Presystoltic urmurs, so important in the diagnosis of mitral stenosis in later life, are almost entirely absent during the first years of life, as are accentuation of the second heart sound at the aortic area and excessive tension of the radial pulse. On the other hand, accen tuation of the second sound at the pulmonary area is observed in the first months of life, especially with congenital heart lesions, and is of excep tional value in diagnosis on account of the slight accentuation due to closure of the senfflunar VRIVCS under normal conditions, a fact first established by Hochsinger. Just as valuable is the diminution or absolute inaudibility of the second sound at the pulmonary, area, au infallible sign of pulmonary stenosis.
Organic endocardial may be simulated in childhood by cardiopulmonary murnturs, intrathoracic venous murmurs and rapid respiration. Statements of the occurrence of accidental cardiac mur murs in early childhood are for the most part founded upon mistakes made in hearing cardiopulmonary murmurs (systolic vesicular breath ing, according to Wintrich). This systolic murmur, first recognized by Hochsinger in childhood, arises in the portions of the lungs nearest to the heart and is due to the entrance of air into the edges of the lungs during inspiration, this air being changed regularly uith systole and diastole. Rapid respiration and accelerated heart action, conditions which are present in childhood especially, are necessary' for the ap pearance of this phenomenon. These murmurs are always systolic, very harsh, sometimes completely concealing the first sound of the heart, at other times sirnply appended to it. They are differentiated from organic murmurs only by their variability, above mentioned, which, however, is not always easily discoverable. They become louder when respiration pauses during inspiration; weaker or absolutely, wanting when one's breath is held during expiration. They occur especially frequently after the third year, yet W. Freund, Rheiner and Hochsinger have noted them in infants. In older, easily excitable children, cardio pulmonary murmurs are especially- frequent; Potain's so-called "souffles des consultations" in excited patients are nothing other than cardio pulmonary murmurs. Slight pressure made by the stethoscope at the point of origin of the murmur increases it; with more pressure the murmur is lost. Cardiopnlmonary murmurs occur most frequently over the left ventricle, much more rarely at the apex, and very rarely over the aorta and auricles (D6lahost).
Delaboet explains the so-called accidental murmurs of children, taken altogether, as cardiopulmonary murmurs, and refers the absence of the accidental murmurs in early life to the scanty covering of the heart by lungs during the first months of life, a fact settled by Delabost, as well as by West, Durand, Soltrnann, and Hochsinger earlier. The few cases of so-called anaemic or accidental heart murmurs in early childhood, noted in literature, appear in a different light front the standpoint of the origin of cardiopuhnonary murmurs. Systolic mnr murs at this period of life, if they are not dependent upon organic intracardial affections, are usually considered extracardial, arising in the edges of the lungs when filled during inspiration, and not as true accidental heart murmurs. Only those murmurs which appear as the result of aperiodic vibrations of the valves following nutritional disturb ances of the cardiac musculature, without any anatomic change, are regarded as true accidental heart murmurs.
With low blood pressure and very rapid respiration, organic heart murmurs may also completely disappear, to reappear again when respir ation and pulse-rate diminish, as they do after the administration of digitalis. Nor must the fact be overlooked that myocarditis in children can produce systolic murmurs similar to those of endocarditis, only these murmurs are less constant than the murmurs of endocarditis and may appear with symptoms very like those due to cardiopulmonary mur murs; but the first sound is hardly ever completely concealed by them.
According to Kimla and Scherer there must be great biemorrliage to have produced murmurs in newborn infants.
Steffen, by pressure with the stethoscope on the anterior chest Nvall, could produce a weakening of the heart sounds in rachitic chil dren with yielding chests, besides, he could change the heart sounds into murmurs; while Henoch, by pressure at the pulmonary area artificially caused murmurs there. Such murmurs are not to be con sidered accidental heart murmurs, but artificially produced compres sion murmurs. In high-grade rickets, in which the junction of ribs and costal cartilage cannot be broken inward, the pulmonary artery may be compressed by bending the ribs in, and a constant systolic murmur can be heard, even without the pressure of a stethoscope, which is also not an accidental but a compression murmur.