The Diagnostic Significance of the Venous 
and Arterial Murmurs in the Neck, 
Based on Examinations of Fifteen 
Hundred Persons. 
BY 
JAMES K. CROOK, M.D., 
LECTURER ON CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS AT THE NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
February, 1893. Extracted from The American Journal of the Medical Sciences, February, 1893. 
THE DIAGNOSTIC SIGNIFICANCE OF THE VENOUS AND 
ARTERIAL MURMURS IN THE NECK, BASED ON 
EXAMINATIONS OF FIFTEEN HUNDRED 
PERSONS.1 / 
By James K. Crook, M.D., 
LECTURER ON CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS AT THE NEW YORK POST- 
• GRADUATE MEDICAL SCHOOL AND HOSPITAL. 
The occurrence of certain auscultatory phenomena in the great ves- 
sels of the neck has been familiar to the profession since the days of 
Laennec, more than seventy years ago. Their presence has generally 
been attributed to those pathological changes in the blood constituting 
the condition known as anaemia, but their exact diagnostic relations 
have never seemed to reach any fixed or settled status in practical med- 
icine. The following quotations from text-books and contributions to 
medical periodicals published within the last fifteen years will show 
the diversity of opinion regarding the clinical value of these sounds, 
referring more particularly to the venous hum : 
A. Weil'2 expresses the opinion that “neither the presence of the 
venous hum in itself, nor its intensity, its rhythm, nor its persistence in 
various positions of the head or neck, stands in connection with any 
particular form of disease.” 
Immermann3 writes as follows: “ Two symptoms often met with in 
anaemic patients are worthy of special notice because of their importance 
in relation to diagnosis. They are supposed, not altogether unjustly, 
to furnish valuable evidence of the presence of anaemia. I refer to the 
so-called ‘ anaemic murmurs ’ over the region of the heart, and the bruit 
de diable heard in the veins of the neck.” 
Gerhardt4 believes that “when the venous hum is not produced by 
some accidental influence, it is apt to be due to anaemia.” He thinks 
those cases in which a thrill is appreciated by the finger are significant 
of anaemia and of diagnostic importance. 
Guttmann5 states “ that the typical venous hum is found only in 
anaemia.” 
1 Read before the New York Academy of Medicine, June 21, 1892. 
1 Auscultation of the Arteries and Veins. Leipzig, 1875. 
4 Art. “ Anaemia,” Ziemssen’s Cyclopaedia. New York, 1877. 
4 Lehrbuch der Auscultation und Percussion. Tubingen, 1884. 
5 Lehrbuch der klinischen Untersuchung-Methode. Berlin, 1886. 2 
CROOK: MURMURS HEARD IN THE NECK. 
Fagge1 makes the following statement: “ It is important to notice 
that none of these murmurs (arterial and venous) are of the slightest 
significance from a clinical point of view, so far as the diagnosis of 
anaemia itself is concerned.” 
Flint2 writes thus: “ Of special significance in the diagnosis of anae- 
mia is the presence of certain physical signs. . . . The arterial mur- 
mur is present in only a certain proportion of cases, but the venous 
hum may be heard almost invariably.” 
Eiehhorst3 does not attach much significauce to the venous hum, as 
shown by the following remark: “ The bruit de diable is often heard 
over the bulb of the internal jugular vein (in anaemia), but this sound 
is also often heard in healthy individuals.” 
Striimpell4 concludes as follows: “ Murmurs in the large veins of the 
neck are very often heard in anaemia, either with or without cardiac 
murmurs. . . . We believe that the loud venous murmurs are more 
frequent in the anaemic than in other persons. We cannot claim, how- 
ever, that they are of any great diagnostic value.” 
Apetz5 claims that among six hundred and sixty patients examined 
by him in hospital wards, two hundred and eighty-four (forty-three per 
cent.) presented venous murmurs. Dividing his cases into three classes, 
anaemic, slightly anaemic, and non-anaemic, he claims to have discovered 
fifty-one per cent, of murmurs in anaemic persons, forty-six per cent, in 
slightly anaemic, and thirty-nine per cent, in those not at all anaemic. 
Apetz, therefore, concludes that “ as this phenomenon is so often heard in 
persons who are not anaemic, it possesses very little diagnostic value, and 
should hardly be counted in favor of, or against, the presence of this 
affection.” 
Loomis6 expresses himself thus: “ The constant and important signs 
of anaemia are haemic murmurs, which may be cardiac, arterial, or 
venous.” 
Dr. Bewley,7 in a paper presented to the Royal College of Physicians 
of Ireland, March 6, 1891, arrives at the following conclusion: More 
than half the young persons who are not anaemic have a murmur in the 
neck. The presence of a hum, therefore, is of no diagnostic significance 
in any individual case.” 
Vierordt8 says: This murmur (the venous hum) is sometimes heard 
1 The Principles and Practice of Medicine. London, 1886. 
2 The Principles and Practice of Medicine. Philadelphia, 1886. 
3 A Handbook of Practical Medicine, 1886. 
4 A Text-book of Medicine, 1887. 
5 Virchow’s Archiv, cvii. 
6 A Text-book of Practical Medicine, 1889. 
7 Lancet, vol. i., 1891. 
8 A Text-book of Clinical Diagnosis. Leipzig, 1891. CROOK: MURMURS HEARD IN THE NECK. 
3 
in many healthy persons. . . . Strictly speaking, no diagnostic impor- 
tance is to be attached to the phenomenon.” 
It will thus be seen that the testimony in reference to the meaning of 
these vascular sounds, as shown by the foregoing statements and opin- 
ions of recognized authorities, is very confusing, and in some instances 
absolutely contradictory. In view of this unsatisfactory state of con- 
temporaneous evidence, the author determined, about a year since, to 
make a personal investigation of the subject, and ascertain, so far as 
examinations of a large number of persons would show, what relations 
these phenomena bear to diseased conditions, and what value to place 
upon them as a means of diagnosis. The investigation was begun early 
in June, 1891, and was terminated early in March, 1892. During that 
period fifteen hundred persons of various ages and conditions were 
examined. With reference to the diseases from which these persons 
were suffering, they may be classified as follows: 
Bronchitis, with various complications of asthma, emphy- 
Cases. 
sema, influenza, malaria, etc. . 
611 
Dyspepsia and intestinal disorders 
177 
Phthisis pulmonalis ........ 
122 
Diseases of the heart, functional and organic 
95 
Anaemia and chlorosis 
31 
Muscular rheumatism, lumbago, etc. .... 
41 
Renal affections, acute and chronic ..... 
17 
Articular rheumatism, acute and chronic . 
Various unclassified complaints, headache, nervousness, 
14 
insomnia, pregnancy, pneumonia, etc. . . . . 
Normal cases, persons presenting no appreciable patho- 
349 
logical condition 
43 
Total 
1500 
The great preponderance of thoracic diseases is explained by the fact 
that a majority of the cases were seen at the Chest clinic of the Bellevue 
Hospital, Out-door Department, and at the clinic for General Medicine 
of the New York Post-Graduate Medical School and Hospital. It 
should be stated here that all of these patients were under my own 
treatment or observation. Many of them were kept under treatment 
for a long period of time, and not a few were examined by successive 
classes at the Post-Graduate School. The instrument employed in 
examining the neck. was an ordinary flexible Cammann’s binaural 
stethoscope. The patients were almost invariably examined in sitting 
or standing posture, with the head and neck in an easy and un- 
constrained position ; a small number only being auscultated while 
recumbent. 4 
CROOK: MURMURS HEARD IN THE NECK. 
The examinations of these fifteen hundred persons, as shown in the 
table on the opposite page, resulted in the discovery of fifty-one cases of 
well-marked and unmistakable haemic bruits or murmurs originating in 
the bloodvessels, which equal 3.4 per cent, of the whole number. 
These figures do not include those accidental murmurs induced by 
improper pressure of the stethoscope, or twisting of the neck unduly, nor 
do they include those cases of inspiratory breathing-sounds, which in some 
persons so nearly simulate the bruit de diable. In every case of doubt 
the patient was instructed to temporarily suspend respiration. A study of 
the statistics comprised in the table will reveal the following important, 
and, it seems to the author, conclusive facts: Of the fifty-one cases pre- 
senting haemic bruits, we find that forty-three were females, in a total 
of six hundred and eighteen females examined—slightly under seven 
(6.95) per cent. There were eight males who presented bruits out of 
a total of eight hundred and eighty-two males examined—a little less 
than 1 per cent. This would indicate that these vascular phenomena 
are about seven times as common in females as in males. Analyzing 
the cases with reference to the age of greatest frequency, we obtain the 
results, by decennial periods, exhibited on the opposite page. 
These numerical data indicate that these murmurs occur with far 
greater frequency during early adult life than at any other period of 
existence. Taking the period from fifteen to twenty-five years inclusive, 
we find that 39 of the 51 cases of the vascular bruits occurred during 
this time (more than 76 per cent, of the entire number). The youngest 
person presenting a bruit was a girl, aged thirteen years, with chlorosis, 
and the oldest was a man, aged forty-eight years, suffering from em- 
pysema. The average age of the 51 persons with cervical murmurs was 
a little over twenty-three years. 
A most important point for analysis relates to the diseases of those 
persons in whoTn the vascular murmurs were discovered. A study of the 
subject resulted as follows: Of 31 well-marked cases of anaemia and 
chlorosis, we find 28, or more than 90 per cent., presented haemic bruits. 
The next disease in order of frequency of vascular sounds is phthisis 
(in which affection we know anaemia to play an important part). Of 
122 cases, we find that in 8 vascular murmurs were present. Among 
the remaining 1349 persons examined, we find only 15 in whom a true 
haemic bruit could be elicited. Several of these are marked “ anaemic ” 
as complications of some other affection, and, while the author has no 
numerical data bearing on this point, a majority of them might properly 
have been indorsed in the same way. We notice, further in the table, 
that in almost all of the cases of vascular bruit marked “ loud ” or 
“ distinct,” anaemia or chlorosis is given as the disease condition present. 
Of 43 healthy persons examined, only 1 exhibited a vascular murmur; in 
this case there was a rough carotid murmur heard on the right side only. CROOK : MURMURS HEARD IN THE NECK. 
5 
Table of Cases Presenting Cervical Murmurs. 
No. 
Sex. 
Age. 
Disease. 
Vascular sounds. 
1 
M. 
20 
Dyspepsia, cardiac 
palpitation 
Slight venous hum right side. 
2 
F. 
18 
Chlorosis 
Distinct venous hum right side. 
3 
M. 
22 
Phthisis 
! Faint venous hum right side. ■ 
4 
M. 
28 
Phthisis 
Distinct hum right side. 
5 
F. 
13 
Chlorotic anaemia 
Slight hum right side. 
6 
F. 
28 
Dyspepsia; quite an- 
aemic 
Loud hum right, and carotid murmur both sides. 
7 
F. 
18 
Chlorosis 
Loud venous hum left side. 
8 
F. 
24 
Chlorosis 
Loud venous hum right side. 
9 
F. 
23 
Mitral regurgitation ; 
chlorosis 
Loud hum over right external jugular vein, arterial mur- 
murs both sides. 
10 
F. 
16 
Bronchitis; anaemic 
Slight carotid murmur left side. 
11 
F. 
27 
Phthisis 
Faint venous hum (side not noted). 
12 
F. 
38 
Metrorrhagia 
Venous hum right side. 
13 
F. 
40 
Menorrhagia 
Slight venous hum and arterial murmurs (location not 
noted). 
14 
F. 
21 
Peritonitis; very an- 
aemic 
Venous hum right, and arterial murmurs both sides. 
15 
M. 
23 
Normal ; no disease 
Rough carotid murmur right side. 
16 
M. 
31 
Phthisis ; somewhat 
anaemic 
Slight venous and arterial murmurs both sides. 
17 
M. 
32 
Ingrowing nail 
Slight venous hum (location not noted). 
18 
F. 
24 
Peritonitis 
Venous hum right side. 
19 
F. 
24 
Anaemia 
Faint arterial murmur right side. 
20 
F. 
17 
Debility 
Slight venous hum both sides. 
21 
F. 
25 
Phthisis; very anaemic 
Venous hum and arterial murmurs right side. 
22 
F. 
17 
Phthisis 
Slight venous hum both sides. 
23 
M. 
48 
Euipyaema 
Developed venous hum and arterial murmurs while un- 
der observation. 
24 
F. 
27 
Malarial fever 
Venous hum right side. 
25 
F. 
18 
Chlorosis 
Venous hum and arterial bruit right side. 
26 
F. 
21 
Chlorosis 
Faint carotid murmurs (side not noted). 
27 
F. 
17 
Chlorosis 
Faint venous hum right, carotid bruit left side. 
28 
F. 
36 
Probably aortic sten- 
osis 
Chlorosis 
Rough bruit over right carotid. 
29 
F. 
14 
Carotid and venous (location not noted). 
30 
F. 
20 
Chlorosis 
Venous hum right side. 
31 
F. 
18 
Chlorosis 
Carotid and venous right, carotid left side. 
32 
F. 
18 
Exophthalmic goitre 
Faint carotid bruit right side. 
33 
F. 
30 
Left subclavian aneur- 
Bruit from aneurism. 
34 
F. 
16 
Chlorosis 
Venous hum right and left sides. 
35 
F. 
23 
Chlorosis 
Venous hum both sides. 
36 
F. 
23 
Phthisis 
Faint arterial right side. 
37 
F. 
25 
Anjemia 
Faint venous left, carotid right side. 
38 
F. 
16 
Chlorosis 
Arterial murmur and venous hum right side. 
39 
M. 
35 
Nephritis; dyspepsia 
Hum over right external jugular. 
40 
F 
16 
Chlorosis 
Distinct right and taint left venous hum. 
41 
F. 
15 
Chlorosis 
Loud arterial and venous riglu, faint left side. 
42 
F. 
18 
Chlorosis 
Venous hum right side. 
43 
F. 
16 
Bronchitis ; constipa- 
tion 
Slight right carotid bruit. 
44 
F. 
21 
Chlorosis 
Venous hum (location not noted). 
45 
F. 
16 
Chlorosis 
Venous hum both sides. 
46 
F. 
22 
Chlorosis 
Venous and carotid bruits both sides. 
47 
F. 
22 
Chlorosis 
Right and left venous bruits. 
48 
F. 
18 
Chlorosis 
Slight venous and arterial murmurs both sides. 
49 
F ; 
18 
Chlorosis 
Venous hum both sides. 
50 
F. 
16 
Bronchitis 
Slight venous hum right side. 
5! 
F. 
16 
Bronchitis; anorexia 
Faint venous hum right side. 
Years. 
Under 10 
26 persons examined, 
no 
bruits 
Per Cent. 
From 10 to 20, 
135 “ 
(< 
22 
(< 
(16.29 ) 
“ 20 to 30, 
476 “ 
( < 
21 
< i 
( 4.41 ) 
“ 30 to 40, 
374 “ 
U 
6 
<< 
( 0.016) 
“ 40 to 50, 
239 “ 
(t 
2 
(< 
( 0.008) 
“ 50 to 60, 
155 “ 
no 
U 
“ 60 to 70, 
80 “ 
u 
(< 
u 
“ 70 to 80, 
13 “ 
a 
“ 
“ 
“ 80 to 90, 
2 “ 
(t 
* * 
< 6 
CROOK : MURMURS HEARD IN THE NECK. 
A question of some interest relates to the points of origin and the 
location of these lisemic bruits. An analysis of the facts in the table 
bearing on this subject shows venous murmurs present in 42 cases, as 
follows : 
Cases. 
On right side alone, in 21 
On left “ “ ....... 2 
On both sides, in 12 
On side not noted, in 7 
Venous murmurs present without arterial bruit in 26 cases. Arterial 
murmurs present in 25 cases : 
Cases. 
On right side alone, in 9 
On left “ “ “ 3 
On both sides, in 9 
On side not noted, in 4 
These data furnish some curious facts. They indicate that these cer- 
vical murmurs, both venous and arterial, are frequently present on one 
side of the neck alone, and far more frequently on the right than on the 
left side, the proportion being more than 10:1 for the venous and 3 : 1 
for the arterial bruit. The figures show further that the bruit de diable 
is considerably more common than the arterial murmur, and, also, that 
each variety is frequently present in the same individual without the 
other. These facts were first noted by the author while engaged in the 
study of chlorosis in 1886, and were contained in an article on that dis- 
ease contributed to the New York Medical Journal of June 11, 1887. 
Until the present analytical investigation they seem to have received no 
subsequent verification. With reference to the location of the greatest 
audibility of these cervical sounds the author may be allowed to quote 
from this contribution : “ After numerous clinical investigations I would 
locate the maxim intensity of this bruit—i. e., the venous hum—in a 
plane rather external to the course of the great vessels of the neck. The 
space will correspond very nearly to a triangle having a base about two 
inches in length formed by the upper border of the inner third of the 
clavicle, the sides intersecting at a point about two inches above that 
bone.” After six years’ further experience with these murmurs, the 
author would now add that this area might be extended inward so far 
as to include the space underlying the sternal tendon of the sterno- 
clfeido-mastoid muscle. In many cases the bruit can be heard only in the 
triangular depression (when this exists) between the two tendons of this 
muscle. In other cases it is best heard at the outer border of the supra- 
sternal notch. In some cases, when the hum is not at all appreciable 
over the internal jugular vein, it may be heard over the external jugular, 
near the outer edge of the above-described triangular area. When 
heard over the external jugular the murmurs maybe caused to instantly CROOK: MURMURS HEARD IN THE NECK. 
7 
disappear by firm pressure with the stethoscope and arresting the flow of 
blood in the vessel. The bruit de diable is not absolutely continuous, 
but may rather be described as intermittent, being loudest during 
inspiration. This has been ascribed to an intra-thoracic suction-force 
which hastens the return-current of blood through the jugular veins 
during inspiration. Referring to the location of greatest distinctness of 
the systolic arterial bruit, we may again quote from the article above 
referred to. We there find it stated that “this area is located at the 
summit of the thorax in front, and the root of the neck over the carotid 
arteries.” The author would modify this statement only by noticing the 
fact that these hsemic systolic bruits of ansemia seem to be transmitted 
not infrequently up the carotid artery of one side only, and much oftener 
up the right than up the left side. 
Conclusions.—The important deductions from the foregoing statistical 
study of these vascular phenomena may be briefly summarized as follows: 
1. Hsemic bruits are rarely heard in healthy persons. 
2. They are not often heard in persons not showing a considerable 
degree of ansemia. 
3. They are heard in 90 per cent, of persons showing a well-marked 
degree of ansemia. 
4. They are, therefore, of great significance in the diagnosis of this 
condition. Tfye Jotirijal 
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