Vous êtes sur la page 1sur 9


July 18, 1964, vol. 91

Much research has been carried out recently De nombreuses recherches ont 6t6 demi.re-
into the means by which heart sounds and ment consacr6es aux voies par lesquelles
murmurs reach the stethoscope from thefr les bruits et les souffles du coeur parvien-
point of origin. Heart sounds originate as nent au st6thoscope .i partir de leur point
vibrations of the cardiac valves and travel d'origine. Les bruits du coeur naissent sous
as transverse vibrations with low velocity forme de vibrations des valvules cardiaques
over the walls of the ventricles and great et se d.placent, sous forme de vibrations
vessels. Where these structures are in con- transverses, ?i faible vites.e, le long des
tact with the thoracic surface they emerge, parois des ventricules et des gros vaisseaux.
at the 'auscultatory areas', and spread like Quand ces structures anatomiques sont en
ripples over the chest surface. Murmurs contact avec la paroi thoracique, elles y
originate in the cavities receiving the blood emergent aux foyers d'auscultation et leurs
stream, and are loudest in the cavity that is vibrations se propagent comme des ondula-
less distensible. Frequency, damping in tran- tions sur la surface du thorax. Les souffles
sit and the possible misinterpretation of naissent dans les cavit6s ois se d6verse le
apparent 'splitting' seen in phonocardio- torrent circulatofre et sont plus intenses
graphic records are discussed. This basic dans la cavit6 la plus rigide. Les auteurs
knowledge of modes of transmission allows 6tudient la fr.quence, l'amortissement en
the interpi.etation of unusual locations of cours de d6placement, et la possibilit6
auscultatory areas in disease states, and ex- d'erreurs d'interpr.tation des images frac-
plains some puzzling findings obtained with tionn6es lues sur les trac6s phonocardio-
microphones mounted on cardiac catheters. graphiques. La connaissance sCire des modes
de transmission permet d'interpr6ter cer-
taines localisations insolites des foyers
d'auscultation dans des pathologies et
d'expliquer certaines constatations intri-
gantes obtenues au moyen de microphones
mont6s sur des sondes cardiaques.
Canad. Med. Ass. J. FABER AND BURTON: HEART Sou.ns 121
July 18, 1964, voL 91

work of Henderson and Johnson,6 Dean,7 Wiggers,8 been shown that heart "sounds" travel as trans-
and particularly of Dock,9' 10 Rouanet's explanation verse vibrations in the wall of the heart (precisely
has been generally accepted. similar to the conduction of the pulse wave in
The cause of the second heart sound has never arteries). The vibrations consist of alternating local
been seriously challenged. However, it has recently outward and inward movements of the ventricle
been shown that there is an interval of about 0.023 that travel towards the apex.4 The blood which is
second between the moment when the pressure displaced back and forth by the vibrating mitral
gradient across the mitral valve reverses and the valve causes these "ripples" on the left ventricle
occurrence of the first heart sound, and from this and left atrium. The proof of this particular mode
it has been concluded that the first heart sound of conduction consists of the demonstration that the
is not due to closure of the atrioventricular pressure in the ventricle and the tension in the
valves.11' 12 The existence of this interval does not ventricular wall increase and decrease simultane-
exclude but rather supports Rouanet's explanation. ously during the vibrations of the mitral sound.
Henderson and Johnson6 compared the valve Transmission of sound in the human heart can
closure with that of a door that was blown shut also occur directly from one structure to another
by a sudden gust of wind. Obviously, it takes some contiguous structure in apposition, but not ana-
time, after the onset of the gust, before the door tomically connected, even if there is no connection
is shut. It can be shown by calculation4 that the between their cavities which would allow conduc-
interval, 0.023 second, is the time necessary for tion in the form of "pulse waves". Magri et al.13
the valve to shut after the reversal of the pressure recorded phonograms externally from the exposed
gradient at the beginning of systole. human heart and showed that a mitral opening snap
The classical theory is strengthened further by is well transmitted to the pulmonary artery and
our recent direct evidence4 that the first sound is that the second sound (aortic and pulmonary valve
due to vibrations sustained by the atrioventricular closures) is transmitted to the atria. The left atrium
valves. The crucial part of the proof is the obser- and the major arteries are in direct contact with
each other and easily transmit transverse vibrations
vation that the vibrations corresponding to mitral in their walls, although these vibrations are attenu-
sounds recorded from the left atrium are of opposite ated during this transmission. Transmission by
phase to those recorded from the left ventricle. direct contact on the outside is not efficient, as the
No other interpretation of this fact seems possible energy of vibration of only that small part of the
than that the sounds originated in the closure of wall that makes contact is transmitted; this is,
the mitral valve. however, the common way in which sound is trans-
mitted from the cardiovascular system to the
The first heart sound consists of a mitral and a Conduction in the heart of the second heart
tricuspid component which generally occur simul- sound is very likely similar to that of the mitral
taneously, or almost so. We have destroyed the sound; however, we did not study this conduction
tricuspid valve in dogs to be able to study the experimentally. It is generally accepted that the
mitral component alone and shown4 that the second sound is caused by the closure of the semi-
mitral sound, which originates as a vibration of lunar valves, and in a healthy subject consists of
the mitral valve, travels over the left ventricle from an aortic and a pulmonary component, in that
the base of the heart to the apex. The velocity of order.14' 15 We may assume that the second sound
this conduction is only about four metres per is due to vibrations in the semilunar valves, by
second (13 feet per second). This value is based analogy with the first heart sound.
on data for frequencies from 20 to 40 cycles per The mitral and tricuspid components of the first
second (cps) only. The frequencies of audible sound originate between the ventricles and the
heart sounds range from about 20 to 1000 cps. atria and are transmitted to both, and it may seem
This very slow conduction rate is very strong hard to explain why they are louder in the ventri-
evidence that the heart sounds are not conducted cles than in the atria when recorded by intracardiac
in the heart in the form of "sound", in the strict microphones.14 This difference in loudness, which
physical sense of the word,* as conduction in this is also observed when external microphones are
form would be many hundreds of times faster applied to the heart muscle, may probably be ex-
(about 1500 m./sec. in tissues). Indeed, it has plained by the reduced distensibility of the filled
ventricle compared to that of the empty atrium at
*A transverse vibration is one where the direction in which
the particles vibrate is perpendicular to the direction of the time of early systole. Equal and opposite dis-
propagation. waves on water are an example as the direc-
tion of the vibration is vertical whereas the direction of
placements of the valve between these cavities
propagation is horizontal along the surface. This is true cause higher pressure oscillations in the ventricle
also of pulse waves in arteries. 'Sound' is by definition a
longitadinal vibration, that is, a vibration where the particles than in the atrium, as the ventricle is less able
vibrate back and forth in the direction in which the to "make room" for the blood displaced by the
vibration is propagated. For convenience, the word 'sound'
is used in this paper for any vibration that can he heard
when conducted to the ear. Sound travelling in air is an valve. The presumed greater loudness in the atrium
example of sound in the physical sense. The transverse
vibrations of heart sounds are converted into true sound at
of the opening snap of a stenosed mitral valve'4
the chest piece of the stethoscope. would be caused by the opposite difference in

Fig. 1.-Damping vs. distance travelled in arteries. The

intensity at the most proximal point on the aorta of a dog
where the sounds were measured is arbitrarily set at 0
decibels. Based on data on two dogs (reference 2) cps =
cycles per second.

Sounds are damped during their transmission

along arteries. This rate of decrease in intensity
is more marked at higher frequencies. Fig. 1 shows
how the intensities of sounds of different frequen-
cies decrease during transmission along the aortas
of dogs. It can be seen that a sound of a frequency
of 400 cps decreases 60 decibels (one million times)
in intensity when it travels a distance of 20 cm.
(8 in.) along the aorta. A sound of 400 cps of an
intensity almost unbearably painful to the ear would
have to travel only about 30 cm. (1 ft.) along the
aorta to become inaudible.
Obviously, sounds in arteries-especially murmurs,
which contain higher frequencies than heart sounds
-do not travel very far before they are attenuated
below the threshold of the ear. In a dog's aorta
the second sound can be recorded by a phono-
catheter only within 20 cm. from the heart. In
humans one can hear the second sound on the
skin overlying the carotid arteries, but the higher
frequencies have been attenuated already and the
sound so heard is relatively "dull".
Anything that interferes with the transverse
motion of the wall of a blood vessel, e.g. a constric-
tion or stenosis, or a clamp placed on the outside
of the vessel (Fig. 2), causes additional attenuation
particularly of the low frequencies travelling in
that vessel. Until recently, it was believed that con-
duction of murmurs in arteries was facilitated in
the direction of the blood stream,17. 20, 22, 23 as indi-
cated by records from phonocatheters, but it ap-
pears that this apparent "facilitation" is caused by
the "clamp effect" of the stenosis responsible for
Canad. Med. Ass. 3.
July 18, 1964, vol. 91
FM.II A. BURTON: HL.T SouI..I)s 123


From the apical region of the left ventricle, from
the area of contact between the right ventricle and
the chest wall, or from the great vessels that come
in contact with the thoracic wall, the vibrations of
the heart sounds and murmurs traverse the wall to
the skin, at the classical "auscultatory areas". No
evidence as to the mode of conduction in this
short pathway througia the wall is available. It is
probable that here the transmission is by longitudi-
nal, compressional waves, i.e. as true "sound waves",
travelling with high velocity.
Conduction over the body surface has been in-
vestigated experimentally"24 by recording simul-
taneously from several microphones placed at
different points on the thorax, and measuring the
differences in time of arrival, e.g. of the mitral
sound, at these points. The time differences turn
out to be of the order of several milliseconds. By
using the multiple differences in time of arrival
between all the pairs of microphones it has been
possible, by a kind of "dead reckoning" like that of
navigation, to prove that the sounds originated at
"secondary sources" on the surface of the chest,
and spread like ripples from these "secondary
sources", which are the classical auscultatory areas
for the various sounds. The data exclude the ex-
planation that the sounds arrived at other points on
the chest by direct transmission though the under-
lying tissues, although sounds may be conducted
to more than one secondary source under some
exceptional circumstances, e.g. conduction of second
sound to neck via carotid arteries.
An interesting demonstration of the existence of
these secondary sources which has possible practical
application to auscultation is that placing a re-
straining weight over one of these points reduces
that particular heart sound heard elsewhere on
the thorax, e.g. a lead disc placed over the mitral
area selectively suppresses the mitral sound
wherever it can be heard. We have not pursued
this, not being experienced in clinical auscultation,
but we suggest that it might be very useful, when
trying to distinguish between simultaneous sounds
or murmurs of different origin, to suppress one of
the components by this means (or by pressure of
the fingers over the appropriate area). For example,
the mitral sound might be distinguished better from
the tricuspid sound if the stethoscope were placed
at the mitral area, and the fingers pressed on the
tricuspid area. However, so far our colleagues tell
us that they are unable to verify this.
When the mitral valve is replaced by an artificial
valve in patients with mitral disease, the sounds
produced by the artificial valve are said to have a
secondary source not at the apex but closer to the
base of the heart.24 This probably indicates that
in these patients, who have dilated hearts, the area
July 18, 1964, vol. 91

of contact between the left ventricle and the chest The velocities with which sounds are conducted
wall is not limited to the apex as it is in normal are very much higher on the sternum than else-
subjects. where on the chest. When a mitral sound is re-
The effects of the common pathway on the corded from several points on the chest, it is seen
surface of the thorax on auscuitation are threefold: to travel with its normal velocity from the mitral
area to the edge of the sternum. It then travels
a. Admixture of Sounds of Different Origin across the sternum with a very much greater
Wherever the stethoscope bell is placed (even if velocity until it arrives at the other border of this
bone; from here on the mitral sound travels again
on the classical areas for specific sounds), sounds with its normal low velocity over the right side
from different origins may reach it simultaneously; of the thorax.26 The velocity of conduction on the
e.g. the mitral and tricuspid sounds are often no sternum was too high to be accurately measurable,
longer individually recognizable in the first heart but it probably is the velocity of sound in bone,
sound, even when the stethoscope is placed on the which is about 3400 metres per second-2 miles
mitral or tricuspid areas respectively. Simultaneous per second.27 This increased velocity of conduction
recordings from microphones placed at two differ- is not found over the ribs; these structures are
ent places do, however, show unequivocally that probably too small and too deeply buried in the
the complex is made up of vibrations that arrived soft tissues to have a measurable effect on the
from two different origins, by different pathways,' conduction velocity of sound passing over the
with different time delays (Fig. 3). surface.

Fig. 3.-Top tracing showing first and second heart sound (time base 100 m.sec./cm.).
Middle and bottom tracings showing the first heart sound only, recorded from microphones
at two different places on the thorax (time base 10 m.sec./cm.). The waves in first part of
the sound, i.e. the mitral component, lead in the bottom tracing, but the second part of the
sound, i.e. the tricuspid component, 'lags'. A pass-band of 120 cps was used. [From Faber,
J. J,. and Burton, A. C., Circulation Research, 11: 100, 1962, by permission of the American
Heart Association, Inc.]

b. Distortion of the Sounds due to c. Distortion by Damping

Heterogeneity of the Thoracic Wall Heart sounds travelling over the chest are sub-
The precordium consists of soft tissues and bones. ject to a considerable attenuation. This attenuation
This heterogeneity is clearly reflected by its acous- is mainly due to the damping properties of the
tic properties. The velocity of conduction and the tissues, but also to the spread of the sounds over
attenuation of sound on the sternum are very a larger area as they travel away in all directions
different from those on the rest of the thoracic wall. from their secondary sources.3 Fig. 4 shows how
The velocities with which sounds are conducted much sounds of different frequencies are attenuated
over the chest wall are lower than was previously during their progression over the surface of the
thought. The velocity of conduction of a sound of chest. Evidently, higher frequencies are much more
a frequency of 100 cps is on the average 15 metres attenuated than lower frequencies, even more so
per second (about 50 ft. per second) ,1,25 This than in arteries (cf. Fig. 1). This accords with the
velocity increases somewhat with frequency; von experience that heart sounds, especially murmurs,
Gierk&5 reported that in the soft tissues of the become "duller" the farther they travel away from
extremities the velocity of conduction is approxi- their auscultatory area. Murmurs consisting entirely
mately proportional to the square root of the fre- of high frequencies, such as the murmur of aortic
quency, and the few recordings of our own in regurgitation, cannot travel very far before they
which different frequencies were investigated become inaudible.
showed the same relationship for different frequen- The sternum differs from the rest of the pre-
cies of heart sounds conducted over the surface cordium also with respect to its damping properties.
of the chest.26 For sounds of frequencies under 100 cps, the damp-
July 18, 1964, vol. 91

mode of conduction has never been established
directly, it has been shown that the heart sounds
travel over the chest surface originating from a
"secondary source" rather than directly through
the thorax from their origins in the heart. A mitral
sound heard somewhere on the precordium did
not come straight from the heart but travelled first
from the mitral valve over the left ventricular wail
.-.100 . to the apex to be transmitted at the region of con-
tact between the apex and thoracic wall to the
200 .
mitral area on the chest wail where it is heard best.
The mitral area acts as a "secondary source" of the
mitral sound.' Not only is the mitral sound heard
best here, it arrives there first, and spreads to
N000 .
other points from this secondary source. Similarly,
Fig. 4.-Damping vs. distance travelled over the chest wall. the tricuspid area corresponds to the area of contact
The intensities of sounds of different frequencies are plotted
on the vertical axis; the distances travelled are plotted along of the right ventricle (Fig. 5) with the chest wall,
the horizontal axis. Calculated from measurements on five and the aortic and pulmonary areas are the points
human subjects reported in reference 3.
where the aorta and pulmonary artery respectively
are closest to the chest wall. It seems likely that
ing is about the same everywhere on the pre- the aortic and pulmonary sounds travel a few centi-
cordium and sternum. But sounds consisting of metres along these arteries before they are trans-
higher frequencies are much less damped during mitted to the chest wail.
transmission over the sternum than during trans-
mission over the rest of the precordium.3 The at-
tenuations shown in Fig. 4 apply to soft tissues
and ribs. The sternum is not a very informative
area for auscuitation; an abnormal sound may be
present there, but it is impossible to tell where on
the sternum it is loudest and, hence, from where it
On rare occasions conduction though bones is
evident, e.g. when very loud murmurs reach the
elbow or other unusual places by transmission
though the skeleton. Levine and Likoff28 recorded
murmurs from the olecranon in some of their pa-
tients. These murmurs were not conducted along
the brachial artery, as inflation of a sphygmano-
meter cuff around the upper arm did not abolish
the conduction. Neither were they conducted
through the soft tissues as the damping of sound Fig. 5.-Transverse section of the human thorax. The apex
of the left ventricle and almost the whole anterior surface
in soft tissues is too high to allow conduction over of the right ventricle are in contact with the 'inside' of the
mitral area and tricuspid areas of auscultation, respectively
such distances. If conduction along bones over (L.A. = left atrium, L.V. = left ventricle, R.A. = right
unusual distances is observed, it is probably safe atrium, R.V. = right ventricle, T. = tricuspid valve, M. =
mitral valve, and Au. = descending aorta.) Modified from a
to assume that the original sound is very loud and drawing in reference 29.
that it is transmitted to the skeleton somewhere
close to its place of origin, most likely from the Clinical Illustrations
ascending aorta to the sternum or from the left Clinical observation is consistent with the pre-
atrium or the arch of the aorta and descending
aorta to the spine. Usually the intensities of heart ceding conclusions regarding the transmission
sounds and murmurs travelling in soft tissues are properties of the thoracic tissues. Compare, for
much reduced before these sounds reach bony instance, the diastolic murmur of mitral stenosis
structures. with the systolic murmur of a mitral regurgitation.
Although both are caused by turbulence created
Auscultatory Areas as Secondary Sources by the mitral valve, they differ in their place of
In summary, the low velocity of conduction and origin. The turbulence of the diastolic murmur is
the high degree of attenuation of sounds travelling located primarily in the left ventricle, whereas the
on the chest surface make conduction in the form turbulence of the regurgitant murmur is located
of "sound", i.e. as compressional waves, very un- in the left atrium30 as turbulence occurs down-
likely. Also, the shape of the thoracic wall, which stream from the lesion that creates it. Conse-
is a sheet rather than a block of material, suggests quently, the diastolic murmur of mitral stenosis
a different mode of conduction. Although the exact is loudest in the left ventricle and best audible on
Canad. Med. Ass. 3.
July 18, 1964, vol. 91

auscultation is subjective, and therefore not quite

reliable, this defect is not inherent in "objective
methods", such as phonocardiography. While
phonocardiographic records are usually representa-
tive of hemodynamic events which caused the
vibrations, one possible source of misinterpretation
must be considered.
Phonocardiographic records of heart sounds often
seem to show several components in the first sound,
although all of those components are not usually
heard separately with the stethoscope. The ear is
able to recognize close splitting, e.g. the splitting
of the second sound into an aortic and a pulmonary
sound, and even though the resolution that can
be achieved in a phonogram exceeds that of the
ear, it seems questionable whether the several
components that have been distinguished in the
first sound are really separate entities. It is at
least conceivable that the phenomenon of "beats",
well known in acoustics, is responsible for their
generation. When two vibrations or sounds of
slightly different frequency are "mixed", the re-
sultant amplitude (as of the chest wall) is the
algebraic sum of the two simultaneous amplitudes.
If the frequencies are different these pass inter-
mittently in and out of phase, and their sum waxes
and wanes. The lower tracings of Fig. 6 represent
simulated mitral and tricuspid sounds respectively.
The upper tracing shows what would be recorded
from a chest surface where these sounds are mixed.
The "silent" interval between the two "components"
does not at all represent a true silent interval
between these two sounds, yet the splitting in the
top tracing is much more convincing than that in
most published phonograms of the first heart sound.
Moreover, the number of artefactual components
(beats) is by no means limited to two; the number
of beats generated depends on the duration of the
sound and on the difference in frequency between
the two sounds that make up this sound. Indirect
evidence that mitral and tricuspid sounds do give
rise to beats on the chest surface has been re-
ported.3 It was found that the amplitude of the
first sound on the chest surface did not show a
regular pattern around the mitral and the tri-
cuspid area, although sound from an experimental
source did show such a regular decrease in ampli-
tude with distance.
These artefactual components are caused by the
physical properties of the phonocardiograph. A
phonocardiograph registers the amplitudes of
sounds rather than their intensities or energy.
Sounds of the same intensity have amplitudes in-
versely proportional to their frequency, so that
low-pitched sounds have larger amplitudes than
high:pitched sounds of the same intensity. Since
the low-frequency components of heart sounds are
relatively more intense than the high-frequency
components, phonograms tend to show the lowest
frequency present in heart sounds, as is obvious
from the almost purely sinusoidal wave forms they
display. The lowest frequency in the mitral sound
Canad. Med. As& J. FABER AND BuwroN: HEART SOUNDS 127
July 18, 1964, vol. 91

results of physiological and biophysical experiment-

ation and clinical experience with auscultation.

*ii The interpretation of cardiac murmurs and sounds is

based primarily on the knowledge of hemodynamics
gathered during the past half-century. Further insight
is gained from a description of the properties of sound
transmission in the tissues of the thorax.
Heart sounds and opening snaps originate in the
valves, which separate two cavities, and are loudest in
that cavity that has the lower distensibility at the
moment of occurrence of the sound. Murmurs originate
in the cavity that receives the blood flow responsible
for their production. Sounds and murmurs are then
Fig. 6.-Artifically split heart sounds. A 'mitral sound' conducted from their place of origin over the heart,
simulated by a sine wave generator is displayed on the face
of the cathode ray oscillograph by the middle tracing, and
over the walls of arteries, and over the thoracic wall
a simulated 'tricuspid sound' is displayed by the lower where they are picked up by the stethoscope.
tracing. The combined sounds as they would be recorded
on the chest surface are displayed on the top tracing. The Conduction in the heart itself is characterized by a
'splitting' does not represent two true successive compon- low velocity of conduction. The degree to which sounds
ents, but is due to 'beat notes', i.e. the resultant of two are damped in the heart is not accurately known, but
sounds of different frequency.
very likely the degree of damping increases with the
frequency of the sound. Heart sounds are transmitted
and the one in the tricuspid sound may give rise from the heart to the thorax at the places where the
to several beats and thus to "silent" intervals which wall of the vibrating cavities touch the chest wall.
separate components" that do not represent sepa- Conduction of sound in arteries occurs, but the
rate sounds. Beats must be excluded before one attenuation of sounds over the arterial wall is high and
can accept that apparent components in external increases with frequency. The velocity of conduction
or intracardiac phonograms are separate sounds is equal to the velocity with which the pulse wave is
from different origins. conducted (about 5 m./sec.).
Conduction of sound over the chest wall is distin-
As the ear is far more sensitive to relatively high guished by a low velocity of only about 15 m./sec.,
frequencies than to low ones (the maximum sensi- increasing with frequency, and a very high degree of
tivity is at about 200 cps), it hears almost the whole damping, which also increases with frequency. Sounds
spectrum of different frequencies present in heart on the chest wall spread from the points where they
sounds and is less likely to hear the beats pro- are loudest, and these points of maximum intensity
duced by the interaction of lowest frequencies as are the points where the sounds are transmitted from
silent intervals. If no splitting can be heard, any the cardiovascular system to the wall of the chest
apparent splitting of heart sounds in a phono.- (secondary sources).
cardiogram* must be serious4j questioned. The These transmission properties account satisfactorily
first sound consists of a mixture of a mitral and a for the place on the chest where abnormal sounds can
tricuspid sound and is perhaps preceded by an be heard best, even when these places seem to be far
away from the anatomical site or pathological lesion
initial vibration, which is often of inaudibly low responsible for the sound or murmur. Certain dis-
pitch and occurs just before the first sound, almost crepancies between the results of auscultation and
simultaneously with the Q wave of the electro- phonocardiography could be explained by the acoustic
cardiogram. The evidence brought forward for the properties of the thoracic tissues and by the technical
existence of a great many other components is features of the phonocardiograph. The limitations of
based on phonocardiographic recordings and has auscultation are different but no more numerous than
so far not been sufficiently convincing. those inherent in more technical methods of recording
heart sounds.
CONCLUSION The authors express their sincere gratitude to Drs. C. W.
Auscultation gives a great part of the information Manning, Margot R. Roach, and C. J. Cropp, to Mrs.
Dorothy Elston, Mr. J. H. Purvis, Mr. C. Flett, and to
that can be obtained with conventional phono- various other sfaff members of the Department of Bio-
cardiography, except precise time relations. But physics. The Ontario Heart Foundation made our financial
phonocardiography may give rise to artefacts support as flexible as is allowed under the structure of
these grants. Part of this work was submitted as a Ph.D.
whereas auscultation is less likely to lead the dissertation by the junior author.
observer astray, and has obvious advantages in ease
of application. Whatever method is used, the acous-
tic transmission properties of the tissues must come 1. FABER, J. 3. AND BURTON, A. C.: Ctrc. Re8., 11: 96. 1962.
2. FABER, 3. J. AND Puxvxs. 3. H.: Ibid., 12: 308. 1963.
into the interpretation of the results. In spite of 3.
FABER, 3. 3.: Ibid., 13: 352. 1963.
Idem: Ibid., 14: 426. 1964.
the impression one may get from the present liter- 5.
McKusIcK, V. A.: Bt&ll. Hist. Med., 32: 137, 1958.
HENDERSON, Y. AND JOHNSON, F. E.: Heart, 4: 69, 1912.
ature, no real discrepancies exist between the 7.
DEAN, A. L., JR.: Amer. .T. Ph.i,,ioL, 40: 206, 1916.
WIGGERS. C. 3. AND DEAN, A. L.. Ju.: Ibid., 42: 476, 1917.
9. Docic, W.: Arch. Intern. Med. (Chicago), 51: 737, 1933.
Spectral phonocardiography" is more reliable in this respect 10. Idem: Circulation, 19: 376, 1959.
but does not quite achieve the same resolution of time. ii. DI BARTOLO, G. D. et al.: Amer. J. Phymol., 201: 888, 1901.
July 18,Med.
1964,Ass. 5.

12. SHAH, P. M. et al.: Csrc. Ree., 12: 386, 1963. 25. voN GIERKE, H. E.: Transmission of vibratory energy
13. MAGRI, G. et aL: Amer. Heart .T., 57: 449, 1959. through human body tissue. In: Proceedings of the
14. McKusIcK, V. A.: Cardiovascular sound in health and First National Biophysics Conference; Columbus,
disease, Williams & Wilkins Company, BaltImore, 1958. OhIo, March 4-6, 1957, edIted by H. Quastler and
15. BOYER, S. H. AND CHISHOLM, A. W.: Circulation, 18: H. J. Morowitz, Yale University Press, New Haven,
1010, 1958. Conn., 1959, p. 647.
16.. LEWIs, D. H. et al.: Ibid., 18: 991, 1968. 26. FAEER J 3 An experimental Investigation of the spread
17. FERUGLIO, G. A.: Amer. Heart J., 58: 827, 1959. of heart sounds. Ph.D. thesis, University of Western
18. ZALTER, R., HARDY, H. C. AND LUISADA, A. A.: ,T. Appi. Ontario, London, 1962.
Physsol., 18: 428, 1963. 27. GoWMAN, D. E. ..rn HUETER, T. F.: Journal of Accousti-
19. KERR, W. J. et al.: Amer. Heart J., 14: 594, 1937. cal Society of America, 28: 35, 1956.
20. KERn, W. J. AND HARP, V. C., JR.: Ibid., 37: 100, 1949.
21. LANGE, R. L., CARLISLE, R. P. AND HECHT, H. H.: Circu- 28. LEVINE, S. A. AND LIKOFT, W. B.: Ann. Intern. Med., 21:
lation, 13: 873, 1956. 298, 1944.
22. LEPE5CHKIN, B.: Ibid., 16: 428, 1957. 29. EYOLESHYMER, A. C. AND SOSIOEMAKER, D. M.: A cross-
23. KERR, W. J.: Amer. Pract., 1: 247, 1947. section anatomy, D. Appleton & Company, New York,
24. SHAH, P. M., MACCANON, D. M. AND LUISADA, A. A.: 1911.
Circulation, 28: 1102, 1963. 30. BONDI, S.: Wien Kim. Wschr., 40: 149, 1927.

A New Instrument for Control of Hemorrhage by

Aortic Compression:
A Preliminary Report
L. J. HARRIS, M.D., M.A., F.R.C.S.[G], F.A.C.O.G.,0

After laparotomy, immediate compression Tout de suite apr.s une laparotomie, la com-
of the aorta with the heel of the hand just pression de l'aorte avec Ia paume de Ia
above the bifurcation of the common iliac main plac6e imm&liatem.nt au-dessus de
arteries is a quick and effective way of Ia bifurcation des art&es iliaques primi-
controlling catastrophic pelvic hemorrhage. tives, constitu. un moyen rapide Ct efficace
This maneuver, which can be maintained d'enrayer des h6morragies pelviennes sou-
for several hours without any harmful vent fatales. Cette manoeuvre peut se pro-
sequelae, enables the surgeon to remove longer durant plusieurs heures sans cons6-
the blood from the peritoneal cavity and qitences fAcheuses et permet au chirurgien
take definitive steps to stop the bleeding, de rendre exangue la cavit6 p&iton.ale;
and the loss of administered blood is ayant pris les dispositions ad&juates pour
halted. An instrument for aortic compres- assurer l'b6mostase, il peut alors cesser les
sion is described which is easily applied transfusions de sang. TJn instrument a
to the aorta; it is controUed by a handle mis au point pour pouvofr facilement com-
outside the abdomen and does not obstruct primer l'aorte; il est muni d'une poign6e
the operative field. It has been found to be de contr6le qui d.passe de l'abdomen et il
valuable, not only in the control of serious n'obstrue pas le champ op6ratoire. Cet in-
pelvic hemorrhage, but also in pelvic strument s'est av6r6 pr.cieux pour enrayer
surgery where considerable blood loss is los h6morragies pelvtennes massives et aussi
anticipated. en chirurgie pelvienne lorsqu'on pr6voit une
perte consid6rable de sang.

PROFUSE pelvic hemorrhage from a ruptured

uterus is a serious emergency. Often blood is be controlled at once if the patient's life is to be
being lost from the ruptured viscus more quickly saved.
than it can be replaced, even though simultaneous Unfortunately, when a laparotomy is performed
transfusions are being run in rapidly at one or more to control the bleeding, the abdomen is often full
sites. Under these circumstances the patient's con- of blood, and the exact source of the hemorrhage
dition deteriorates rapidly and the bleeding must cannot always be located and dealt with inimedi-
Chlef, Department of Obstetrics and Gynecology. New
ately. Because the patient is already in poor con-
Mount Sinai Hospital. Toronto. dition, she may very, readily develop cardiac