Pediutrics

VOLUME 19 MAY 1957 NUMBER 5

ARTICLES

THE INNOCENT(FUNCTIONAL) CARDIACMURMUR IN CHILDREN

By David
Pediatric Cardiac Clinic,

H. Fogel,

M.D.
Stamford, Connecticut

Stam ford hospital,

LW DEVELOPMENT of modern
surgical techniques

cardiac

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
investigation

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

with
will

the
lead

hope

that

tile

final turns

heart, abnormal cardiac silhouette genologic examination or an

electrocardiogram.

on roent abnormal
O@iIl

to remedial

or pallia

It is the author's

tive surgery.

Many

times

the murmur

ion that this general

monest functional

definition

is not spe
is

out to be a functional one. This has prompted the physician to pose questions
concerning mur, tile incidence and characteristics

cifically descriptive for children; the com

murmur in cilildren

not located in the pulmonic area, it is not

is

of the innocent
especially

or functional
in cilildren.

systolic mur
The answer

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

The recently (Modified) for published Guidance in

apical

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.)
This work was motivated during tenure

Jones Criteria Diagnosis of

Rheumatic Fever2 states an innocent (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

as Assisting Cardiac

Physician, Clinic.

New

Haven

Rheumatic

Fever

and

CardiacProgram,Departmentof Pediatrics, YaleUniversity Schoolof Medicine, from 1952 to present.

The case material was from the Stamford Hospital

ADDRESS:1380 Bedford Street, Stamford, Connecticut.

793

794
sociation has

FOGEL recommended

INNOCENT the term

CARDIAC

MURMUR

in very much

like that made

by twanging

nocent murmurbe used in place offunc piece of string. Harris et al.12 took photocardiographic tional or physiologic murmur.1)
A review cal papers of the American on the incidence literature for tracings uniform contrast in children with twanging-string

the past 15 years reveals a paucity of clini

and characteris

systolic murmurs.

These tracings revealed

tics

of this

murmur.
that

These
the

few
murmur

papers
does

wave pattern without to those of mitral

overtones in insufficiency

generally

concede

which revealed an irregular pattern. Other

non-blowing (innocent) murmurs which were described as snorting, scraping and

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

grating
the

also revealed is not produced

Harris

the same pattern

Tile

of

twanging-string murmur. showed that

latter

pattern

by the vibrations
tile pattern

of a string. duced

of the twanging-string murmur

by the vibrations

is pro

other cases68 innocent

were found

systolic murmurs
children

of a solid structure,

in 44 to 61% of the

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

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

which were indistinguishable

insufficiency.

from those of
attempted

Messeloff'

years of age, being most characteristic be tween S and 7 years. Its incidence gradually

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

decreases
murmur

toward
the child

adolescence.

This is the sys

grows out of.Lynxwiler

and Donohoe'@ describe

this innocent

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
causes subject some un of the in nize this which perhaps certainty about the entire nocent murmur.

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

ported

that a loud innocent

murmur

has a
of 1w

groaning quality.
The following are the characteristics the vibratory murmur, as described

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,

Almost a half-century

ago, Still11 de

scribed an innocent systolic murmur which he labelled physiological bruit.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

most commonly

Grade II (on a range of I to

scribed it as variable in audibility and not

audible in the axilla. The murmur would

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
thirds of systole.

the first one-half the vibratory

or two murmur

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

Very infrequently

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

795
configura
and of the chest (pectus excavatum)

heard where there is an abnormal

tion with

abnormal

cardiac

position
mediastinal

(dextrocardia
displace

still has its maximal intensity

margin.
111 children

at the sternal
Rhodes'

levoposition,

This finding
with

has prompted

contention

that innocent
maximal

systolic
intensity

murmurs
at the

apex are so rare that they should

sidereci Rhodes organic uses the until term

be con

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

proven otherwise. parasternal systolic

murmur to describe the innocent vibratory murmur. For the sake of clarity and validity, the vibratory murmur can be designated
parasternal-precordial, troublesome murmurs ferentiated from mitral since most which must insufficiency, of the be dif on the

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

basis of acoustic quality rather than point of maximal intensity, are mid-precordial.
In stating the difference between inno

disappearing with local change of head position. The above description characteristics common systolic murmur over the area. In the experience of
more'6 and the author,

neck pressure

or

conforms to the to the innocent base or puimonic Rhodes, Whitte

this is the second

cent

and

organic believed

systolic
be

murmurs,
corrected. while

two
It is

misconceptions

should after

sometimes
mur

that an innocent
exercise

mur
an

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

disappears

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

parasternally
second change

and

toward
sound and

the

apex.

Tile with
ex

pulmonic in position

is always with

normal.

This murmur

also varies in intensity

foilow-up

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 a child 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. The configuration of tile body seems to play a significant role in the prevalence and/or cause of the innocent murmur. Norris and Landis17 state that this murmur is common in children and in flat-chested individuals, apparently because little lung tissue intervenes between the pulmonary conus and the sternum, so that a slight dis tortion of the vessels results. It is also

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.

796

FOGEL

INNOCENT

CARDIAC

MURMUR

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

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, A significant 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

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;

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

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 DIAGNOSIS OF THE INNOCENT SYSTOLIC 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

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. Interventricular septal defects produce murmurs which may also be confused with loud innocent murmurs. This defect usually produces a loud, harsh murmur transmitted over the entire precordium and heard best to the left of the sternum in the third inter space or lower. It is also transmitted into the mid- or low-interscapular area as com

ARTICLES 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). is a systolic thrill. Invariably, there

797

The murmur of pulmonic valvular steno sis SilOtil(1 cause 110 difficulty. This murmur
is usually Grade III or louder, maximal

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

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

been examined. ferred because

Sixty-three (62.5%) were re of cardiac murmurs; 32

(51.7%) werereferred because 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

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 trans

over

the

aortic

area,

upper
notch

part
with

of the

sternum,

and suprasternal

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 without hospital. This confirmation was a clinical by information study ob

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

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

less intense in the erect position. On follow up examination, the few apical innocent murmurs would invariably be found to have their maximal intensity in the third or fourth left interspace. No cardiorespiratory mur

798

FOGEL TABLE I

INNOCENT

CARDIAC

MURMUR

I)IAGN0SIS

OF 101

PEDIATRIC

PATIENTS

REFERRED

FOR CARDIAC

EVALUATION

.,umberPer Cent

Iuiioeiit @uurinurs No cardiac (lisease or murmur*

Probable rlietit,iziti fevert

54 4
I 0.9 9.9 14.9

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.
nosed diagnosis detection

Among
was of

these,
based a left

169 cases
septai primarily

were
defect. upon Grade

diag
This tile Il-Ill

as interventricular

Rheut,s@itie fever** Rheumatic lien rt (lI5e95C a) Hill), ML

1)) RilI), (@) Itlit) MS ML, MS

10 15

parasternal

systolic murmur,
(5) (1) transmitted scapular to the regions.

often harsh and invariably

interscapular Three years and/or later, sub 89 of

(1) RIlI), Ml, Al

e) RIID, Ml, AS

(@)
16 9

these
scoped

169 children
and had

were re-exammeci,
repeat electrocardiograms.

fluoro

1) RIli), Ml, MS, Al

Congemtal heart disease 17 a) Ventricular septal (lefect 1)) Probably ventricular .septal defect
c) Atrial septal defect

It was found
(1)
(3)

that approximately
the murmur had

75% had
in many

an innocent
In this

murmur

after this re-evaluation. or there

respiration. persisted,

group

il) Sub-aortic stenosis

e) Pure pulmonic stenosis f) Pulmonic valvular stenosis tricular septal (lefect g) Patent ductus arteriosus and ven

(@)
(1) (1) and coarcta (1)

cases
with where

disappeared
position the and murmur

was
In

variability
most cases re

posterior

ferral
where referred remaining (1) (1)

was now absent.

it persisted, to the children it was subscapular who

In the few cases

faint and region. diagnosed often The as

tion of aorta h) Cyanotic, unclassified i) Congenital atrioventricular coiiiplete@

* In addition to negative history,

block,

were

having
physical examina

interventricular

septal

defects

had

systolic

thrills.

It was

thought

that

tile

tion and laboratory

data, no murmur

was heard. Three cases were

INNOCENT These were PATIENTS SYSTOLiC REFERRED

t There was a total of four cases of probable rheu

matic fever with innocent murmurs. listed under the latter category.
** Seven of these had innocent

TABLE II
MURMIRS IX 54 PEnIATIII( FOR (aiwrar E VAIL ATION

murmurs.

not listed under innocent murmur. Listed under innocent murmur.

(en!Site

.VumherPer

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.

intensityApex611.1Pulmonic of maximal area71@2 .9Left space16@9.7Left third intercostal space@546.3I'ransmissionFrom fourth intercostal

transm,mittedalong apexall border61(X)Frons left sternal arealocalized571.4down pulmonic .6Left left sternal border@228

In the author's series there were three cases where a loud (Grade III) innocent systolic parasternal-precordial murmur was transmitted into the back. These murmurs were not accompanied by thrills. In his comprehensive article, Rhodes13 does not mention this phenomenon. Taussig'5 states than an innocent murmur is seldom ac

third

intercostal

space

localizedI6.'2along border1381.3toaxilla1@.5Left left sternal localizedH48down fourth intercostal space

left sternal border1352

ARTICLES
majority as having of these patients initially septal diagnosed defects

799 CONCLUSIONS

interventricular

were tall, thin-chested

ages of 7 and 10 years.

children between
Subsequent

the

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.

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

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

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

tained more consistent

dence and characteristics

criteria

for the mci

murmur.

of this

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

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
roentgenogram and/or

REFERENCES
1. Nomenclature
of Diseases

and Criteria for Diagnosis

of the Heart and Blood

Vessels, 5th Ed. New York, New York

Heart Assn., 1953, p. 27.

2. Jones criteria (modified) for guidance

diagnosis of rheumatic fever. Mod. Con

in

cepts Cardiovas. Dis., 24:291, 1955.

3. Rauh,
4. Sampson,

L. W.:

Cardiac

murmurs

in chil

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

J. J., Hahman, P. T., Halverson,

W. L., and Shearer, school children in

M. C.: Incidence three

of

heart disease and rheumatic

fever in

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

size and contour by Use of Medical
eral Practitioners

Students,
and

Internes,

Gen
6th

Pediatricians,

fluoroscopy.

Normal electrocardiogram.

Ed. Durham, p. 122.

Duke Univ. Press, 1949,

800

FOGEL
J. : Cardiac Robie, sounds
1949.

INNOCENT
status and of ado Harris, PE

CARDIAC

MURMUR

7. Schwartzmann, 8. Friedman, S.,

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

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

W.,

T. N. : Occurrence of innocent adventi

tious cardiac
DIATBICS, 4:782,

in childhood.

sterno e le apice. Le intensitate

grado I e grado

u'aria inter

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,

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.
camente ill

Iste murmure
Su

se trova sporadi
charac

infantes.

occurrentia

1949. 11. Still, C. F.: Common

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

Disorders

and Dis

eases of Childhood,
Oxford, 1918, p. 495. 12. Harris, T. N., Friedman, tion of murmur

3rd Ed. London,

S., and Haub,

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.

C. F.: Phonocardiographic
of mitral sounds in childhood.

differentia
insufficiency

from come commonly heard adventitious

PEDIA'rmcs, 3:845,

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

1949.
13. Rhodes, P.: Diagnosis of innocent heart murmurs in children. Bull. Denver

Rheumat.

Fever

Diagnostic

Service,

cavate)
trocardia

e in anormal positiones cardiac (dex

con levoposition, displaciamento

Feb. 1955. 14. Lvnxwiler, C. P., and Donahoe, J. L.: Evaluation of innocent heart murmurs.

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

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.

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.

SUMMARIO Murmures
A causa effectuate cardiac, ii res cardiac. systolic es confuse

IN INTERLINGUA Cardiac Innocente

(Functional) in Juveniles
del successos de palliation e cura per moderne technicas de chirurgia existe un nove interesse in murmu In juveniles le innocente murmure le plus frequente forma de murmure. il es non semper recognoscite

In be serie
patieilteS

del autor,

consistente
(i.e.

de

101

ill le gruppo

pediatric

de etates

Le thema del murmure innocente es un pauco

proque

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%.

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

Inter be noncomplicate

inriocente murmures
maximal esseva be

systolic, be sito del intensitate

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

septe (12,9%), e be tertie e be quarte spatio in tercostal in 41 (76%). Nulle murmures cardio respiratori esseva notate.

mente como un murmure vibratori. Su locol de