Detection of Fcetal Heart Murmur 
in Gravida with Report of a 
Case. 
By J. N. HALL, M.D., 
Professor of Medicine in Gross Medical College ; Visiting Physi- 
cian to the Arapahoe County Hospital, Colo. DETECTION OF FCETAL HEART MURMUR IN GRANIDA 
WITH REPORT OF A CASE. 
BY J. N. HALL, M.D., 
Professor of Medicine in Gross Medical College ; Visiting Physician to 
the Arapahoe County Hospital, Denver, Colo. 
Osier mentions, in his Practice of Medicine, that foetal endo- 
carditis has been diagnosed in gravida by the detection of a 
rough systolic murmur through the abdominal walls. He has 
kindly given me the references to these cases—two quoted by 
Hochsinger, and the third reported to the American Pediatric 
Society by Christopher of Chicago. Longstreth refers to a case, 
but it is probably one of those quoted by Hochsinger. The re- 
ported cases are briefly as follows: 
H. Barth* saw a pregnant woman who presented, to the left 
and below the navel, instead of the normal foetal heart-sounds, 
a widespread, rough, systolic murmur. The child was still- 
born, and presented, upon section, enormous hypertrophy of 
the heart, especially upon the right side, with thickening of the 
tricuspid valves, and abundant endocarditic vegetation. 
Hennigf reports the second case, occurring in a woman with 
contracted pelvis, who was artificially delivered in the eighth 
month. Before delivery it was found that both heart-sounds 
were replaced by murmurs, and this was confirmed by exami- 
nation of the already cyanotic foetus after delivery. Section dem- 
onstrated the presence of extensive endocarditis about the 
aortic valves, giving rise to both stenosis and insufficiency. 
The case reported by Christopher occurred in the practice of 
Frederick J. E. Ehrmann, of Chicago, who has kindly sent me 
the notes for this paper, an abstract of which I present: 
A German woman, thirty-two years of age, presented her- 
self in the eighth month of her third pregnancy, for examina- 
tion, and everything was found practically normal. The foetal 
heart-sounds were pure, 150 per minute. At time of labor the 
♦Quoted by Hochsinger. 
f Ibid. 2 
Hall: Foetal Heart lMurmur. 
foetus presented O. L. A., and a murmur was found in the left 
iliac fossa, 140 per minute. The female child was born after a 
normal labor, and was normal excepting for a systolic murmur, 
heard over the cardiac region, and transmitted to the neck. 
Cyanosis appeared on the second day, and the child expired on 
the fourth, there having been no material change in the mur- 
mur. The remainder of the report I give in Dr. Ehrmann’s 
words: 
“Diagnosis before birth, possible intra-cardiac lesion, on ac- 
count of the previous clear tones, but later only murmur. The 
umbilical souffle was thought of.” 
“Diagnosis after birth, aortic valvulitis, which, on account 
of the rarity with which inflammation occurs on the aortic 
valves, was thought to be possibly connected with some 
anomaly.” 
“ Post-mortem.—Patent foramen ovale, verrucose thickening 
of aortic valves, and also tricuspid. No pulmonary artery arising 
from right ventricle, but from aorta just above sinus of valsalva.” 
My own case was as follows: 
Mrs. P., American, primipara, seventeen years of age. Po- 
sition, O. R. A. The foetal heart was heard with the ear, as I 
had then no stethoscope with me, 124 per minute, to the right 
of the navel, and nothing abnormal was noted. The placental 
bruit was marked just at the left of the navel. 
The first stage progressed very slowly, pains being absent 
for many hours. The next day at noon they began again, and 
I examined the abdomen with the stethoscope. 
The heart beat at the same rate, being heard about two 
inches downward and to the right of the navel. The first 
sound was rough and blurred, the second being normal. My 
assistant, Dr. S. S. Connacher, examined the case and noted, 
under my direction, the murmur replacing the first sound. I 
stated at this time that, in my opinion, we should find a systolic 
murmur over the child’s heart after birth, probably originating 
from the right ventricle, because of the marked predominance of 
right-sided endocarditis in foetal life. 
A boy weighing seven pounds was delivered at 4 p.m. with 
forceps. For about fifteen minutes he was decidedly cyanotic, 
although the heart could be seen at first, beating forcibly, over 
an area greater than usual. A rough, slightly musical systolic 
murmur, loudest at the junction of the third costal cartilage and Hall: Foetal Heart [Murmur. 
3 
the sternum, was heard by both of us. It was not transmitted 
materially in any direction, and could not be heard in the back. 
The pulmonic second sound was accentuated. From the very 
unusual area of pulsation of the heart 1 had at first supposed the 
organ to be hypertrophied, but I apparently erred in this in not 
taking into account the temporary difficulty in respiration, on 
account of which the lungs had not expanded so as to cover the 
heart to the normal degree. A half hour after birth, respiration 
was well established, cyanosis had disappeared, and the area of 
cardiac dulness was normal. 
On the third day Dr. S. D. Hopkins examined the case with 
me. The murmur was about as at the time of birth, but 
seemed to me somewhat weaker. The pulmonic second sound 
was thought to be three times as pronounced as the aortic. 
Unfortunately I failed to note whether the sound was transmit- 
ted into the arteries of the neck, although I believe that 1 should 
have noted it had such transmission existed. 
During the next week the murmur grew progressively 
weaker, and on the tenth day the heart was entirely normal in 
its action so far as I could determine. 
At the time of my report of this case to the Denver and 
Arapahoe Medical Society on May 25, 1897, I had not had op- 
portunity to study up the possible modes of origin of the 
murmur, and especially had not had access to Hochsinger’s 
invaluable work (Die Auscultation des kindlichen Herzens). I 
believe, however, that I am now able to offer a satisfactory 
explanation of the origin of the murmur. 
It will be recalled that the ductus arteriosus botalli conducts 
the foetal blood from the pulmonary artery to the aorta, the 
artery being unable to conduct the blood to the lungs as after 
birth, because of the non-use of these organs during the foetal 
life. When the lungs begin to receive the blood from the pul- 
monary artery, upon the establishment of respiration, the duct 
begins to close, the closure becoming complete from the fourth 
to the tenth day after birth, according to Gray. 
In persistence of the duct, the physical signs noted are, ac- 
cording to Hochsinger, a loud, whirring murmur, heard loudest 
over the region about the second left interspace, and often trans- 
mitted to the arteries of the neck; and marked accentuation of 
the pulmonic second sound. Upon this latter feature this author 
lays especial stress, the blood-pressure in the pulmonary artery Hall: Foetal Heart [Murmur. 
4 
being decidedly raised by the inter-communication with the 
aorta, with its higher blood-tension, thus accounting for the 
accentuation. 
The murmur in our case disappeared at the time of the nor- 
mal closure of the duct. The child is at this time, four months 
after birth, well developed, and apparently entirely normal. 
Anomalies in structure of the heart, and persistent foetal endo- 
carditis may apparently be properly excluded. We have only 
to suppose a structural defect or endocarditis, limited to the 
duct, and causing roughening or stenosis of its lumen, to ac- 
count for a systolic murmur, which would, as in our case, dis- 
appear with the physiological closure of the duct by the tenth 
day. We assume in this case that the possible endocarditis is 
no longer active. The point of greatest intensity of the mur- 
mur in our case so nearly coincides with that mentioned by 
Hochsinger that we may overlook the discrepancy. 
In closing it should be stated that Hennig believes that we 
may have single or double fetal heart murmurs, audible in utero, 
but not to be heard after birth, and this in cases in which the 
possibility of the location of the murmur in the cord is excluded. 
Jackson Block. FROM 
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