THE INNOCENT(FUNCTIONAL) CARDIAC MURMUR IN CHILDREN

VOLUME 19 MAY 1957 NUMBER 5

T LW DEVELOPMENTof modern cardiac surgical techniques is one of the great milestones in medicine. Its ramifications

have been wide and deep. In its wake of many curative and palliative procedures for congenital and acquired heart disease, there is a renewed interest in the signifi cance of the cardiac murmur. In former years tile murmur was merely noted. Today, it is pursued until its etiology is firmly

estal)lished with the hope that tile final

investigation will lead to remedial or pallia

tive surgery. Many times the murmur turns

out to be a functional one. This has prompted the physician to pose questions

concerning tile incidence and characteristics

of the innocent or functional systolic mur

mur, especially in cilildren. The answer is not readily obtained.

REVIEW OF THE LITERATURE

The accepted definition1 has been listed as, “¿Innocent(functional) murmurs are

usually systolic in time, more often faint

than of moderate intensity and usually

(Submitted July 19, accepted October 17, 1956.)

blowing in quality. They are often incon stant and vary in intensity with cilange in posture. Tile commonest is a systolic mur mur at the pulmonic area, which is usually

best heard with the patient supine and

during expiration. An apical systolic mur

mur is also common. Such murmurs are

unaccompamed by any evidence of struc

tural disease such as an enlargement of the

heart, abnormal cardiac silhouette on roent genologic examination or an abnormal

electrocardiogram.― It is the author's O@iIl

ion that this general definition is not spe

cifically descriptive for children; the com monest functional murmur in cilildren is not located in the pulmonic area, it is not

blowing, and further, an innocent apical systolic murmur is uncommon.

The recently published Jones Criteria (Modified) for Guidance in Diagnosis of

Rheumatic Fever2 states “¿aninnocent (func tional) murmur is systolic, occasionally harsh, is heard best along the left sternal border and usually changes with position and respiration.― (The American Heart As

This work was motivated during tenure as Assisting Physician, New Haven Rheumatic Fever and CardiacProgram,Departmentof Pediatrics,Yale UniversitySchoolof Medicine,from 1952 to present. The case material was from the Stamford Hospital Cardiac Clinic.

ADDRESS: 1380 Bedford Street, Stamford, Connecticut.

793

Pediutrics

ARTICLES

THE INNOCENT(FUNCTIONAL)CARDIACMURMUR

IN CHILDREN

By David H. Fogel, M.D.

sociation has recommended the term “¿in nocent murmur―be used in place of―func tional―or “¿physiologic―murmur.1)

A review of the American literature for the past 15 years reveals a paucity of clini cal papers on the incidence and characteris

tics of this murmur. These few papers

generally concede that the murmur does

not possess a pathognomonic feature that can distinguish it from an organic murmur. No doubt, this accounts for the wide dis crepancy in studies reporting the prevalence of these murmurs in normal children. Some studies35 reveal that 8 to 20% of all children of school age present these murmurs. In

other cases68 innocent systolic murmurs were found in 44 to 61% of the children examined. In the resting state, Schwartz mann7 found an incidence of 44% which increased to 86.6% after vigorous exercise.

Reporting on the physical findings, fluor oscopy and electrocardiograms of 260 pre sumably normal infants and children ob

served during the first 14 years of life, Epstein9 noted precordial murmurs in 50%

which were indistinguishable from those of

mitral insufficiency. Messeloff'° attempted

to analyze the characteristics of the inno cent systolic murmur in 300 children and concluded there was no single criterion for

differentiating the systolic murmur as func tional or organic.

FOUR INNOCENT SYSTOLICMURMURS

One finds that there are four innocent

systolic murmurs. It is the failure to recog

nize this which perhaps causes some un

certainty about the entire subject of the in nocent murmur.

Almost a half-century ago, Still11 de

scribed an innocent systolic murmur which he labelled “¿physiologicalbruit.―The latter was usually heard just below the level of

the nipple in approximately the left para sternal line. It was mostly found in children between the ages of 2 and 6 years. Still de scribed it as variable in audibility and not audible in the axilla. The murmur would

disappear in months or years. Its character istic feature was noted as a twanging sound,

very much like that made by twanging a

piece of string.

Harris et al.12 took photocardiographic tracings in children with “¿twanging-string―

systolic murmurs. These tracings revealed a

uniform wave pattern without overtones in contrast to those of mitral insufficiency which revealed an irregular pattern. Other

non-blowing (innocent) murmurs which

were described as snorting, scraping and

grating also revealed the same pattern of

the “¿twanging-string― murmur. Tile latter

pattern is not produced by the vibrations

of a string. Harris showed that tile pattern

of the “¿twanging-string―murmur is pro

duced by the vibrations of a solid structure,

such as a tuning fork. Therefore, ile sug gested that the term “¿vibratory―be used in place of “¿twanging-string―to describe this innocent systolic murmur.

In his recent comprehensive publication, Rhodes@3 found the systolic vibratory mur mur to be the most common innocent mur

mur in childhood. It may be heard in infancy but it becomes prominent after 2 or S years of age, being most characteristic be tween S and 7 years. Its incidence gradually

decreases toward adolescence. This is the

murmur the child “¿growsout of.―Lynxwiler

and Donohoe'@ describe this innocent sys

tolic murmur as groaning in quality, not harsh or blowing. Taussig15 also has re

ported that a loud innocent murmur has a

groaning quality.

The following are the characteristics of

the vibratory murmur, as described 1w

Rhodes: 1) Its point of maximal intensity is in the third or fourth interspace to the left of the sternal border and can be transmitted along the sternal border. Sometimes the point of maximal intensity lies between the sternum and apex of the heart. 2) The inten sity varies between Grade I and Grade III,

most commonly Grade II (on a range of I to

VI) and the intensity varies with position, tending to decrease in the erect position. 3)

The pitch is medium. 4) The duration is

brief, occupying the first one-half or two

thirds of systole.

heard where there is an abnormal configura

tion of the chest (pectus excavatum) and

abnormal cardiac position (dextrocardia

with levoposition, mediastinal displace

ment). Discussing the diagnosis of rheuma tic fever, Cassals15 described an innocent systolic murmur in childhood as having its maximal intensity in the right and rarely

in the left supraclavicular area, radiating

down the left sternal border. He believes that this innocent systolic murmur is extra cardiac and is an attenuated remnant of

a supraclavicular murmur, diminishing or

disappearing with local neck pressure or change of head position.

The above description conforms to the characteristics common to the innocent systolic murmur over the base or puimonic area. In the experience of Rhodes,― Whitte

more'6 and the author, this is the second

most common innocent murmur in children. It is a short, blowing murmur which varies

in intensity from a Grade I to Grade III, usually being Grade II. It is transmitted

parasternally and toward the apex. Tile

second pulmonic sound is always normal.

This murmur also varies in intensity with

change in position and with foilow-up ex

amination. It is often accentuated by ex ercise. More commonly, it is found in the teen-ager.

Tile third innocent murmur is the cardio respiratory. It is infrequently encountered in children. This has been defined' as usu ally ileard at the apex or over the body of the heart at the margins of the lung. It is almost always systolic in time and varies in intensity during the phases of respiration. Inspiration sometimes decreases or abol ishes it. Norris and Landis'7 describe this murmur as an interrupted or abnormal breath sound produced by the movement of the heart upon the surrounding lung tissue. It is not accurately synchronous with the heart, but often appears in the middle of systole, being distinctly separated from the first sound. It often begins and ends sud denly and is sharply localized and seems close to the ear of the examiner as a high pitched, short squeal.

may be transmitted to the axilla. Ausculta tion witil the patient in the left lateral posi tion will reveal that the vibratory murmur

still has its maximal intensity at the sternal

margin. This finding has prompted Rhodes'

contention that innocent systolic murmurs

111 children with maximal intensity at the

apex are so rare that they should be con

sidereci organic until proven otherwise. Rhodes uses the term parasternal systolic

murmur to describe the innocent vibratory murmur. For the sake of clarity and validity, the vibratory murmur can be designated

parasternal-precordial, since most of the

troublesome murmurs which must be dif

ferentiated from mitral insufficiency, on the

basis of acoustic quality rather than point of maximal intensity, are mid-precordial.

In stating the difference between inno

cent and organic systolic murmurs, two

misconceptions should be corrected. It is

sometimes believed that an innocent mur

mur disappears after exercise while an

organic murmur becomes louder. The cx perience of Whittemorel and Rhodes5 definitely disproves this statement. It was found that most innocent systolic murmurs increased in intensity with exercise. Tile

otiler misconception is judging the signifi caiice of murmurs by their intensity. In

children a typical murmur of mitral in stiffic@encv may be Grade I, while a vibra tory murmur may be Grade III or some times even Grade IV. Taussig15 has found

that “¿achild with a normal heart may have

an extraordinarily loud functional murmur.― Whittemore@ has observed in some thin, younger children on long-term follow-up that these innocent murmurs can be trans mitted to tile infrascapular, rarely inter scapular areas.

A fourth innocent systolic murmur is the so-called hemic murmur which usually re

sembies the innocent pulmonic systolic mur

mur. It is apparently due to the anemia and poor papillary muscle tonus resulting from

anoxia. This latter may also explain the in nocent apical systolic murmur seen in fe brile states not associated with cardiac

enlargement or dilatation. The hemic mur mur may also be due to the increased vel ocity of blood flow accompanying febrile and anemic states.

Although the venous hum should not be

mistaken for a systolic murmur, it may be

worthwhile to draw attention to this inno cent phenomenon. It is a common occur rence in childhood and is a continuous mur mur with a diastolic accentuation. It is heard to the right of the sternum as well as the left, beneath the clavicle. Frequently, it is heard better in the supraclavicular

fossa, varying between Grades I and III;

and is often high-pitched. It is louder in the erect position than in the supine. Char acteristically, the diastolic component dis appears in the supine position. The pul monic first and second sounds can be heard to have good quality above the background of tile venous hum. The cardinal feature of the venous hum is its decrease in intensity or disappearance with rotation of the head or pressure over the neck veins.

DIFFERENTIAL

DIAGNOSISOF THE

INNOCENTSYSTOLIC

MURMUR

Most pediatric cardiologists are in agree ment that the innocent systolic murmur is mistaken most often for the murmur of mitral insufficiency. The latter murmur is typically blowing with maximal intensity at the apex and transmitted to the axilla. It is a high-pitched murmur frequently heard best with the diaphragm. As a rule the first heart sound is muffled, usually con

sidered another indication of valvular

damage. In the left lateral supine position, innocent parasternal-precordial murmurs are still heard best at the sternal border or medial to the apex. This difference in loca tion of the maximal intensity of the murmur in the left lateral supine position is a great

aid in differential diagnosis. The above characteristics of the murmur of mitral in sufficiency conform to the description given in Jones Criteria (@‘Iodified)@for the apical systolic murmur of rileumatic heart disease which states, “¿Asignificant systolic murmur is long, filling most of systole; is heard best at the apex; is well transmitted toward the axiila as over the precordium; and does not change with position or respiration.―

The systolic murmur of various congenital defects can be confused with the innocent.

A knowledge of the pathology of congeni

tal heart disease is essential in interpreting the various murmurs produced. These mur murs can often be differentiated from the innocent murmur by auscultation. In many instances, even the pediatric cardiologist requires the aid of history, electrocardio gram, fluoroscopy and sometimes physio logic data such as those obtained from

cardiac catheterization. The more common

congenital heart diseases whose murmurs can be differentiated from the innocent murmur will be discussed.

The murmur of congenital heart disease which is most easily confused with an inno cent murmur is that of an interatrial septal defect. This murmur has a blowing quality and is transmitted high into the posterior thorax. This transmission is a useful point of differentiation from an innocent murmur. In this malformation the second sound over the pulmonic area is usually more widely split than in normal children. The typical electrocardiogram in patients with an in teratrial septal defect reveals incomplete right bundle branch block. Fluoroscopy usually reveals a small aorta, prominent and active pulmonary arteries, large right auricle and right ventricle. On occasion, all findings are equivocal and cardiac cathe terization must be performed.

pared to the high posterior chest referral of the murmur of interatrial septal defect. In young children the murmur may eXilibit also bone conduction (audible over the

acromium and olecranon). Invariably, there is a systolic thrill.

The murmur of pulmonic valvular steno sis SilOtil(1 cause 110 difficulty. This murmur

is usually Grade III or louder, maximal

over the pulmonic area, and louder in the first interspace than in the third. It is transmitted along the left clavicle and may

present bone conduction. It is usually ac

companied by a systolic thrill. The second soun(l over the pulmonic area may be di minished and pure but usually it is absent. Congenital suhaortic and aortic stenosis

produce rough systolic murmurs ileard best

over the aortic area, upper part of the

sternum, and suprasternal notch with trans

mission into tile neck. Such murmurs also exhibit bone conduction and are as sociated with thrills, felt best in or just above the suprasternal notch. Determina tions of blood pressure will reveal a narrow pulse pressure.

Coarctation of the aorta may produce a systolic murmur over the base. Usually, it is best heard at the level of the fifth left rib posteriorly. There is a sudden diminution in intensity of this murmur as one descends

tile paravertebral column. In all children

with cardiac murmurs palpation of the femoral arteries should be done. If the pulsations seem diminished, blood pressure sllould be taken in one leg as well as both arms. This simple and definitive procedure makes the diagnosis of coarctation of the aorta the easiest of all the structural defects to establish.

CLINICAL STUDY

In seeking further clarification of the character and incidence of innocent mur murs, the author reviewed the records of all children referred to a cardiac clinic, sponsored by a privately endowed com

munity hospital. This was a clinical study

without confirmation by information ob

tained at necropsy. This community cardiac clinic serves a population of about 85,000

and examines any indigent or private pa tient upon referral by a physician. The pro fessional caliber of this clinic was approved by the American and Connecticut Heart Associations in accordance with “¿Recom mended Standards and Minimum Require ments for Cardiovascular Clinics,― 1949.

One hundred one patients in the pediatric

age group (less than 14 years of age) have

been examined. Sixty-three (62.5%) were re ferred because of cardiac murmurs; 32

(51.7%)

werereferredbecause

of rheumatic

fever or rheumatic heart disease; 4 (3.9%) were referred because of congenital heart disease, and 2 (1.9%) for cardiac enlarge ment and chest pain, respectively. Each pa tient was evaluated with respect to clinical history, physical examination, fluoroscopy, electrocardiogram, pertinent laboratory data and follow-up examinations. Table I summarizes all the final diagnoses. Of the 10 patients listed as having rheumatic fever, 7 had innocent murmurs. This would make the actual incidence of innocent murmurs 60.4% of all children referred for cardiac evaluation. The diagnoses listed under con genital heart disease were invariably con firmed or made at the clinic of the New Haven Rheumatic Fever and Cardiac Pro gram, Yale University School of Medicine.

Table II presents an analysis of the un

complicated innocent murmurs studied in 54 pediatric referrals.

In explanation of Table II it should be noted that the data were compiled from the first cardiac examination. Each patient was observed until the diagnosis was firmly established. In almost all cases observation was made over several years. In this interim the murmur varied between Grade I and Grade II in intensity, occasionally Grade III. Uniformly, all these murmurs, includ ing those described as of maximal intensity at the apex, at some time showed variability with positional change; i.e., the murmur

would disappear or become considerably

.VumherPer

(‘en!Site

of maximal

intensityApex611.1Pulmonic area71@2 .9Left

third intercostal space16@9.7Left

fourth intercostal space@546.3I'ransmissionFrom

apex——all transm,mittedalong

left sternal border61(X)Frons

pulmonic arealocalized571.4down

left sternal border@2‘28 .6Left

third intercostal space

localizedI6.'2along left sternal border1381.3toaxilla1@.5Left

fourth intercostal space —¿localizedH48down

left sternal border1352

companied by a thrill nor is it transmitted into the back. However, Whittemore― has found that a loud innocent murmur can be transmitted into the hack. In the New Haven, Connecticut school system Sile ex @

@ amined 1,766 children \vitil cardiac muir

murs. Among these, 169 cases were diag

0.9 nosed as interventricular septai defect. This 9.9 diagnosis was based primarily upon tile 14.9 detection of a left parasternal Grade Il-Ill

systolic murmur, often harsh and invariably

(5) transmitted to the interscapular and/or sub

(1) scapular regions. Three years later, 89 of

(@) these 169 children were re-exammeci, fluoro

16 9 scoped and had repeat electrocardiograms.

It was found that approximately 75% had

(1) an innocent murmur after this re-evaluation.

(3) In this group the murmur had in many

(@) cases disappeared or there was variability

(1) with position and respiration. In most cases

(1) where the murmur persisted, posterior re

ferral was now absent. In the few cases

(1) where it persisted, it was faint and often (1) referred to the subscapular region. The (1) remaining children who were diagnosed as

having interventricular septal defects had

systolic thrills. It was thought that tile

TABLE II

INNOCENT SYSTOLiC MURMIRS IX 54 PEnIATIII( PATIENTS REFERRED FOR (‘aiwrar E VAIL ATION

TABLE I

I)IAGN0SIS OF 101 PEDIATRIC PATIENTS REFERRED FOR CARDIAC EVALUATION

.‘,umberPer Cent

Iuiioeiit@uurinurs 54

No cardiac (lisease or murmur* 4

Probable rlietit,iziti fevert I

Rheut,s@itie fever** 10

Rheumatic lien rt (lI5e95C 15 a) Hill), ML

1)) RilI), MS

(@) Itlit) ML, MS (1) RIlI), Ml, Al

e) RIID, Ml, AS

1) RIli), Ml, MS, Al

Congemtal heart disease 17 a) Ventricular septal (lefect

1)) Probably ventricular .septal defect

c) Atrial septal defect

il) Sub-aortic stenosis

e) Pure pulmonic stenosis

f) Pulmonic valvular stenosis and ven tricular septal (lefect

g) Patent ductus arteriosus and coarcta

tion of aorta h) Cyanotic, unclassified

i) Congenital atrioventricular block, coiiiplete@

* In addition to negative history, physical examina

tion and laboratory data, no murmur was heard. t There was a total of four cases of probable rheu matic fever with innocent murmurs. Three cases were listed under the latter category.

** Seven of these had innocent murmurs. These were

not listed under innocent murmur. @ Listed under innocent murmur.

murs were encountered in this group of patients.

The innocent systolic murmur over the pulmonic area was found to be blowing in quality. It was observed in seven children at the ages of 6, 6, 8, 9, 11, 13 and 14 years. This innocent pulmonic murmur comprised

12.9% of all the innocent murmurs.

majority of these patients initially diagnosed as having interventricular septal defects were tall, thin-chested children between the

ages of 7 and 10 years. Subsequent growth

of tile child altered some of the characteris tics of the murmur. It is interesting to note that Whittemorel6 found the incidence of innocent murmurs to be 60.8% in those 1,766 school children diagnosed as having cardiac murmurs by the private or school physician.

DISCUSSION

The most prevalent cardiac sign in chil dren, tile innocent systolic murmur, has

been the focus of many varying opinions.

Because of renewed interest, more informa tive ol)servations are now finding their way into the literature. As a result, there are ob tained more consistent criteria for the mci

dence and characteristics of this murmur.

One deduces from the available studies that there are four types of innocent systolic murmurs; viz., tile parasternal-precordial, the pulmonic, the cardiorespiratory and the hemic. The latter two are infrequent in

childhood.

In the author's series, of the 101 patients less than 14 years of age, 54 (53.5%) children had uncomplicated innocent systolic muir murs. Seven children with a history of rheu matic fever also had an innocent systolic murmur which would make the murmur's total incidence 60.4%.

Of the uncomplicated innocent systolic murmurs, the site of maximal intensity was at the apex in 6 cases (11.1%), at the pul monic area in 7 (12.9%), and in the third and fourth intercostal spaces at the left sternal border in 41 cases (76%). No cardiorespira tory murmurs were noted.

To discharge a patient with an innocent systolic murmur from further cardiac follow-up, the following criteria are used:

Negative clinical history.

Typical characteristics of an innocent

systolic murmur.

Normal cardiac size and contour by

roentgenogram and/or fluoroscopy. Normal electrocardiogram.

CONCLUSIONS

The most common murmur in childhood is the innocent systolic murmur.

There are four types of innocent sys tolic murmurs; the “¿vibratory―parasternal precordial, the blowing pulmonic, the car diorespiratory, and the hemic.

The “¿vibratory―parasternal-precordial

systolic murmur is the most common in

childhood. The blowing pulmonic systolic murmur is next in frequency and tends to

become more prevalent in tile teen-age

group as the “¿vibratory―parasternal-pre cordial murmur decreases in incidence.

In the author's series of 101 children referred with suspected organic heart dis ease, the incidence of innocent systolic mur

murs was 60.4% which included seven cases in which there was a history of rheumatic

fever.

ACKNOWLEDGMENT

The author wishes to express appreciation to Drs. Ruth Whittemore, Richard J. Waters and Harold M. Marvin for their suggestions and comments.

REFERENCES

1. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Blood Vessels, 5th Ed. New York, New York

Heart Assn., 1953, p. 27.

2. Jones criteria (modified) for guidance in diagnosis of rheumatic fever. Mod. Con cepts Cardiovas. Dis., 24:291, 1955.

3. Rauh, L. W.: Cardiac murmurs in chil

dren. Ohio State M. J., 36:973, 1940.

4. Sampson, J. J., Hahman, P. T., Halverson,

W. L., and Shearer, M. C.: Incidence of

heart disease and rheumatic fever in

school children in three climatically

different California communities. Am. HeartJ., 29:178, 1945.

5. Wilson, May G.: Rheumatic Fever. New York, Commonwealth Fund, 1940, p. 390.

6. Davison, W. C.: The Complete Pedi atrician: Practical, Diagnostic, Thera peutic, and Preventive Pediatrics for the

Use of Medical Students, Internes, Gen

7. Schwartzmann, J. : Cardiac status of ado

lescents. Arch. Pediat., 58:443, 1941.

8. Friedman, S., Robie, W., and Harris,

T. N. : Occurrence of innocent adventi

tious cardiac sounds in childhood. PE

DIATBICS, 4:782, 1949.

9. Epstein, N.: Heart in normal infants and children; incidence of precordial systolic murmurs and fluoroscopic and electro cardiographic studies. J. Pediat., 32:39, 1948.

10. Messeloff, C. R.: Functional systolic mur

murs in children. Am. J. M. Sc., 217:71,

1949.

11. Still, C. F.: Common Disorders and Dis

eases of Childhood, 3rd Ed. London,

Oxford, 1918, p. 495.

12. Harris, T. N., Friedman, S., and Haub,

C. F.: Phonocardiographic differentia

tion of murmur of mitral insufficiency

from come commonly heard adventitious

sounds in childhood. PEDIA'rmcs, 3:845,

1949.

13. Rhodes, P.: Diagnosis of innocent heart murmurs in children. Bull. Denver

Rheumat. Fever Diagnostic Service,

Feb. 1955.

14. Lvnxwiler, C. P., and Donahoe, J. L.: Evaluation of innocent heart murmurs.

South. M. J., 48:164, 1955.

15. Taussig, H. B.: Congenital Malformations

of the Heart. New York, Commonwealth Fund, 1947, p. 398.

16. Whittemore, Ruth: To be published. 17. Norris, C. W., and Landis, H. R. M.: Dis

eases of the Chest, and the Principles

of Physical Diagnosis., 6th Ed. Philadel phia, Saunders, 1938, p. 293.

18. Cassals, D. E.: Diagnosis of rheumatic

fever. Ped. Clin. North America, p. 251, 1955.

SUMMARIO IN INTERLINGUA

Murmures Cardiac Innocente

(Functional) in Juveniles

A causa del successos de palliation e cura effectuate per moderne technicas de chirurgia cardiac, ii existe un nove interesse in murmu res cardiac. In juveniles le innocente murmure systolic es le plus frequente forma de murmure.

Le thema del murmure innocente es un pauco

confuse proque il es non semper recognoscite

que quatro typos de innocente murmure sys tolic debe esser distinguite.

Le murmure parasternal-precordial es le plus commun murmure in juveniles. Illo es un

murmure non-sufflante. Illo es describite usual

mente como un murmure vibratori. Su locol de

intensitate maximal es in le tertie o quarte in

terspatio sinistre, e illo pote esser transmittite al longo del margine sternal. In certe casos le puncto del intensitate maximal se trova inter le

sterno e le apice. Le intensitate u'aria inter

grado I e grado III (in un scala ab I a VI).

Crado II es le plus usual. Le intensitate varia con le position del subjecto. Illo tende a de crescer in position erecte. Le duration es breve,

le altor medie. Iste murmure se trova sporadi

camente ill infantes. Su occurrentia charac

teristic es in juveniles de inter S e 7 annos. Verso le etate de adolescentia sui incidentia se

reduce gradualmente.

Le murmure systolic pulmonic ha le secunde

rango de frequentia in juveniles e le prime in adolescentes. Illo es breve, de qualitate suf flante, e usualmente de grado II in intensitate.

Le intensitate maximal se trova in le secunde

interspatio sinistre al margine sternal. Jib varia con position e respiration e ill certo casos illo se radia verso le apice. Ilbo es etiam audite in

anormal configurationes thoracic (pectore ex cavate) e in anormal positiones cardiac (dex

trocardia con levoposition, displaciamento

mediastinal)

-Le murmure cardiorespiratori es trovate in frequentemente in juveniles. JIb es audite usualmente al apice o supra Ic corpore del corde al margines del pulmon. Jib es quasi

semper systolic e varia in intensitate con le

respiration. Ilbo pare esser locate proxime al aure del auscultator e ha be appareiltia de Ufl breve e altisonante crito.

Le si-appellate murmure hemic resimila usualmente le innocente murmure systolic puil

monic. Illo es apparentemente causate per le anemia e be inadequate tono del muscubo papil

lan que es le effectos de anoxia. Jib pote etiam resultar del accelerate fluxo de sanguine ill

statos febril e anemic.

In be serie del autor, consistente de 101

patieilteS ill le gruppo pediatric (i.e. de etates

de minus que 14 annos de etate), 54 (53,5%) habeva noncomplicate innocente murmures systolic. Septe patientes con un historia de febre rheumatic etiam habeva un innocente murmure systolic. Isto augmentarea le inciden tia del murmure a 60,4%.

Inter be noncomplicate inriocente murmures

systolic, be sito del intensitate maximal esseva be

apice in sex casos (11,1%), le area pulmonic in

1957;19;793

Pediatrics

David H. Fogel

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