In cases of mitral obstruction . . . occasionally heard over the pulmonary area and below this region, for the distance of an inch or two along the left border of the sternum, and rarely over the lowest part of the bone itself, a soft blowing diastolic murmur immediately following or, more exactly, running off from the accentuated second sound, while the usual indications of aortic regurgitation afforded by the pulse, etc., are absent.
So to this day the Graham Steell murmur remains an early soft diastolic bruit heard at the upper left sternal edge in severe pulmonary hypertension, usually but not necessarily due to mitral stenosis. It is uncommon, occurring in 1-10% of patients with mitral stenosis, usually when pulmonary hypertension is severe. Although some authorities have disputed the origin of the murmur and attributed it to aortic regurgitation, modern diagnostic methods have largely confirmed its origin from the pulmonary valve.3
The man to whose name the murmur is irretrievably linked, Dr. Graham Steell, was born in Edinburgh in 1851 where he obtained his medical degree in 1872. He studied medicine and learned German in Berlin for one year and then became house physician at the Royal Infirmary of Edinburgh, where he acquired a lifelong interest in heart disease. In 1878 he moved to Manchester and spent an unusually long ten years as junior doctor in residence at the Royal Infirmary before becoming attending physician and later professor of medicine. A skillful clinician, he was unusually reserved and shy, spoke with a nasal twang, and was a poor communicator and awkward lecturer, once unkindly depicted in a cartoon as addressing an audience of only three students. Although he was productive, publishing some 50 medical papers and a textbook of heart disease, he seems “to have made little impact on the emergence of modern cardiology.” He retired in 1911 and, despite a full array of medical illnesses throughout his life, lived to the ripe old age of 91.1
Dr. Steell listened to his patients through a large bell earpiece attached to an unusually long wooden monaural stethoscope. Dedicated, highly experienced, and hard-working, he belonged to a generation to whom no other diagnostic aids were available. In old age, some 140 years ago, he wistfully predicted that clinical medicine was in danger of losing some of its charm. His association with the murmur is fortuitous, an example of eponymous serendipity and of “the process of collective negotiation and judgment which leads to immortality for a select handful of doctors.”1
- A. G. Fraser and C. F. Weston, “The Graham Steell murmur: eponymous serendipity,” Journal of the Royal College of Physicians of London 25 (1991): 66.
- K. E. Cohn and H. N. Hultgren, “The Graham-Steell murmur re-evaluated,” New England Journal of Medicine 274 (1966):486-489.
- J. D. McArthur and I. P. Sukumar, et al., “Reassessment of Graham Steell murmur using platinum electrode technique,” British Heart Journal 36 (1974) :1023-1027.
George Dunea, MD, Editor-in-Chief