and its surgical treatment. Br Heart J 1945;7:1-36.
25. Bramwell C. Graham Steell. BMJ 1942;4:115-9.
26. Graham Steell, M.D., F.R.C.P.: emeritus professor of medicine, Manchester University. BMJ 1942;1:129.
27. Fraser AG, Weston CF. The Graham Steell murmur: eponymous serendipity? J R Coll Physicians Lond 1991;25:66-70.
28. Steell G. The murmur of high pressure in the pulmonary
artery. Med Chron 1888;9:182.
29. Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of cardiovascular medicine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:193-226.
30. Treves F. The surgeon of the nineteenth century. JAMA
1900;35(5):293-5.
31. Thomas Hodgkin. BMJ 1924;2:70-1.
32. Mulcahy R. The early descriptions of aortic incompetence.
Br Heart J 1962;24:633-6.
33. Hodgkin T. On retroversion of the valves of the aorta. Lond
Med Gaz 1828;3:433-43.
34. Berry D. History of cardiology: Henri Louis Roger, MD. Circulation 2006;114:f172.
35. Roger H. Recherches cliniques sur la communication congé-
nitale des deux cœurs, par inocclusion du septum interventriculaire. Bull Acad Med 1879;8:1074-94.
36. Henri-Louis Roger (1809-1891): Roger’s disease. JAMA
1970;213:456-7.
37. Cardiology. In: Candy D, Davies EG, Ross E. Clinical paediatrics and child health. London: W.B. Saunders, 2001:173-82.
38. Wood P. The Eisenmenger syndrome or pulmonary hypertension with reversed central shunt. Br Med J 1958;2:755-62.
39. Ramaswamy P, Anbumani P, Srinivasan K. Ventricular septal
defect, general concepts. (http://emedicine.medscape.com/
article/892980-overview.)
40. Dunn PM. Sir Frederic Still (1868-1941): the father of British
paediatrics. Arch Dis Child Fetal Neonatal Ed 2006;91:F30810.
41. Still GF. On a form of chronic joint disease in children. Med
Chirg Trans 1897;80:47-60.
42. Idem. Common disorders and diseases of childhood. London: Henry Frowde, 1909.
43. Hamilton EBD. George Frederic Still. Ann Rheum Dis 1986;
45:1-5.
44. Ruschhaupt DG. Murmurs. In: Koenig P, Hijazi ZM, Zimmerman F, eds. Essential pediatric cardiology. New York: McGrawHill, 2004:9-22.
Copyright © 2010 Massachusetts Medical Society.
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