OHSU

Music of the Heart: Rhythms and Murmurs

The human heart begins to beat its lub-dub rhythm at approximately three weeks after conception when it is made up of approximately 40,000 cells. At this stage, the embryonic heart beats in rhythm with the mother's heart rate, beating at a normal rate of 70-80 beats per minute. As an infant grows the heart rate speeds to 120 beats per minute and slows once again as the child reaches young adulthood. From birth to death the heart pumps without cessation.

image001Original artwork by Clarice Ashworth Francone

 

However, one's normal heart rate has a "dance-like plasticity and variability," speeding up and slowing down. It does not beat in march-step or with any sort of regularity. Rather, it is constantly regulated by our nervous system. Movement or anxiety increases this rhythm, while meditation or slow breathing will slow its pace. It has also been shown that the heart is greatly influenced by music. Fast and syncopated music can speed the heart while soft and soothing melodies and rhythms can calm it.

Physician Luciano Bernardi and his team of researchers, at Italy's Pavia University, have found that "hearing swelling crescendos increased blood pressure and heart and respiration rates. It also narrowed the blood vessels under the skin. The opposite occurred during the slower passages and silent pauses…"

Students of medicine receive training in the art of listening to distinguish the sounds of the healthy heart from the sounds of the ailing heart. The sensitive ear hears the beat of the heart as two discrete sounds; the lub of the first heart sound: the closing of the mitral and the tricuspid valves, and then the dub of the second: the snapping close of the semilunar or aortic and pulmonic valves. When the heart is damaged, a murmur can be heard between these two beats.

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Immediate auscultation – Children's clinic: People's Institute, Portland, Oregon

When murmurs indicate a heart diseased, the terms describing the murmur are those also ascribed to music, such as, crescendo and decrescendo; and then graded by intensity in pitch, shape, quality, duration, and timing. Sir William Osler said "The practice of medicine is an art, based on science." It has been said that listening to the heart "is the art of the matter, individual skill and acuity of senses cannot be completely standardized," so rigorous training in listening to the heart is received in order to recognize the types and variations of disease of the heart.

The sick heart murmurs of its abnormalities and awakens the skilled physician to the ailing heart. An integral part of a physical examination is auscultation. Listening to the heart dates from as far back as Ancient Egypt where "audible signs of disease" were noted in manuscripts dated from the 17th century BC. The term auscultation derives from the Latin word auscultare, which is to listen. Physicians listened to the heart, the lungs and the gastro-intestinal system to determine a patient's state of health first by laying their hands and ears to the body of a patient, a practice known as immediate auscultation.

image005The practice of immediate auscultation continued broadly until 1819 when a young French physician, René-Théophile-Hyacinthe Laennec published his findings about his development of the monaural stethoscope. Laennec first rolled a piece of paper into a cylinder, placed one end to the patient's chest and held the other end to his ear and found that he was able to hear the actions of the heart more distinctly than the simple application of hand to the wrist or ear to the chest or back. By this means, Laennec was able to identify pathologies that before had been undetectable. He named his instrument the stethoscope, from stethos (chest), and skopos (examination).

image007Early monaural stethoscopes

The ever present modern binaural stethoscope with two ear pieces was invented in 1851 by Arthur Leared. The new standard instrument was perfected by George Cammann, whose design was commercially produced beginning in 1852. 

image009Binaural stethoscope used in pioneer days in Oregon

As early as 1872, the rhythms of the heart were recorded using electric wires attached to a patient's wrist. The technology was perfected throughout the early 20th century resulting in the electrocardiograph machine. The cumbersome machine has since been replaced by compact electronic devices that record the heartbeat on computers.

Before 1900 heart disease was little known, but with the onset of more sedentary lifestyles and poor eating habits, heart disease has increased. Medical science continues to research the causes and cures of heart disease by developing new tools and techniques that help to sustain the music of the heart.

Digitalis, derived from the foxglove plant, was discovered by William Withering in the late 18th century, and is widely used as an effective remedy for congestive heart failure. The first practical pacemaker, developed in 1950, regulated the heart rate for the heart that could no longer sustain its own natural rhythms. The first fully implantable pacemaker was implanted in a human in 1958. The first heart transplant performed in 1967 was done after years of research in immunology, which began in the late 1700's, and the discovery of immunosuppressant drugs.

To name just a few, Herbert Griswold, Charles Dotter, Melvin Judkins, Albert Starr and James Metcalfe were among the early innovators in cardiology at the University of Oregon Medical School. In the 1950's full time faculty members were few at UOMS. At the time, the school was staffed by volunteer "downtown practitioners" like Homer P. Rush in cardiology.

image011Herbert Griswold, MD

Herbert Griswold, who had trained with Helen Taussig and Richard Bing, initiated cardiac catheterizations at UOMS. By 1959 Griswold had replaced Dr. Rush as Chief of Cardiology. It was during this same decade that Charles Dotter and Albert Starr joined the staff. In the late 1950's, the NIH granted a substantial sum of money to Griswold, Starr and Dotter to support   the cardiac catheterization lab and research clinics.

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Charles Dotter, MD         A pioneer in the field of cardiovascular and interventional radiology, Charles Dotter (UOMS 1952-1985) introduced transluminal angioplasty in 1964. And pioneer Melvin Judkins (UOMS 1961-1970) developed a transfemoral technique for selective coronary arteriography in the mid-60's.             

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Melvin Judkins, MD

image017Albert Starr, MD   

In 1960, the first successful mitral valve replacement was performed by Albert Starr at the University of Oregon Medical School using the caged-ball artificial valve developed by Starr and Lowell Edwards.

image019 James Metcalfe, MD

In 1961, the Heart Research Laboratory was established, bringing together scientists and researchers from around the world. James Metcalfe joined the team of international clinicians, scientists and students in the new HRL in 1961 where his research concentration was in the area of cardiovascular physiology in pregnancy and oxygen supply to tissues. Because of his influence, research collaborations demonstrated the "virtues of interdisciplinary cooperation."

And so we continue to research and develop new techniques and tools that enable physicians to listen and to repair the music of the heart. Ongoing research continues at many centers around the world including the OHSU Heart Research Center. The HRC was founded in 1994 to bring together scientists and physicians throughout the University. Besides studying the origins of heart disease, teams of HRC scientists are making exciting discoveries in other areas that help to assure that the beat goes on.

The operation of nature consists of splitting the united or uniting the divided; this is the eternal movement of systole and diastole of the heartbeat, the inhalation and exhalation of the world in which we live, act, and exist. 

Johann Wolfgang von Goethe (1749 - 1832)

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Original artwork by Clarice Ashworth Francone