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The n e w e ng l a n d j o u r na l of m e dic i n e o c c a siona l no t e s 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 n engl j med 363;22 nejm.org november 25, 2010 The New England Journal of Medicine Downloaded from www.nejm.org by HIMMATRAO BAWASKAR on November 24, 2010. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. 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 1st AUTHOR Ma ICM sufficiency but does not have a decrescendo; it is reer academic and REG Firascible 1visionary. His pro- 2nd FIGURE 3rd TITLE convention. TheyRevised heard best at the left sternal border. The mur- phetic warnings CASE bucked inEMail 4-C Line 15 SIZE mur resolves with treatment of anemia. cluded questioning value prolonged bed Enon the ARTIST: mst of H/T H/T FILL 28p Combo rest in hospitalized patients in the 1930s and, a AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset. decade later, cautioning that high-fat diets could 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 n engl j med 363;22 nejm.org november 25, 2010 2165 The New England Journal of Medicine Downloaded from www.nejm.org by HIMMATRAO BAWASKAR on November 24, 2010. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. 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- n engl j med 363;22 nejm.org november 25, 2010 The New England Journal of Medicine Downloaded from www.nejm.org by HIMMATRAO BAWASKAR on November 24, 2010. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. 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 The New England Journal of Medicine Downloaded from www.nejm.org by HIMMATRAO BAWASKAR on November 24, 2010. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. 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. journal archive at nejm.org Every issue of the Journal is now available at NEJM.org, beginning with the first article published in January 1812. The entire archive is fully searchable, and browsing of titles and tables of contents is easy and available to all. Individual subscribers are entitled to free 24-hour access to 50 archive articles per year. Access to content in the archive is available on a per-article basis and is also being provided through many institutional subscriptions. 2168 n engl j med 363;22 nejm.org november 25, 2010 The New England Journal of Medicine Downloaded from www.nejm.org by HIMMATRAO BAWASKAR on November 24, 2010. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.