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f t i > • i 4

L, ^-..-^ tv ^ /"r/. V /: '. .. J ,

ON TIIK

SYSTOLIC BRAIN MURMUR

OHJLDEEN.

AVTLLIAM ()SI;KR, 1\I. D., INI. U. C. V. Lond.,

PROFESSOR 01' TUK INSTITUTKS OF MKDiriM:, MCCillX UMVKKSITY, MONTUEAl,

[liijiriiitfdfioin tlw /Joston MtiUcal ainl Surgical Journal.]

CAMBRIDGE :

^txntcb at tt^t iii\}cmr}t ptc^0<

1880.

rfm

ON THE

SYSTOLIC BKAIN MURMUR OF CHILDREN.

BV Wll. .1AM 09LKK, M. I)., M. R. C. 1'. LOND.,
Professor of tke Inuituux of Medicine, Med Hi. University, Muntreal.

I DKSIKK in the fuilowin^i: communication to call
attention to this interestiii«,' clinical phenomenon, first
(lescrihed hy Dr. J. Fisher, of Boston, in the Medical
Magazine for 1H3;!. Like many other observations,
this one has .-uffered from the lapse of time, and has
been, to a great extent, forjiotten and neglected. In
conversation with many physicians, some of them spe-
cially conne«-ted with pediatrics, 1 have been surprisetl
to find how few were even aware of the existence of
such a murmur. Very cursory nuiJition is made of it
in works on auscultation and, with a few exceptions,
those on disi.'ases of children. \]\> to 1803 the Ger-
man and Freiich physicians had written many papers
on the subject, an<l within the past few years interest
has been re-arous«;d in it by the publication of impor-
tant memoirs byJurasz^ and Epstein.- p:nglish and
American physicians have not given it much attention,
and in the literature as collected by Jurasz tlie only
references are AVhitney, the American Journal Medical
Sciences, 1643, and d. W. Smith, the Lancet, 18o9.

In the autumn of 187G. 1 was asked by a medical
friend to see a child, aged three years, with a remark-
able murmur in the head, about which the parents

1 I)a» 3VstoIiscl«e HiniKPriiuscli tier Kinder, IleidelberK- 1877.
'- Heitra'f: zur K.niitniss iles sysU.lischcn Schadelgertiusches der
Kinder. Trag. 1S78.

4 The Systolic Brain Murmur of Children.

were very anxious. Tlie cliild was a wt'll-noiirislicid
little girl, with a ruddy complexion, well-lbrn)ed head,
I'ontanelles closed ; no evidences of rickets. On |»1mc-
ing the ear upon any part of the head a loud, high-
pitched systolic inunnur could be heard, variable in
intensity, loudest in the temporal regions, also audible
in the carotids, and disappearing entirely on compres-
sion of these vessels. There was no heart disease.
The mother had noticed the noise in the head, she
thought, from the time the child was a year old, and
the child also appeared conscious of its j)rescncc, but
s:«id she only heard it at intervals. The medical at-
tendant had suijirested the jiossibilitv of aneurisu), but
there did not seem to me to be nny evidence in favor
of such a view. I had a distinct recolI(M'tion of the
fiict that :i murmur was described as occurring in the
brains of children, but 1 thought it was always audible
over an opi'U fontanelle, Jind ]);ii'taking of the nature
of a venous hunn oriuinatinjx in the lonjifituditial sinus.
As the child was in jjood health, and the murmur
hiul persisted for nearly two years, I gave a favorable
prognosis. The mother did not aj)iiear satislied, but
I heard nothing fv-i ther of the case for some months,
when 1 recogu'/ed ii in the description of a Case of
Supposed (iununy Tumor of the lirain, in which the
murmur was ."itributed to the possible existence of a
svphilitic growth pres.-ing uj)on the vessels at the base
of the brain. About the same time Juras//s memoir
came to hand, and renewed my interest in tlu^ case,
which lijis proved to be one of unusual value froni the
length of time whicn the nmrmur has continued. The
history of the child from the spring of 1877 to the
ju'esent is as follows: she has thriven, and is now a
l)right, intelligent little girl of seven, ])erfectly healthy,
luvid not enlarged, and no trace of swollen lymphatic
glands in the neck. 1 have examined her on four oc-
casions, and found the murmur peisistent, with the
same characteristics. On the 15th of May of the pres-

year 1 examined her again, and found it still very
ent

The Syatollc Brain Murmur of tViilihrn. 5

J<:

(]istiuot, loudest in tli(! teinpoiMl r«'Lji<)!is. r.itlici' ukm'o
vjirial)lo in iiitciisitv tlum liifluTto, uinl .soiiu'tiiiuvs dis-
appcuriiiij ontirely for a feu moments. It was with
dilliciilty lu;anl in tlio carotids.

I have examined ahont sixty <'hildren for this mur-
mnr, and have discovered it in ei;^ht cases, all nn-
der tliree vears of a;;e : t)iie, a case; of dironie hydro-
cephiiins; one, chronic intestinal car.'iri'h with rick«'ts ;
tlie others appeared In.'althy. Anion;: the sick chil-
dren examined in whom no mnrmnr existed were s«^v-
eral cases of rickets, two of tuhercnlons meninuitis, and
one of chronic hydr()ceph:dns. Dr. .lames IJell, lat*)
honse snrn;e()n of the ^Slontical (Jeneral Hospital, ex-
amined one hundred eliildrcM, and found only six in-
stances of the "brain nmrnuir;" hnt, as he remarked,
th(! dillienlty of (letectinij a soft, lo.v-pitched /irin'f in
tin; head of a strnL'.ulin.U ejiild in a busy, " ont-door "
room makes it prol)al)le that in many instan(n's it was
overlooked. No special iH)te was ke[)t in these cases
of the condition of tlu! children.

( )l»,s(!rvers differ very nmcli in their estimation of tho
import of this nun-nmr, some re^ardini;- it as patlmloj;-
ica!. otliei-s as physiological. Dr. Fisher lhon<fht it to'
he I he former, and described variations of the nuninni'
in such disi^ases as wlioo|tiii^' (ion^li. conu'estion of the
brain, acute and chronic hvdrocc[)lialus, and apo|>lexy.
liarthez and Killiet (IS."»;1) thcujiht that it afforded
a di;iiinostic si,i;n between racliiiic hypertrophy of tho
brain and chronic hydrocephalus. IJoi^er (l.sr)*.)) and
Henoch (1>S()1) regarded it as specially connected with
rickets. Wirthiicn ( IS.';,")), on ^he other luuid, lielieved
it to be jdiysiolo^ical. and stati's that it is heard nn>st
frc(!uentlv oMsr the heads of robust children. The
views ot these and other writers are i;ivcn very fully
in «Iuras//s mono^i'aph, and the di^C()rdance of opinion
is amply illustrated.. This author coii(;lndes that it is
not ])atholouical, but occurs in both healthy ami dis-
eased children, and does not stand in direct connection
with any {)articular disease. In reading over the rec-

G The Systolic Brain Murmur of Children.

onls of cases it is ccirtaiiily noteworthy liow freiiuent
tlio suhjcct of tii(! murrnur is described as rickety.

Tlieri! iM remarkiihlo iiiiaiiimity ainoiiir all tlu^ writers
as to the ai,'o at which the iniirinur i)n'vail.s, the ex-
tremes in the reconled cases heiiijr l)ie third month and
the sixth year, the majority of instances occurring dur-
ing the second year. The cas(! of the litth' girl above
given is of interest, therefore^, in this connection, as she
is now over seven years of a^'e, and further from the
fact of th(} persistence of the murmur since infancy. I
have not found any recorded instance of the murmur
persisting for such a length of time.

Tlu! seat of the prochiction of the niurmur is placed
by most authors in the arteries at the base ol llu5 brain
and in llu^ carotid <'anal. Ilennig believed it to be
venous, and jiroduced in the longitudinal sinus. It is
worthy of note that in the majority of the cast's a mur-
mur is also heard in the carotid arteries.

tJurasz has brought forward evidcfiict! to prove that tlio
murmur originates in the carotid canul, and as his ex-
planation of it has not. sofai'as I know, been j)ublished
in any Iviglish oi- American Jmirnal, it may be worth
whil(! to give a smnmary of his views : lie measured
the width of the upper and lower orilices of the carotid
canal in twenty-live adults and tw(!nty-liv(? new-born
infants. Jn the former the inferior aperture varied
from (i.l m. to 1 cm. in ti: ; long, and 0.4 to 7.(1 m. in
the short dianu'ter; the superior aperture from T). I
to 8 m. in the longest, and .">..') to 7. 1 m. in the shortest
diameter. JMeasuiements in the mature lu'tus and new-
born when compart.'d with these show a diilerenc(! of
from 4.1 to G.2 m. for the long, and .1.7 to 4.0 ni. for
the short diameter of the inferior aperture, and o.I to
4..') m. for the loui;, and o.o to o.l) m. for the short di-
ametcM' of tin; superior aperture. The carotid canal
must therefore enlarge considerably in the course of
development. Does this take place gradually, or
<loes it occur more rapidly at one [)eriod than another?
His observations ami measurements go to show that up

Tlie Systolic Brain Murmur of Children. 7

to the sixth month the caiial dot's not enhir^e, remain-
ing UMcliun^od ; hut from this (hito it widens rapidly, so
that from iha third to the sixth year the (limensions of
the adult canal are attained. The enlargement is held
to he due to the increase in volumi! of the carotid artery,
and not to an independent growth, that is, expansion,
of the hone; and this heing the case it is not impossihle
that a temporary local disproportion ensues hetwetni
the rapidly enlarging caroti'l artery and the surround-
ing hony wall, or, •' in other words, a temporary steno-
sis of the carotid takes plac(; in the carotid cnnal."
This physiological stenosis is held to he the cause of
the systolic hrain murmur, which is to he regarded as
a normal occurrence. It is the expression of a struircle

1 1 1 • I • OO

hetween the artery and its hony nivestment, which per-
sists until hy the pressure of the pulsations the canal
has heen widened to a suitahle deirree.

Epstein ^ criticises this theory and the anatomical
data on which it is hased, denying the rapid expansion
of the carotid canal aftcu* the sixth nujuth and its en-
largement hy the pulsation of the artery. Taking the
following circumstances as favoring the production of
vascular murmurs, namely, wide vessels, rapid hlood
flow, diminished peri[)heral resistance, elasticity, and
thinness of the walls, he proceeds to show that these
prevail to an unusual degree in infancy, particularly in
tire vessels of the head, which, according to IJeneke, are
relatively larger than the others of the hody. In children,
also, the arterial walls are thinner, the capillaries wider,
the hlood flow more rapi<l, and consequently the blood
pressure is low. The existence of such conditions, es-
pecially in anaemic children, is regarded as the predis-
posing, if not the exciting, cause of the hrain murmur,
lie calls attention to a fact of great im[)ortance in this
connection : in two cases there were found, /?os< mortem^
enlarged and hard lymph glands in the course of the
carotid arteries, and in all children examined subsequent-
ly^ in whom the murmur was heard, the presence of eu-

1 Loc. cit.

8 Tfie Systolin Brain Murmur of Children.

l{im'<l irlands in tliis sltiitition was (hsU'riiilncd. Ho
su<;m'st8 tliat l\u'. murmur may hv duci to till; cause.

So far as my liinitc<l exi-tirifiice goos, I am not in-
cliiiod to y'ijard the murmur as of any special patho-
lo^'ical si^niilicaMce. There can be no (h)uht, ho\v(!ver,
Ironi the numerous observations ol Krem'h and(i<'r-
man physicians, that itoc(Mirs most frc-qucntly in weak,
rickety <;liildr<'ii, but its presence and persistence in per-
fectly healthy infants are .sullicient to disprove the pe-
culiar connection which some have sujiposed it to have
with this disease. Thus I havi; had a strong, wcU-
devdoped child under observation since birth ; the mur-
mur appeared at the fourth month, and has now con-
tinued for twenty-two months, with little or no change;.
Though not prepared to criticise Jurasz's ingenious
viev/, not having entered into the anatomical (pu'Stiou,
1 think that the case's of the little girl above mentioned,
in whom the murnuir has lasted for six years, and the
intant in which 1 have followcil it for twenty-two
months, are strongly opposed, if not fatal, to any such
theory. If the carotid canal is wi<lened b}' the [»ulsa-
tion of the artery, it is scarcely conceivable that a
2)hysiolo(jical stenosis could j)ersist for six years.

1 have not been able Jo detect any special eidarge-
ment in the cervical glaiids along the carotids in tlie
cases which have come under observation since receiving
Epstein's pami)hlet. In .)ne case there were two en-
larged and linn glands behind the sterno-mastoid mus-
cle on the right side. Unless the enlarijement is con-
sidcrable, it is dillicult to feel the deep glands along the
carotids, particularly if the child is well nourished.
Epstein's suggestion is, however, worthy of further in-
vestigation.

>msiis^^!^0^.