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REPRINTED FROM UONTREAL MEDICAL JOURNAL.
Januaxy 1899.
ON SO-CALLED FUNCTIONAL HEART MURMURS.'
BY . • : . ..
Maude E. Abbctt, B.A., M.D., (From the Medical Clinic of the Royal Victoria Hospital, Montreal.)
Among the signs of organic diseasu which perplex the diagnostician by appearing when the organism is in health, or at least upon its borderland, cardiac systolic murmurs take a prominent place. Their occurrence as signiHcant of a purely functional disturbance without an}' underlying valvular lesion, is of course well recognised, but their frequency in this connection is perhaps scarcely appreciated V)y the profession. In the discussion on " The Prognosis of Cardiac Disease in its Bearings npon Life Insurance," led by Sir Wm. (Jairdner at the rr ent meeting of the British Medical Association '^ systolic murmurs are b.xely mentioned among all the doubtful signs of cardiac disease complicating an " estimation of life." Yet it is chietiy in relation to such questions as those of life 'nsurarce that the .subject is of special interest and assumes some proportions as a difficult problem demand- ing solution. Indicative on the one hand, of that form of organic disease which most seriously threatens longevity, yet, on the other, consistent with nothing more serious than a temporary lowering of the general tonus, a well marked systolic mui'mur is capable of plunging the conscientious medical examiner into most uncomfort- able doubt. For the subject is unfortunately as obscure as it is im- portant, "v '
Not only is the murmur subject to all the variations governing the principles of sound, but further, one's conclusions can have but a rela- tive worth, for they are rarely verified by autopsy, and can only be
1 Read before the Montreal Medieo-Chirurglcal Society, Nov. 2l8t, 1898.
2 British.Medical Journal, Sept. 17th, 189a
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formed by continued observation of cases and by amassing an abundant material.
Some months ago, Dr. C. F. Martin suggested to me a statistical study of systolic murmurs as they occun-ed in the medical records of the Royal Victoria Hospital. 1 am indebted to the authorities of the hospital for their kind permission to carry out this suggestion and I have to thank Dr. Martin for much assistance in the ari'angement and revision of the w^ork.
It must be admitted that the term " Functional Murmur " as at present usually employed, is a misnc^mer. On the one hand, ali mur- murs are functional, vi^hether due to organic disease of the heart or to a malady of the blood itself, inasmuch as they depend on an impair- ment of function of the valves, or the parts in their immediate vicinity, or else to eddies abnormally carried in the course of the circulation. On the other hand, vi^hat are usually called functional murmurs, are often, indeed very often, due to a degeneration of the heart muscle, be it in the cells of the wall itself or in the cells of the papillae or trabe- culse.
It is difficult to define functional murmurs in any other way than as temporary murmurs occurring in a heart with no other signs of valvular disease, and which ultimately disappear. This will exclude the organic murmurs which from time to time cannot be heard at all even when extensive valvular vegetations occur, and will admit of the term being applied where chlorosis, typhoid fever, etc., occasion mur- murs through the altered conditions of blood or heart muscle. Hence we would say that temporary parenchymatous degeneration of the myocardium produces functional (not organic) murmurs.
Leube* has recently analysed the various conditions under which systolic murmux's occur and the require.uonts for a differential diag- nosis. His classification is, briefly, somewhat as follows :
1. Accidental Murmurs : Systolic, heard most strongly at the base ; may or may not be transmitted ; no pulmonary accentuation ; no increase of cardiac area.
2. Relative Mitral Insufficiency : Pure systolic moderately loud murmur ; a weak impulse ; moderate pulmonary accentuation ; mod- erately increased cardiac area to right and left ; relatively small often irregular pulse (myocarditis or myo-asthenia) ; history.
3. Acute Mitral /Endocarditis : Soft systolic murmur at apex ; cardiac area slightly increased to the left ; pulmonary second moder- ately accentuated ; pulse and heart impulse relatively strong, co- existence of fever or of some infectious disease.
* Zur Diagnose der Systolischeri Herzgeraiischen, Deut. Arch. f. Klin. Med. Nov. 5tb, 1896.
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4. Chronic Disease of Mitral Valve : Systolic murmur ; generally louder and harsher ; increased cardiac area ; marked pulmonary accen- tuation ; impulse moderately increased ; pulse relatively strong and regular ; frequent association with the signs of mitral stenosis ; his- tory of adequate cause for assuming organic cardiac disease.
Pure systolic murmurs then may be regarded as :
(a) Valvular, depending on an organic deformity of the mitral valve, or upon its relative incompetence due to so-called cardiac myo- asthenia or to a myocarditis ; and
(b) Non-valvular, accidental, or hasmic, heard best over the base of the heart and produced, according to most authorities, in the great vessels by lack of tone in their walls, or by lowered peripheral blood pressure. Such pure accidental murmurs when typical are supposed to present little difficulty in diagnosis for they are basal and unac- companied by pulmonary accentuation or increase of the cardiac area, and claim differentiati(m only from aortic and pulmonary stenosis.
These latter are not easily confounded with ba.sal functional mur- murs. But with apical murmurs the matter is quite ditierent and presents constant perplexity. Here it is necessary for prognosis to differentiate not only a relative incompetency from the true insuffi- ciency of a diseased mitral valve ; it is also most important to distin- guish the permanent relative insufficiency of organic cardiac disease (primary dilatation with hypertrophy, myocarditis, etc.), from the temporary relative insufficiency of ansemic or febrile conditions where the valves fail to close simply from weakness of the papillary muscles and trabeculae, or from dilatation due to lack of tone of the cardiac muscle itself.
From Jan. 1895, to Sept. 14th, 1898, the number of cases admitted to the wards of the Royal Victoria Hospital, were some 3,302 ; of these, I have examined the case reports of 2,780. All cases were rejected whose histories showed pure systolic murmurs known to be due to organic cardiae disease, whether pericarditis, myocarditis or endocarditis, and, as possibly organic, all cases where there was a record of previous or concomitant chorea, tonsillitis, acute and chronic rheumatism, arterio-sclerosis and acute and chronic Bright's disease. I retained for study 589 cases in which pure systolic murmurs occurred (21 per cent). After eliminating cases giving a previous history of rheumatism, nephritis, etc., or showing arterio- sclerosis from this number, there remained a total of 466 cases, or not quite 17 per cent, of pure sybtclic murmurs occurring in patients in whom there was nothing either in the previous history or in the general condition to suggest organic cardiac disease ; with the excep-
tion of a possible old endocarditis based on a previous history of scar- latina which occurred in a certain proportion of cases, and which I noted but did not eliminate.
This (17 per cent.) is a high percentage, and it will be objected to it, that without doubt many of these are really cases of organic cardiac disease of insidious onset ; but when one considers that in some of the many cases rejected because there was a bare suggestion of (itiology, the murmurs may have been functional, and further, that, present as this sign often is when the patient is suti'ering from a malady that would never suggest it, the less marked murmurs must, even in these carefully kept records, have sometimes escaped observation, it is evident that this percentage of 17 per cent, must be pretty clo.se upon the facts.
In the subjoined classification, various plans are adopted and the effort has been made to seek a diagnosis of the underlying physical condition. In functional murmurs, thi.s is generally admitted to be an anaemia or a toxaemia leading, possibly through the nerve centres, to lowered vascular tonus and to consequent irregularities in the blood current.
I have divided all the conditions as follows :
1. Murmurs occurring in febrile and afebrile conditions.
2. Murmurs occurring in anaemia and non-anaemic conditions.
8. Murmurs occurring in pulmonary tuberculosis. This being kept separately as here the condition includes to a marked degree, fever with cachexia and anjemia.
4. Classification according to the nature of the sound with special reference to :
(a) Site of murmur.
(h) Transmission
(c) Condition of pulmonary second .sound.
(d) Rhythm.
(e) Cardiac enlargement.
With reference to the statistics it is of note that :
In 466 cases with undoubted functional murmurs, 269 were in afebrile, and 163 in febrile cases.
Of the 269 afebrile cases, 185 showed anaemia; 74 none.
Of the 163 febrile cases, 85 showed anaemia ; 78 none.
In 44 cases of pulmonary phthsis, 35 showed anaemia ; 9 none.
The following table will indicate the main features it is desired to illustrate as suggested in a feiv of the diseased conditions with func- tional murmurs and the characteristics associated therewith. The relative frequency of murmurs in febrile and afebrile conditions and in pulmonary phthisis is also shown.
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It will be seen from the foregoing how frequently functional inur- iiiura have been found when no apparent cause was discovered ; neither antemia, fever or other usually recognised cause ; and further, that in site and rhythm of munnur some unusual conditions occur.
In the true ancemias are included, pernicious aniemia, chlorosis, Hodgkin's disease and anaemia secondary to hcwmorrhage or carcinoma. These form 87 cases of which 24 have apex murmurs ; 86 have mur- murs at apex and base, while in only 21 were the murmurs mainly at the pulmonary cartilage.
The origin of the murmur cannot always be read from its situation ; Dr. Heitler, in an article on "The Localisation of Systolic Mitral Murmurs " * makes an exhaustive study of this point. He states that his researches lead him to disbelieve the dogma that murmurs of dif- ferent timbre are necessarily of different origin, even though they be heard less loudly in the interspace. He argues that murmurs are formed of a mixture of sounds which are not transmitted as a whole in any direction, but that certain parts are heard best where the conditions for transmission are most favorable, and he cites a case, seen post-mortem to be one of pure mitral regurgitation, where there was a loud musical murmur at the apex growing fainter towards the base and a loud murmur at the aortic cartilage of the same quality as that at the apex.
This is confirmed by other authorities in the case of regurgitant murmurs due to endocarditis where roughened surfaces combine with altered blood currents to produce a mixture of sounds, but in func- tional cases there are probably less complicated conditions. In these ansemias where the double murmurs which occurred, are often des- cxibed as of different timbre, rough at one orifice, blowing at the other, they are frequently transmitted in two directions : into the axilla from the apex, and upwards from the pulmonary orifice, indicating that they really are the double murmurs of a relative mitral insufficiency and of a physiological pulmonary stenosis. Such at all events seems quite as plausible an explanation as any other.
Leube, in his article lays much stress on the site of the murmur. He states that in lesser degrees of blood alteration, accidental mur- murs are produced in the great vessels at the base from lowered tonus of their walls through the action of impoverished nerve centres, while the more severe grades of anaemia and intoxication lead to a myo-as- thenia or even a myodegeneratio cordis, and to the apical murmurs of relative mitral insufficiency.
The ansemic cases I have studied tend emphatically to confirm this
f Wiener KUn. Wooh., No. 17, 1897.
dictum. In pernicious anannia, representing the most extreme degree, we know tiiat there do exist often extensive degenerative changes in tlie myocardium leading to wealcening of tlie heart and tlie papillary muscles and to conseiiuent dilatation. Here then are the conditions for a relative insufficiency, and hero every nuirmur is apical. Of the IGca.ses, 10 occurred alone at the apex and pulmonary cartilage, and the only one heard best at the pulmonary is transmitted into the axilla, indicating that it too is an apical murmur. In chlorosis, on the other hand, where there is a lesser degree of blood alteration, there arc only seven cases at the apex against 15 at the pulmonary area, and 19 heard with equal force both at the pulmonary cartilage and apex. Of the seven cases with a murmur at the apex, five showed only slight chlorosis, .scarcely sufficient one would think to produce a relative insufficiency ; the thought is suggested that although mitral valvular murmurs are heard best at the apex, all apical Tiiurnuirs are not necessarily valvular.
The apical murmurs of pernicious ansetnia, however, do not always present the other cardiac conditions that we would expect to find in a relative mitral incompetency of some duration. The murmur is generally transmitted, but in only ten cases is there cardiac enlarge- ment or pulmonary accentuation ; but the absence of these signs is explained by the physical facts. We cannot expect nnich increase in area whei'e the heart though frequently dilated, is atrophied rather than hypertrophied, and the right ventricle must often be too weak to give rise to pulmonary accentuation. In pernicious anaemia where pulmonary accentuation does occur (as in mo.st advanced cases) it is probably dependent on the dyypiui'a, due to the imperfect aeration of the tissues by the diminished number and power of the oxygen-carry- ing elements of the blood.
The cases of exophtltaimlc (joitre illustrate the same point as do the an8emia.s. It is known that in this disea.se in cases where there is much vasomotor disturbance, there is apt to be dilatation of the over worked heart resulting in a relative mitral insufficiency. In the ten cases before me there is only one that does not show marked implica- tion of till' vasomotor system ; in this one there is but a slight anaemia (erythrocytes 4,000,000, haemoglobin (Fleischl) 70 per cent.) and the murmur is hsemic in its character being heard only at the pulmonary cartilage without pulmonary accentuation or cardiac enlargement.
In all the other nine cases there is vasomotor disturbance and the murmur is at the apex, generally well transmitted into the axilla. In live of the cases another murmur is also described at the pulmonary,
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in two of these, this second murnmr is probably hwinic in character for there is marked antnniia.
Typhoid fever may be taken as an examph; of a condition in which functional murmurs are extremely frequent, which contrasts stronj^fly with anaemia. Here the njore rapidly actin<j heart, the low tension pulse, the increased metabolism and evident intoxication of the system (jxplain nmch more readily the strain on the cardiac system, of which the murmur gives evidence, than tlo the changes associated with a moderate anu-mia. But, under such widely diftering clinical circumstances, a common symptom makes one look for a common cause and tlie inference lies near, that in anasmia as in typhoid, a toxaemia rather than a hydrasmia is at work, in the one case acting slowly and insidiously, in the; other, suddenly, acutely, and poisoning rather than impoverishing the nerve centres. Other facts suggest this idea also. Everyone knows that one meets with systolic functioial murmurs often in apparent health, and in 7H of the.se 466 cases, there is present neither anajuiit) nor fever, but often a condition which suggests some form of intoxication. Instances of such conditions included among these murnmrs are : 48 diseases of the digestive .system (including six cases of cirrhosis), gout, acute alcoholism, morphinism, etc.
Out of about 298 cases of typhoid examined, a pure .systolic murmur was noted in 78, making .something over 29 per cent.
In this disease as in all infectious fevers, an apical murmur always suggests the possibility of an acute endocarditis ; this is however, rare ; Osier states that he did not find it in any of his cases and that it was present in only 11 of the 2,000 Munich autopsies. Parenchyma- tous degenex'ation on the other hand is undoubtedly common, and yet though this is naturally often the main underlying cause for these nmrmui's, they often declai'e themselves functional in other ways, by disappearing during the active course of the disease.
Since the year 1896, minute daily records have been kept of the typhoid cases in the hospital. These " typhoid charts " reveal some interesting facts as regards the cardiac condition. When a murmur develops, although it frequently has a course parallel to the height of the fever, it often, too, appears and disappears quite irregularly with- out any apparent reference to this. In no condition of high contin- ued fever are the variations in the cardiac condition more striking than in typhoid. The sounds vary in character and relative inten- sity ; murmurs appear and disappear : signs of cardiac dilatation come and go, as the stx'uggle between the reactive powers of the individual and the invading toxins of disease goes on in the organism.
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The seemingly caHual occurrence of these inurinurs at the apex replacing thos** at the piiliiutiiary and again a t't!W days later giving place to them, differing too in no way from the basal murmurs in quality, makes one (piestion Leuhe's statement that the htemic mur- mur is always at the base and that a murmur at the apex is always duo to a relative mitral insufficiency.
The transient nnirmurs of typhoid are best illustrated by a glance at two or three of the cases :
Cask I. — (Murmur corresponds with course of fever). A. B.> admitted on 8th day of disease. High temperature until 25th day when defervescence began ; normal temperature 41st day.
On admission, faint blowing systolic umrmur at apex, not trans- mitted ; louder murmur at [)ulmonary cartilage ; faint murmur at aortic, accentuation of pulmonary 2nd .souikI. The.se conditions noted daily until 17th day when the basal murmur disappeared; that at the apex pei'.sisted ; on the 24th day (conniiencing defervescence) this also disappeared. The heart was examined daily until the 62nd . ■ y and there was no I'ecurrence of the murmur.
Case II. — (Murmur ended with pyrexia but disappeared and reappeared again during its course.) C. D., admitted on 22nd day, temperature 105f ; high pyrexia until 42nd day ; temperature slightly lower (lOf/j until 45th day, when defervescence began ; tem- perature not normal until 95th day.
On entrance a blowing systolic murmur was heard at apex and pul- monary cartilage, noted for three days ; on 27th day, no vmrmur at pulmonary nor at apex, but here lengthening of the 1st sound ; on 33rd day, a faint blowing systolic murmur developed at apex, noted daily until 65th day when it disappeareil ; daily examination of the heart until 95th day revealed no return of murmur.
Case III. — (Murmur at pulmonary cartilage during height of fever ; interval with no murmurs ; murmur developed at apex during con valescence). E. F., admitted on 27th day, defervescence began on 42nd day, temperature i^- rmal on 48th, no recrudescence.
On entrance, systolic murmur at pulmonary with pulmonary accen- tuation ; this was noted every day until its disappearance on 36th day ; on the 61st day (temperature normal ; patient doing well in every way, still quiet in bed), a systolic murmur developed at the apex, heard as a rougher sound at the pulmonary, noted daily until the 69th day when it disappeared. On the 71st day (two days interval with daily note of no murmurs) murmurs were again heard at apex and pulmonary which persisted (daily note) until'the 84th day. Patient dis- charged 87th day ; pulmonary 2nd sound remained accentuated at exit.
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Hysteria and functional nervous disorders. — In these, out ot" 62 iminnurs 32 occurred in subjects who showed no antuniia ; 14 of tliese murmurs occun*ed at the apex ; eight at the puhnonary cartilage • Hve as double murmurs at both apex and base while one is heard at the aortic cartilage. Some of them bear all the characters of func- tional murmurs, being unaccompanied by other signs of cardiac dis- turl)ance, cither enlai'gement or pulmonary accentuation. With no anjtofnia and no intoxication present, how are we to explain the tem- porary disturbance of the vasomotor sy.stem which the systolic murmur indicates ? Is it possible that here, not poisoned nor im- poverished, but disordered nerve centres are acting, and doing their part as inefficiently as do the higher inhibitory centres ?
Lastly, with reference to the nature of the sounds, the following features may be of interest :
As regards the site of the murmur, it occurs at the apex in 170 cases, in 98 of which there is aneemia, in 72 none. It is at the pul- monary area in 12G cases, in 90 there is anaemia, in 30 no ansemia.
In 112 eases it is heard both at apex and base, sometimes with equal force, sometimes as a double murmur ; in 79 of these there is anaemia, in 33 none.
In 48 cases tlie site is irregular (at the aortic or ensiform cartil- ages, etc.), 26 of these occur in anaemic and 22 in non-ansemic subjects.
In character the murmur is described as "soft, low, blowing," often " faint," sometimes " short " and " long," about 20 times ; in three cases it is described as " musical," twice at the apex and once at the pul- monary area. It is described 42 times as " rough " or " harsh," and in all but 15 cases this applies to a murmur situated at the pulmonary cartilage.
Intensity is a point of some importance, for the murmur is in gen- eral low as opposed to the usually louder and harsher organic mur- murs, but no hard and fast rule applies to anything about a functional murmur. " Loud " is applied to some 16 cases.
As regards transmission, murmurs heard at the apex are trans- mitted "towards the axilla" in 43 cases, and "into the axilla" in 73 cases. In 7 cases the murmur is described as heard " in the back " and "at the angle of the scapula." These cases are, 4 of chlorosis, 1 of lymphatic leukiiemia, 1 of incipient exophthalmic goitre, and 1 of tuberculous meningitis. In none of these, except perhaps the latter, is there reason to suspect organic cai'diac disease.
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Pulvioiuivy accentiuition occurrc'l in 191 cases, in 127 of which the puhnonary system was diseased. In aljout one-thir<l of the cases, it was noted as " slight," more often it was present in anaemic sultjects.
The rhythm of the functional murmur, with more special refer- ence to the diastolic sound. Among the cases studied I have found 10 diastolic murmurs which I have not been able to rtyect as organic by any of the criteria I have used. They occur in the following diseases :
Chlorosis, splenic leukaemia, functional and cardiac disturbance, exophthalmic goitre, catarrhal jaundice, cerebral thrombosis, chronic bronchitis, and dementia.
So distinguished an authority as Strlimpell states positively that he himself has observed a case of undoubted functional murmur which was diastolic in rhythm ; and Sahli explains this (when occurring at the base) as a transmission of the bruit de diahle from the neck. Leube, on the other hand, considers them so uncertain as to be better left aside in making any critical enquiry into the subject. He himself has never heard a diastolic murmur which he believes to be functional. Without discussing this disputed point, I quote a few of the cases :—
1. Exophthalmic Goitre : Blowing systolic murmur heard best at apex, heard also over praecordium and at aortic and pulmonary cartil- ages. Faint blowing diastolic murmur at pulmonary cartilage, heard down along left border of the sternum ; pulmonary 2nd sound heard louder than aortic 2nd ; dulness normal ; apex beat normal position ; 1st sound of heart heard at apex ; pulse compressible
2. Phthisis: Patient died 13 days after admission. Heart normal on entrance except for accentuated pulmonary 2nd sound, five days ante-mortem, systolic and diastolic murmurs were heard at 3rd right interspace, transmitted down right border of sternum ; po-sisted until death.
3. Splenic Leukaim,ia: (Haemoglobin 14 per cent.). Blowing sys- tolic murmur at apex, transjnitted to axilla ; blowing systolic murmur at pulmonary transmitted upward ; systolic and diastolic murmurs at aortic cartilage ; pulmonary accentuation and 2nd sound at apex much accentuated ; apex beat and dulness in left mannnary line ; pulse regular, tension low.
4. Dementia: Patient was a boy of 15, small and undeveloped; diastolic murnmr at pulmonary cartilage ; no enlargement of cardiac area or accentuation of pulmonary second sound.
Some cardiac enlargement was noted in 66 cases, and seemed gen-
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erally to be consequent on a relative mitral insufficiency. In ten cases, relative dulness began at the right sternal border, in 30 cases it was noted at the midsternum.
V^i.'i 9?. \
General reonarks: A functional murmur is usually, though not always, systolic in rhythm ; while frequently at the base, it is very commonly situated at the apex ; in the more severe degrees of ansemia or intoxication it is more common at the apex, in milder disturbances at the base. In intensity it is generally " low " and " faint " ; in quality, "soft" and " blowing," especially when at the apex. Rough, harsh, functional "nurmurs are generally situated at the pulmonary cartilage. The aiurmur is often transmitted from the apex to the axilla, and, as due to a relative mitral insufficiency, may even be heard in the back. Moderate pulmonary accentuation is frequent. In those cases where the murmur is basal and appears to be accidental, it is generally associated with anaemia. Moderate, enlargement of the cardiac area is fairly common, and points to a relative mitral in- sufficiency.
The cases studied illustrate especially the following points : 1 In cases of antemia, pulmonary accentuation is often associated with a pure accidental murmur.
2. Functional murmurs frequently occur where there is neither anaemia nor fever. They are then often associated with some other condition suggesting intoxication.
3. Diastolic murmurs have been noted which do not appear to have an organic origin.
4. Although accidental murmurs are generally heard at the base and those of relative mitral insufficiency at the apex, accidental mur- murs are probably sometimes heard at the apex ; (as in moderate anaemias where the murmur may occur at the apex unaccompanied by pulmonary accentuation or cardiac enlargement and disappear after a short time ; or in high fevers where a murmur at the apex is replaced after a few days by one at the pulmonary cartilage of the same character.) On the other hand; murmurs produced at the mitral valve are occasionally, though rarely, heard best at the pulmonary cartilage.
Two conditions which it may be quite impossible to distinguish from each other by physical signs are :
A functional murmur at the apex with signs of moderate dilatation (relative mitral insufficiency), and an organic mitral murmur with signs of compensatory change. A decision can often only be reached
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by considering the patient's general condition and the persistency of the murmur. This last is the clinching point and is the final criterion to which uncertain cases must be brought. In plain terms, we must tvait to diagnose the murmur until it is no longer there to diagnose. In this short paper such a large number of case reports have neces- sarily been dealt with in the most superficial way. Many points,— such as the persistency of the first sound of the heart— have not even been mentioned ; and there remain the 123 cases where the previous history or present condition suggests organic cardiac disease ; a com- parison of these with the 466 cases glanced at in this paper where the murmurs were all apparently functional, would be very interesting. But a closer study of a subject such as this, is better combined with work at the bedside. The examination of these cases yields results which are use'' chiefly as a basis for furthur study, and which become valuable when the conclusions drawn from them are confirmed by the prolonged observation of individual cases by a single observer. I hope at some future date, through the continued kindness of the authorities of the Royal Victoria Hospital, to be able to make further use of the material before me in a more thorough investigation of the subject.