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It will be noted that the patients have been divided into groups on clinical considerations other than the
character of the murmur, which is similar in all groups. It was thought that the murmurs in the various groups
might be differentiated from each other on clinical grounds, such as whether they were localised or diffuse, or
confined to any given posture of the patient, but this did not prove to be the case. It will be seen that localised
murmurs and murmurs which are heard in the prone position only are to be found in most of the groups.
Localised murmurs.
Group. Cases
IA 1
IB 1
IC 1
ID 3
III 1
IV 3
Murmurs heard in prone position
only.
Group. Cases.
IA 2
IC 3
ID 2
IIC 3
IID 2
III 3
IV 3
Group IA may all be congenital murmurs ; the murmurs were present when the patients were first seen,
they have persisted, and there is no history of juvenile rheumatism and no development of signs of carditis.
In the cases of R.F. and D.F. a diagnosis of congenital septal defect is considered to be extremely probable, because
these two patients are sisters and there is a third sister, N.F., who has a murmur which is exactly similar in position
and distribution, but louder and rougher, and which indicates, we think, an obvious congenital defect. In two
cases it will be noted that there is a history of temporary pain over the praecordium ; in neither is there any
marked bony depression over the heart, the murmur is not heard in the standing position, is loudest in expiration,
and is persistent after the pain is relieved ; a mechanical endocardial cause is not suggested.
On the other hand, there are many cases in the following groups which, had they been seen at one consultation
only, would be indistinguishable from the cases in Group IA. For example, all cases in Group IB, had they been
seen for the first time after the murmur developed, would have appeared to be the same in type, and yet they
are not congenital. (The only one which might be a possible exception is M.B., whose murmur is best heard in
the standing position.) Similarly, in Group IC the murmurs are not distinguishable and it is only the history of
juvenile rheumatism (without a history of carditis) which in any case makes a congenital origin for the murmur
doubtful. Cases Group ID also, had the patients been seen only when the murmur was present, would have resembled
those in IA except for the history. There is no reason, however, why a history of juvenile rheumatism should
not be superimposed on a congenital case.
In these cases in Group IA, which are not definitely thought to be due to a slight congenital abnormality,
the murmurs may have no significance and may be disregarded in considering the child's future activities, but
physiological and haemic murmurs are not usually so persistent, and a comparison with the other groups here
again leads to difficulties in diagnosis. In Group IIA, C.B. when first seen was a similar case to those in IA,
yet with no history of juvenile rheumatism; mitral incompetence has developed; while D.H., if seen now
for the first time, would not be distinguishable, the parent would give no rheumatic history, although the bouts of
tachycardia and pyrexia which were present may have been rheumatic in origin.
In Group IC the murmurs are similar to those in IA, there are no other signs of carditis, the murmur has
persisted although the average observation time is less than in Group IA, but there is a history of juvenile
rheumatism in this group. One hesitates to describe a murmur as physiological when there is this history. For
example, in Group IIC, E.B. had a history of rheumatism, and P.H. of rheumatic pains, when first seen, but they
had no evidence of carditis beyond the basal murmur, and yet later, without any further evidence of a rheumatic
attack, they both developed apical murmurs, one conducted towards the axilla. In Group IID the case of S.R.,
had she been seen for the first time after the development of the basal murmur, when the electrocardiogram was
physiological, and before the development of the apical murmur, would have been similar to those in Group IC,
and yet a mitral incompetence developed. Had the case of J.W. been seen during the phase when the basal
murmur was present, it is only the abnormality of the electrocardiogram which would have distinguished it from
those in IC. In Group III, active or acute carditis has preceded the onset of the basal murmur in all cases, and
yet in all of them there are periods in which, had the case been seen for a short time only, they might have been
placed in Group IC, although in some the electrocardiogram would have revealed some cardiac damage. In
Group IV, G.B., R.B., C.D., R.L. and L.L. are similar cases.
Summary. (1) In the cases analysed, murmurs cannot be assessed from a consideration of their localisation or
of the posture of the patient in which they can be heard. Diagnosis and prognosis are therefore not assisted
by this investigation.
(2) In view of the fact that a number of these cases of basal murmurs, with no other signs of cardiac
involvement, subsequently develop a carditis, it would appear that these murmurs should not immediately
be dismissed as necessarily of no significance, especially if there is a history, which suggests even mild juvenile
rheumatism.
The honorary secretary, Mrs. Jacobson, has continued her valuable assistance in the work of taking electrocardiograms
and supervising and helping in the extensive social work of the centre. In addition, regular and
helpful assistance in filing and giving out case papers has been rendered by Mrs. Bluck, and in home visiting by
Miss Reitlinger, Miss Grier and Miss Dudley Baxter. The officers of the council are grateful for their invaluable
assistance.