THE EFFECT OF CHANGE OF POSTURE UPON 
HEART MURMURS. 
Read at the Annual Meeting of the American Climatological Asso- 
ciation, at Richfield Springs, New York, June 24, 1892. 
BY 
VINCENT Y. BOWDITCH, M.D., 
Boston, Massachusetts. 
Reprinted from the International Medical Magazine for November, ISO'S. THE EFFECT OF CHANGE OF POSTURE UPON HEART 
MURMURS. 
In presenting to you a number of cases in which I have noticed in the 
last three years some rather peculiar phenomena in cardiac murmurs, I 
cannot, perhaps, give you anything especially original either in the way of 
observation or explanation of the facts, yet, as I have been unable to find 
special references to them in medical books, I have thought it worth while 
to see if others here had had experiences similar to mine, and to learn what, 
if any, deductions had been made from your observations. 
I refer to the change which comes under certain conditions in the char- 
acter and intensity of the abnormal sounds in a certain number of cases, by 
no means all, of cardiac disease, whether functional or organic in origin. 
By this I do not refer to the fact known to every beginner in the practice 
of medicine that exertion will often bring out a murmur which disappears 
again during rest, but that a change of the patient from a sitting to a lying 
position, or the reverse, will quite frequently cause a marked difference in 
the character of the adventitious sounds conveyed to the ear, a fact often 
noticed after repeated experiments at one examination of the patient. 
I have been struck chiefly by the following facts, viz.,-that systolic 
murmurs heard at the base of the heart are, in most cases, where any differ- 
ence is noticed at all by change of position, intensified when the patient is 
lying down, although the reverse is true also at times. 
Again, although I am inclined to believe that the former condition oc- 
curs chiefly in cases where the murmur is inorganic (anaemic cases), yet I 
have undoubtedly noticed it in others where all the symptoms of organic 
disease are present. 
Less frequently, a difference in character of basic diastolic murmurs has 
been 'oticed by change of position, some cases showing greater intensity 
when th* patient lies down ; about an equal number showing the reverse. 
The samf tay be said of murmurs at the apex of the heart. 
c special moment is the fact that in a few cases a change of posi- 
•vill cause the disappearance or reappearance of a murmur. The most 
striking case of this was in a woman whom I examined very carefully in 
the out-patient department of the City Hospital at different times. There 2 
VINCENT Y. BOWDITCH, M.D., ON 
was a history of three attacks of inflammatory rheumatism with subsequent 
symptoms of cardiac disease (prsecordial pain, palpitation, etc.). 
Upon examination, whenever the patient lay down, a basic systolic mur- 
mur was heard, which completely disappeared when she rose to a sitting 
position. On the contrary, however, a prsesystolic murmur at the apex, 
distinctly and loudly heard when the patient was sitting up, became very 
faint and at times completely disappeared upon her resuming a horizontal 
position, these facts appearing each time the experiment was made, and cor- 
roborated by three assistants who, without being biassed by any remark from 
me, noticed the same phenomena. I saw this patient three times at short 
intervals, the same facts being noticed each time, although at the last exami- 
nation after treatment the difference in the change of the apex-murmur 
was not as marked as on the earlier occasions. 
From forty-two cases which I have examined with special reference to 
the point in question, I find the following results : 
Twenty-one showed an increased intensity of murmur when the patient 
was lying down. 
Of these, 9 were murmurs at the base. 
" " 8 " " " " apex. 
" " 2 " " both in base and apex. 
" " 2 could not be located absolutely. 
Five showed increased intensity of murmur when the patient was 
sitting up. 
Of these, 2 were murmurs at the apex. 
" " 3 could not be located, but were more or less diffused. 
Sixteen showed no special difference in the murmurs upon change of 
position. 
Of these, 6 were murmurs at the base. 
" " 9 " " " " apex. 
" " 1 could not be located. 
Since beginning my paper I have been much interested in reading in 
the New York Medical Record of June 11a brief resume of a paper bear- 
ing on this subject by Dr. O. B. Campbell, of Ovid, Michigan, read before the 
American Medical Association, in which he reaches much the same conclu- 
sions that I have. I have been given to understand also that Dr. Loomis 
made some remarks on the same subject at the last Congress of American 
Physicians and Surgeons; but I have been unable to find a report of his 
remarks, and trust we may have the benefit of his experience in the dis- 
cussion to-day. 
Out of one hundred cases examined by Dr. Campbell the murmur be- 
came more distinct in the recumbent position in seventy-eight, more dis- 
tinct in the upright position in six, unaffected by change of position in 
twelve, not heard standing but developed by lying down in four. 3 
THE EFFECT OF CHANGE OF POSTURE UPON HEART MURMURS. 
It would seem, therefore, that there is no definite law by which we can 
determine which position affects these changes most. The fact remains, 
however, that the murmurs are frequently affected in character by change 
of position, and this once noticed may lead to something more definite in 
the future. 
It is easy to theorize as to the cause of these changes, and in the case 
which I have quoted as especially striking, the theory which had seemed a 
plausible one to me would seem to have been corroborated, viz., that when 
the patient is in a supine position, the heart by gravity tends to fall back- 
wards towards the spine, thus causing the great vessels as they emerge from 
the heart to bend upon themselves, thus making an increased obstruction to the 
flow of blood and an intensified systolic murmur at the base. On the other 
hand, the prsesystolic mitral murmur is less distinct to the ear by the falling 
away of the heart from the chest-wall when the patient is lying down, and 
intensified as the heart comes forward again upon the patient's rising. 
Unfortunately for the truth of this theory, however, cases occur in which 
the exact opposite of the above conditions are found, and we are, therefore, 
obliged to look for some other explanation of the facts noticed. The theory 
that the difference in the sounds may be attributed, after all, to exertion on 
the part of the patient can, I think, be safely put aside, for in nearly every 
case I have made the patient change the position at least five or six times in 
each single examination. 
In either position an equal amount of exertion is used, whether the 
patient lifts himself up to a sitting posture (the legs being extended in the 
bed), or lets himself slowly back into a reclining position ; hence my reasons 
for attributing these changes of sound to some other cause than exertion 
alone. 
Of course, it cannot be claimed that practical results in the treatment 
of cardiac disease are obtained thus far by such observations, yet every 
recorded fact in medicine, however small, has its own worth, and will prove 
a help, whether directly or otherwise, in the future to our knowledge of 
disease. 
One thing certainly can be claimed, and it is of importance, that certain 
abnormal conditions of the heart have at times been brought out which 
would have remained hidden had not the methods of examination as sug- 
gested been adopted. 
In the case quoted, for example, had the patient been examined in a 
recumbent position solely, the presence of a mitral stenosis might easily 
have passed unnoticed. So much have I been impressed by these facts since 
I first noticed them, that although in many patients nothing of importance 
is detected by mere change of position, yet I do not now feel that I have 
done thorough justice to any doubtful case of cardiac disease unless I have 
examined the patient in both attitudes. International 
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