Noises Heard at a Distance from the Chest

Second Series

¹ The Department of Medicine of the College of Medicine and the University Hospitals, State University of Iowa.

A variety of clinical conditions that may be associated with precordial sounds heard by the unaided ear at a distance from the chest is assembled, compared, and assessed. The commonest causes of such sounds are cardiac murmurs produced by valve rupture or other lesions, often abrupt in onset and a consequence of stress or strain. Next in order of frequency come interstitial mediastinal and pulmonary emphysema, both spontaneous and traumatic. These are followed by spontaneous and traumatic pneumothorax, pneumopericardium, noises the heart produces by striking aircontaining gut, air embolus, and a small mysterious miscellany of unexplained sounds. Since the noises have diverse sources there is no pathophysiological common denomiator to compare with the clinical fact of abnormally great volume of sound. With such differences in cause and, hence, in necessary treatment and prognosis, attention should be directed to the cause, which usually comes to light on careful clinical scrutiny.

Four additional years of searching have added some new pearls to my strand, but it is far from complete. I introduced the heresy that children do not have such sounds because they had small hearts and small thoracic sounding boards. Looking for such noises, Dr. John Wild and I found them nine times in children, even infants, with such lesions as ventricular septal defects, aortic or pulmonic stenosis or tricuspid atresia. Hufnagel valves, being more prevalent, have added to the list. Aortic aneurysms, going all the way back to Lancisi, have added four; and chest deformity, myxoma of the left auricle, ruptured tendinous cords, pneumoperitoneum and a murmuring spleen have swelled the list. Our knowledge of the mysterious complexities of clinical medicine grows with experience perceived, understanding disciplined and inquiry directed. We find what is there only if we sacrifice that part of ourselves which is given in complete attention and concentration. We see and hear what is there only if we look, listen, and focus. We find what we search for not what we look at.

If the spirit of Robert Hooke were with us tonight, his interest in natural phenomena would have had some stimulus, and perhaps he would be amused at my answers to his query, "Who knows but that one may discover the works performed in the several offices and shops of a man's body by the sounds they make, and thereby discover what instrument or engine is out of order!" This commemorative tribute I trust Louis Mark would have enjoyed and given his approval. Finally, lest too much astringent mirth make you think the subject is not important, I conclude, in all humility, with a verse of scripture (Jeremiah 17:9): "The heart is deceitful above all things. . . . Who can know it"