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 selec-
tions that should satisfy novices and seasoned
clinicians alike.
Aus tin Flint Murmur
Austin Flint was an American physician practic-
ing 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 writ-
er, he is credited on more than 200 published
articles and wrote one of the major textbooks of
Videos and audio his time, A Treatise on the Principles and Practice of
recordings are Medicine, which persisted through six editions.1
available at The Austin Flint murmur is a mid-diastolic rum-
NEJM.org
bling sound present in selected cases of non-
rheumatic aortic regurgitation. The sound is
indistinguishable from mitral stenosis. Flint pos-
tulated 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 incom-
ing blood from the left atrium, and the regurgi-
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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 sub-
mitted his work on mitral-valve prolapse to the
journal Circulation, but the manuscript was refused
for its “overstated conclusion.”6,7 After consider-
able 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 Knowl-
edge, Barlow’s work is the 13th most cited paper
in the 101-year history of the journal (which be-
came Heart in 1996), with nearly 400 citations.6
In his paper, Barlow described the features
of mitral-valve prolapse in 90 patients with non-
ejection clicks, late systolic murmurs, or a combi-
nation of the two. The click corresponds to the
point at which the voluminous mitral-valve leaf-
lets reach maximal stretch. The musical late sys-
tolic 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 concur-
rently, but more commonly the click initiates the
murmur. There may even be multiple consecu-
tive 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 cor-
responding phonocardiographic tracings that con-
firmed his findings.8 Barlow’s syndrome refers
to the spectrum of symptoms caused by mitral-
valve prolapse.10 Patients’ experiences range from
the click or murmur alone to palpitations, chest
pain, or syncope.11,12
 occasional notes

C a b ot– Lo cke Murmur

Richard Cabot was an American physician and a

trailblazing educator (Fig. 1). Recognized by his
peers and medical trainees as an expert diagnos-
tician, 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 in-
strumental in establishing the first in-hospital
social service department in the United States, at
Massachusetts General Hospital in 1905.13 Col-

Copyright Bettman/CORBIS.
laborating with his colleague Frank Locke, Cabot
published a series describing three cases of se-
vere anemia with diastolic murmur in patients
who had been given a diagnosis of valvular dis- Figure 1. Dr. Richard Cabot Auscultates a Patient’s Chest before an Audi-
ease but were found to have normal heart valves ence of Physicians in Boston, 1926.
on autopsy.14 The Cabot–Locke murmur is a dia-
stolic murmur that sounds similar to aortic in-
ICM AUTHOR Ma RETAKE 1st
sufficiency but does not have a decrescendo; it is reer academic and REG Firascible
FIGURE 1visionary. His pro- 2nd
3rd
heard best at the left sternal border. The mur- phetic warnings CASE bucked
EMail
TITLE convention. TheyRevised in-
15 Line 4-C
mur resolves with treatment of anemia. cluded questioning Enon the value
ARTIST: mst of H/T prolonged H/T bed
SIZE

rest in hospitalized FILL

patients in the Combo
1930s and, 28p
a
AUTHOR, PLEASE NOTE:
C are y Co omb s Murmur decade later, cautioning
Figure that
has been high-fat
redrawn and diets
type has could
been reset.
Please check carefully.
lead to clogged arteries. He also popularized
The Englishman Carey Coombs was a rheumatic Sutton’s law: bankJOB:robber 36322 Willie Sutton’s ISSUE: expla-
11-25-10

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 re-
with an opening snap. vealed that the descending branch of the left
coronary artery was markedly stenosed, whereas
D o ck ’s Murmur the heart valves, great vessels, and coronary artery
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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 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 persis-
tent 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. Al-
though 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 Gib-
son 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 cra-
nial to the scapular spine. The murmur grows
louder as the child ages and arterial dilation in-
creases, and the area of maximal intensity may
migrate farther left.22,24
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 — nota-
bly, George Balfour, for whom Steell worked as
a house officer at the Edinburgh Royal Infirma-
ry in 1873.26 Steell nevertheless published nu-
merous articles describing the murmur clearly
and in depth.27 He posited that the pulmonary
regurgitation was usually the result of chroni-
cally elevated blood pressure in the pulmonary
artery, resulting from mitral stenosis (Video 4,
2166 n engl j med 363;22  nejm.org  november 25, 2010
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Copyright © 2010 Massachusetts Medical Society. All rights reserved.
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 local-
ized area at the left upper sternal border.28,29
Ke y– Hod gkin Murmur
Charles Aston Key was one of the most promi-
nent surgeons of the early 19th century. Key op-
erated in London, the undisputed pinnacle of
surgical activity during his time, and was a con-
temporary of Thomas Hodgkin, the physician for
whom Hodgkin’s lymphoma is named.30 Hodg-
kin 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 regurgi-
tation at the time, causing dilatation of the as-
cending 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
The French physician Henri-Louis Roger was a
pediatrician who developed a special interest in
auscultation while working in Paris at the chil-
dren’s hospital, Hôpital des Enfants-Malades,
during the mid-late 1800s.34 Comparing autopsy
findings of interventricular defects with mur-
murs previously documented in the medical rec-
ord, Roger recognized that holes in the inter-
ventricular 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 com-
pared with that of a rushing waterfall. It is ac-
companied by a harsh thrill. The smaller the
ventricular septal defect, the louder the murmur.
Roger emphasized the benign nature of congen-
 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 hyper-
tension, right heart failure, and endocarditis.
Maladie de Roger describes patients with asymp-
tomatic ventricular septal defects. Patients with
symptomatic ventricular septal defects, which
cause cyanosis and progressive pulmonary hy-
pertension, have Eisenmenger’s syndrome.37-39
S till’s Murmur
English physician George Frederic Still, the fa-
ther of British pediatrics, is best known for his
eponymous rheumatic disorders: a juvenile fe-
brile 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 Prin-
cess Elizabeth (who would become Queen Eliza-
beth 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 ster-
nal 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 in-
tensity with fever, anxiety, or exercise.42 Its cause
is unknown, although it has been suggested that
the source may be vibration of the chordae ten-
dineae in the left ventricle or the sound of blood
gushing into the aorta.44
Conclusions
The modern era of diagnostic cardiology is fo-
cused on costly technologies, with regular use of
electrocardiography, echocardiography, and cor-
onary angiography. However, it is the authors’
opinion that physicians continue to enjoy and
value the bedside exam. In addition to its diag-
nostic function, there is considerable therapeutic
n engl j med 363;22  nejm.org  november 25, 2010
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Copyright © 2010 Massachusetts Medical Society. All rights reserved.
benefit in the application of the stethoscope to
the chest. We hope the description of these mur-
murs will stimulate renewed interest in the bed-
side exam.
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 Cali-
fornia, San Francisco — both in San Francisco.
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