THE DOUBLE INTERMITTENT MURMUR OVER THE FEMORAL ARTERIES AS A SIGN OF AORTIC INSUFFICIENCY (published in 1861)
Dr. Paul Louis Duroziez (1826 - 1897)
Former chief of the Clinic of the Faculty at the Charite Hospital (Service of Professor Bouillaud)
Du double souffle intermittent crural, comme signe de l'insuffissance aortique. Arch. Gen. de Med. Paris. 107: 417-443, 500-605, 1861. Translated by Erich Hausner, M.D. Amsterdam, New York.
The femoral arteries, which are subjected to auscultation less frequently than the carotids, offer very valuable information; they are especially unique in their behavior, they are readily compressed and in this respect offer the same advantages as the radial arteries: they are larger than the carotid arteries and have the advantage of being more distant from the heart.
The femoral artery merits careful study. On compression of the femoral artery, a shock or thrill is felt and auscultation reveals a sound, similar to the sound of toc or a sound of unique blowing character, a simple intermittent blowing murmur. The entire femoral artery is capable of giving rise to this blowing murmur. The character of the murmur varies with changes in the blood, the size of the artery, the condition of the vessel wall, and the contractile force of the heart. After compressing the artery for some time and gradually releasing the pressure in a subject with chlorosis (anemia in young women), a continuous humming murmur will appear; at times a continuous, humming sound is audible, at other times a double murmur is audible.
The so-called intermittent double murmur which occurs in certain cases, is a different murmur and our study will concern it. The intermittent double murmur over the femoral arteries was described in aortic insufficiency; but no one, I believe, has given it the significance that it deserves. Everyone has mentioned the murmur occurring in arterial diastole (souffle de la diastole arterielle) which quite frequently occurs without compression of the artery; but very few authors mentioned the murmur occurring during systole. Very frequently it does not appear of its own accord, but must be produced and sought for. The first murmur results from the powerful contraction of the ventricle, but as the second murmur is produced by the systole of the arteries in the legs, a less powerful force, its production must be facilitated by compression of the artery.
In cases of uncomplicated aortic insufficiency, wherein the heart beats vigorously and the arteries pulsate and react forcefully, the double murmur is audible; when, contrarily, aortic insufficiency is complicated by a considerable degree of aortic or mitral stenosis, a not uncommon occurrence, the arteries are moderately distended with blood and thus the second murmur is difficult to hear. It must be carefully sought and even then it will not appear regularly; it will not be detected when weak pulsations are present. It appears or disappears in relationship to increased or decreased action of the heart. At times it can be heard over both femorals, at other times only over one; briefly, distention and recoil, adequate systole of the arteries, are required for its presence; a careful examination is indispensable.
The double murmur can be produced in two ways, by means of the stethoscope or by means of the hand. With the stethoscope pressure is exerted to completely compress the artery; at a certain moment the double murmur will appear; only when the second murmur can be readily produced is it possible to place the stethoscope on the artery without pressure and then gradually slight pressure can be exerted with the hand above and below the stethoscope. Pressure above will produce the first murmur, while pressure below will produce the second murmur; it is evident that the second murmur is produced by the arteries of the legs, which propel the blood backwards and in some manner empty the capillaries.
The double intermittent murmur is of interest not only from the standpoint of diagnosis. The reflux of blood explains some of the symptoms occurring in aortic insufficiency and explains the sudden death which is occasionally observed.
A great disturbance occurs in the circulation; the blood no longer circulates evenly, so to speak, but comes and goes into the arterial system and stagnates in the veins, which continuously try to empty themselves. In the presence of aortic insufficiency, the heart during its powerful diastole, aspirates the blood from the lungs through the pulmonary veins at the same time that it receives the blood from the capillaries; the right ventricle and the lungs are emptied of blood. The blood supply is poor; the patients are pale, die from anemia and syncope. They do not tolerate venesection well.
What a difference occurs with mitral stenosis! Here, on the contrary, the blood is stagnant, forced into the veins, into the right side of the heart and the lungs; the patients die from apoplexy and suffocation; venesection gives relief.
These are two conditions, in opposition to each other, and one may be considered as being beneficial to the other.
Auscultation is an important issue in this connection. We have distinguished by our observations the auscultatory phenomena and particularly those concerning the femoral arteries.
1. In all heart cases wherein the double intermittent murmur was audible over the femoral arteries, aortic insufficiency was found at autopsy.
1. The double intermittent murmur audible over the femoral arteries, described by many authors in aortic insufficiency, has to my knowledge never been given as a constant sign of this lesion.
2. Most commonly it is not present and it is necessary to produce it by compression.
3. In aortic insufficiency blood is first propelled from the left ventricle into the extremities, and, being repulsed by the peripheral arteries and drawn back by the left ventricle, flows from the extremities towards the heart.
4. The finger, compressing the artery about two centimeters above the stethoscope, produces the first murmur; two centimeters below, the second murmur.
5. The secondary murmurs which can be produced by lesions of the pericardium, by mitral stenosis, tricuspid stenosis, by pulmonary insufficiency, can be differentiated from the murmur of aortic insufficiency with the help of the double murmur over the femoral arteries, which exists only in the latter condition.
6. If aortic insufficiency is complicated by one or more of the lesions mentioned, and if the diagnosis is rendered difficult by these complications, the phenomena in the femoral arteries will help or even establish the diagnosis.
7. The femoral phenomena less clearly differentiate aortic valvular lesions and lesions of the aorta. The double murmur may appear in certain aneurysms without insufficiency being demonstrable after death.
8. The temporary insufficiency can be demonstrated by the evanescent intermittent double murmur.
9. A continuous murmur can originate in the arteries; this, however, is never audible in aortic insufficiency with its constant intermittent double murmur over the femoral arteries.
10. The double intermittent femoral murmur occurs in typhoid fever, chlorosis, lead intoxication, but only temporarily; it is soon replaced by continuous murmurs.
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