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High Speed Phonocardiography

An Approach to the Frequency Analysis of the Vibrations

Originating in the Heart*

Siena, Italy

IGH SPEED phonocardiography is a new the study to those vibrations which have a
H method devised for an objective and de-
tailed analysis of the vibrations which compose
definite clinical importance . The latter cor-
respond to the data of clinical auscultation and
the heart sounds and murmurs . are recorded by conventional phonocardiog-
It is well known that the timing of ausculta- raphy . 9 While the frequency of cardiac vibra-
tory phenomena and their time relationship tions has often been empirically evaluated in
with other physiologic parameters are useful for conventional phonocardiograms, an exact count
clinical diagnosis . However, the information requires special methods .
supplied by conventional phonocardiography Several authors have stated that heart
may be limited by the technical characteristics sounds and murmurs can exceed 500 c .p .s .
of the instruments employed . The frequency At the standard film speed of 100 mm . per
analysis of the vibrations of the heart sounds and second, or less, it would be impossible to re-
murmurs at the standard speed of the film cord and count these vibrations exactly .
(100 mm, per second or less) is sometimes diffi- Conventional phonocardiograms, therefore, are
cult in conventional phonocardiography . inadequate for this purpose . With high speed
The frequency characteristics of cardiac phonocardiography, on the other hand, it is
murmurs were studied by Cabot and Dodger possible to analyze the single vibrations of the
and by Williams and Dodge,' who listened to heart sounds and murmurs, to study their shape
heart murmurs through electric filters . A simi- and to count them exactly .
lar method of filtering and listening was applied
by Butterworth et al .' They found most sys-
tolic murmurs between 80 and 120 c .p .s ., most The apparatus for high speed phonocardiographyt
mitral diastolic murmurs between 40 and 100 includes the following parts : (1) A five gun oscillo-
c .p .s . and most aortic and pulmonic diastolic scope (Galileo No . R17D) with synchronized beams
murmurs between 100 and 120 c .p .s . and a Dumont 7YP7 tube . (2) A cinecamera
(Galileo No . R153V) . (3) A frequency selector
In 1938 Mannheimer described "calibrated
with five filters . These are band-pass filters having a
phonocardiography," a useful method for slope of -40 decibels per octave . The frequencies
analysis of the cardiac vibrations . Another selected were 40 to 80, 80 to 160, 160 to 320, 320
method of "calibrated phonocardiography" to 640 and 640 to 1280 .
was more recently described by Maass and This apparatus permitted the simultaneous visual-
Weber .' In 1956 Luisada and co-worker's ization and recording of two phonocardiograms, two
described the method of "selective phono- electrocardiograms, and the fifty cycles AC, which
cardiography ." "Spectral phoriocardiography" was used as a time signal . The simultaneous
(McKusick) is another development for the recording of an arterial or venous pulse instead of an
study of frequency of the cardiac vibrations . electrocardiogram or of a phonocardiogram was also
possible . The sweep speed of the electronic guns of
The method, however, is different from those
the oscilloscope could vary from 2 .5 cm . per second to
of conventional phonocardiography . 15 M . per second , so as to permit the perfect record-
According to Luisada,s one can consider
either the entire spectrum of vibrations or limit 1 Built by the 0 . T . E . Company, Florence, Italy .
' From the Institute of Physical Diagnosis of the University of Siena (Italy), directed by Prof . F . Lenzi .

JULY 1961 63
64 Caniggia, Bertelli and Lodone

Fic. 1 . Mural stenosis : diastolic murmur with presystolic accentuation, loud M,, mitral
opening snap . Top left: Simultaneous recording of two electrocardiographic tracings (V i,
V), two logarithmic phonocardiographic tracings from mitral (M) and pulmonary (P) areas,
and of 50 c .p .s. AC, as time marker . Sweep : 10 cm . per second. Bottom left, top right and
bottom right: High speed analysis of prcsystolic murmur : logarithmic phonocardiograms from
same area at a speed of 2 M . per second .

ing of any type of vibrations including those of high Heart murmurs were seen to be composed of a
frequency . series of vibrations rather irregular in shape and
The heart sounds were recorded either from two frequency with the exception of musical mur-
separate areas of the precordiutn (two phonocardio-
murs, which were made of equal vibrations
grams with the same technical characteristics were
like a pure sine wave . A study of the basic
recorded) or from the same area (two phonocardio-
frequencies' -15 revealed that the fundamental
grams with different technical characteristics were
recorded .) Crystal microphones were used . One frequencies of the greatest number of murmurs
amplifier had a flat response from 40 to 8000 c .p .s . (including the murmurs of mitral stenosis,
while another had a logarithmic response (-14 ventricular scptal defect, aortic or pulmonic
decibels at 60 c .p .s ., -8 decibels at 100 c .p .s ., stenosis and aortic or pulmonic dilatation)
-4 decibels at 400 c .p .s_, -2 decibels at 600 c .p .s ., were less than 150 c .p .s . while murmurs of
0 decibels at 1000 c .p .s .) . This system provided a aortic insufficiency were usually less than 250,
harmonic analysis of heart sounds and murmurs and and only a few musical murmurs showed fre-
an accurate study of the frequencies of the single
quencies of 300 to 350 c .p .s .st
bands examined .' - 'S
Mitral Stenosis: Figure 1 deals with a case of
RESULTS mitral stcnosis . The standard phonocardio-
gram records a harsh diastolic murmur which
MAIN VIBRATIONS OF HEART SOUNDS begins after the opening snap of the mitral
AND MURMURS valve ; the first sound is very loud . The high
Using the method described, the basic vibra- speed phonocardiograms clearly reveal the
tions of the cardiac sounds and murmurs were vibrations of the same murmur with a fre-
recorded . quency of 150 c .p .s .


High Speed Phonocardiography 65

Fie . 2 . Aorlic incompetence (two cases) . A, decrescendo aortic diastolic murmur . Top : simul-
taneous recording of two electrocardiograms (V i , Vs), two logarithmic phonocardiograrns from
mitral (M) and aortic (A) areas, and of a 50 c .p .s. AC . Sweep : 5 cm. per second . Middle :
,ame recording at 10 cm . per second. Bottom : high speed (2 .5 M. per second) analysis of
diastolic murmur . B, dcscresccndo aortic diastolic murmur . Loud As, faint aortic systolic
murmur. Top : simultaneous recording of two electrocardiograms (Vr, V) . two logarithmic
phonocardiograms front mitral (M) and aortic (A) areas and of a 50 c.p .s . AC . Sweep : 10
cm . per second . Middle : same recording at 20 cm. per second . Bottom : high speed (2 .5 M .
per second) analysis of diastolic mrmur. Both murmurs were blowing in quality ; the mur-
murs displayed on the right had a rather low periodicity .

Aortic Insufficiency : The murmurs of two cases Pulmonic Stenosis: Figure 3 deals with a case
of aortic insufficiency are presented in Figure 2 . of pulmonic stenosis . A harsh and loud
The diastolic murmur in decrescendo recorded diamond-shaped systolic murmur was recorded
over the aortic area is evident in the standard in the second left interspace (see the standard
and medium speed phonocardiogram . The and medium speed phonocardiograms on the
case in Figure 2B has a loud second sound . left) . The main vibrations of this systolic
The main vibrations of these diastolic murmurs murmur recorded in a high speed phonocardio-
are quite different in shape and frequency, being gram have a rather low frequency (150 c .p .s .) .
300 c .p .s . in the case on the left and 150 c .p .s . Tetralogv : Figure 4 shows a phonocardiograrn
in that on the right . Both murmurs had a in a case of tetralogy of Fallot following a
typical decrescendo character on auscultation . Blalock operation . The tracing shows a sys-

JULY 1961
66 Caniggia, Bertelli and Lodone

FIG . 3. Pulmonary stenosis : Harsh, diamond shaped, systolic murmur in pulmonary area .
Top left : simultaneous recording of two electrocardiograms (V I , V0), two logarithmic phono-
cardiograms from mitral (M) and pulmonary (P) areas, and of a 50 c .p.s . AC. Sweep : 5
cm . per second . Bottom left : same registration at 10 cm . per second. Top right: high speed
(2 .9 M . per second) analysis of pulmonary systolic murmur (protosystolie phase A) . Bottom
right : high speed (2 .9 M . per second) analysis of pulmonary systolic murmur (mesosystolic
phase B) .

tolic murmur in the rnitral area and a continuous selector which permits simultaneous recording
murmur in the second left interspace . The of the same sound (or murmur) in different
irregular shape of the main vibrations and their bands of frequency, a harmonic analysis was
low frequency (150 to 200 c .p .s . for the systolic made possible, thus permitting differentiation of
murmur, 200 c .p .s . for the diastolic) are revealed . the phenomenon of diaphonesis from the actual
Musical : Murmurs Figure 5 is the record of a harmonics .
"seaa gull murmur" in a case of aortic insuffi- It is well known that vibrations, especially if
ciency . The vibrations of this musical murmur extremely amplified, may appear, not only on
appear regular in the high speed phonocardio- their own frequency hands, but also on contig-
grams (B, C) . They are regularly sinusoidal uous hands, in spite of filters having a slope of
and identical to each other ; their frequency is -40 decibels per octave . This was experi-
high (300 c .p .s .) . mentally checked by means of a signal generator .
The musical murmurs are actually repre- With the harmonic analysis at the standard
sented by pure sine waves ; their frequency is sweep speed, often tall vibrations in the 80 to
high as compared to the nonmusical murmurs 160 c .p .s . band, and smaller vibrations in the
but not as high as the most "high-pitched" upper frequency bands (160 to 320 c .p .s . and
heart sounds . 320 to 640 c .p .s .), were observed . Vibrations
of high frequency exist sometimes but not al-
HARMONIC ANALYSTS OF HEART SOUNDS ways . With high speed phonocardiography
AND MURMURS it is possible to establish that the small vibrations
As our apparatus for high speed phono- recorded in the upper frequency bands arc often
cardiography iss provided with a frequency identical in frequency and shape to the main


High Speed Phonocardiography 67

NES""t, 111U11111r1 iri1r111rlpr0rtM

Fn :. 4 . Fallot's teiralogy (after Blaloek's operation) . Mitral systolic murmur (M), accentu-
ated second sound and continuous murmur at second left intercostal space (subclavicular
area) . Top left. : simultaneous recording of two electrocardiograms (V 1 , Vs), two loga-
rithmic phonocardiographic tracings from mitral (M) and left subclavicular (P) areas . and of a
50 c .p .s. AC . Sweep : 5 cm . per second . Bottom deft same recording at 10 cm. per second .
Top right : high speed (2 .4 M. per second) analysis of systolic murmur . Bottom right : high
speed (2 .4 M . per second) analysis of diastolic murmur .

vibrations recorded in the 80 to 160 c .p .s . band . The upper harmonics are negligible with nor-
Their appearance in the upper frequency bands mal amplification and can be observed only
is'then due to diaphonesis . with markedly greater amplification . Their
Diaphonesis: Figure 6 gives an example of intensity is often not greater than t/ ;o of that
diaphonesis . The vibrations recorded in the of the main vibrations, and such as to render
160 to 320 e .p .s . hand are identical in frequency, unlikely their effect on the characterization of
and similar in shape, to the vibrations recorded the sound to which they belong .
in the 80 to 160 c .p .s . hand . On the other hand, Superimposed Diaphonesis and Harmonics: Vibra-
when harmonics are really present they are tions due to diaphonesis and harmonics may he
clearly recorded in their own frequency bands . superimposed phenomena ; often harmonics
Harmonics: Figure 7 gives an example of correspond to only a few main vibrations,
second and third harmonics recorded in a case which in other tracings emerge by diaphonesis
of mitral stenosis . These vibrations belong to on the upper frequency bands . This is demon-
the accentuated first sound . These harmonics strated by Figure 8, which presents tracings
are exceptionally widespread . This is more from a case of syphilitic aortitis . A systolic
common for heart sounds than for murmurs . click is present over both the mitral (M) and
A second harmonic is often visible in our aortic (A) areas . A large diamond-shaped
tracings hut is always of smaller magnitude than systolic murmur with accentuated second sound
the fundamental vibrations . It appears with is present in the aortic record . A high speed
greater frequency near the peak of each of the phonocarcliogram shows that the main vi-
main vibrations . A third harmonic is more brations have a frequency of 150 to 200 c .p .s .
seldom recorded . Another section of the same figure presents the

JULY 1961
68 Caniggia, Bertelli and Lodone

yw se . .

FIG . 6 . Diaphonesis: diamond-shaped systolic murmur,

faint first and second aortic sounds in a case of aortic
stenosis . Top : simultaneous recording of electro-
cardiogram (V,), 50 c.p.s . AC . and of three different
frequency bands simultaneously recorded from the same
area (80 to 160 ; 160 to 320 ; 320 to 640) . Sweep : 20
cm . per second . Bottom : same registration at 2 .2 M . per
second . The principle vibrations are evenly inscribed
in frequency bands 80 to 160 and 160 to 320 .
FIG . 5 . Aortic incompetence : musical (sea gull) aortic
diastolic murmur . Top : simultaneous recording of two
electrocardiograms (VI, Vc), two logarithmic phono-
cardiograms from mitral (Mitr .) and aortic (Aort.)
areas, and of a 50 c.p .s . AC . Sweep : 5 cm . per second .
Center : high speed (2 .25 M . per second) analysis of
musical aortic diastolic murmur . Bottom : high speed
(7 M . per second) analysis of musical diastolic murmur .
Note the perfect regularity of sine waves of musical
murmur .

harmonic analysis of the same murmur at me-

dium and high speed . A second harmonic is
clearly recorded in the 160 to 320 frequency
band . The first two vibrations pass into the
160 to 320 hand by diaphonesis ; the others arc
actually the second harmonics of the funda-
mental . No harmonic is recorded in the 320 to
640 frequency band, because the amplification
is the same in all the frequency bands, and this is FIG . 7 . Second and third harmonics : harmonic analysis
inadequate for recording the high frequency of an accentuated first sound of mitral stenosis with high
vibrations . speed phonocardiography. Left : second harmonic is
clearly recorded on 160 to 320 c.p .s . frequency band .
Harmonic analysis can be done with greater Right : third harmonic is clearly recorded on 160 to 320
amplification in the upper frequency bands in c .p .s . frequency band . Sweep : 2 .2 M . per second .


High Speed Phonocardiography 69

sic . 8 . Hu>monic analysis of aortic systolic murmur (luetic aortitis) : diamond-shaped aortic
systolic murmur, accentuated A 2 , protosystolic click . Top lvfb simultaneous recording of two
electrocardiograms (V, . Vu), two logarithmic phonocardiograms from initial (M) and aortic
(A) areas, and of a 50 c.p.s. AC . Sweep : 10 cen . per second . Bottom left : high speed (2 .4 M .
per second) analysis of systolic murmur . Top right simultaneous recording of electrocar-
diogram (V,), 50 c .p .s. AC, and of three different frequency bands simultaneously recorded
from same area (80 to 160 : 160 to 320 ; 320 to 6411) . Sweep : 20 cm . per second (medium
speed harmonic analysis) . Bottom right high speed (2 .4 M . per second) harmonic analysis
of systolic murmur. Note the good inscription of second overtone on three last fundamental
vibrations .

order to record vibrations which otherwise The amplification required reveals that the
would not be visible . Harmonic analysis in a energy of the upper harmonic vibrations is
case of aortic insufficiency is presented in Figure small (about I/ s of the main vibrations) .
9 in order to study the blowing diastolic murmur
"in decrescendo ." The high speed phone-
cardiogram at standard amplification shows a From a theoretic point of view, high speed
good reproduction of the second harmonic phonocardiography has particular interest as it
(160 to 320 frequency band) ; the higher har- permits recording and description of the fine
monics (320 to 640 frequency band) are very details of the sound vibrations of the heart
small and sparse . sounds and murnu rs . The various component
The amplification is five times greater in the parts of these murmurs are distinctly recorded
160 to 320 frequency band and ten times greater so that it is easy to establish their frequency and
in the 320 to 640 frequency band . The second form .
harmonic appears in the 160 to 320 frequency A complete study by means of harmonic
band where some fundamental vibrations are analysis allows one to recognize with certainty
also recorded by diaphonesis (third, fourth, the harmonics corresponding to each basic
fifth) . In the 320 to 640 frequency band, vibration, a fact which has practical value .
harmonics are well recorded : second harmonic In fact, students of phonocardiography always
of the third (fundamental) vibration, third tried to increase their knowledge of the fre-
harmonic of the fourth and fifth, and fourth quency of vibrations of heart sounds and mur-
harmonic of the sixth vibration . murs . High pitched murmurs, for example, are

JULY 1961
70 Caniggia, Bertelli and Lodone

aortic insufficiency than in mitral stenosis, even

when the murmur is "musical ."


High speed phonocardiography makes it

possible to analyze objectively and in detail
the vibrations of heart sounds and murmurs .
The apparatus for high speed phonocardiog-
raphy includes a cathode ray oscilloscope with
five independent electronic guns and a sweep
speed which can range from 2 .5 cm . per second
to 15 M . per second . This phonocardiographic
equipment is provided with a frequency selector
of the "pass-band" type which permits the simul-
taneous recording at high speed of the same
sound analyzed at various frequencies (harmonic
analysis) .
Heart murmurs arc composed of vibrations
which are irregular in shape and frequency .
Only the musical murmurs are composed of
vibrations of similar amplitude, following a
pure sine wave . With the above technic, the
main frequencies were found in the range 100 to
150 c .p .s . for mitral murmurs, in the range
150 to 250 c .p .s . for the murmur of aortic in-
sufficiency . The highest-pitched murmurs are
"musical' (300 to 350 c .p .s .) .
High speed harmonic analysis clearly records
harmonics when they really exist . The second
harmonic is often recorded and its intensity is
about 1/,, of the basic vibrations . The upper
harmonics are negligible with average ampli-
fication and can only be recorded with greatly
increased amplification .

FIG . 9 . Harmonic analysis of diastolic murmur (aortic in-
competencc) : decrescendo blowing murrcmr . Top : 1 . CABOT, R . C. and DODGE, H . F . Frequency
simultaneous recording of electrocardiogram (V,), 50 characteristics of heart and lung sounds,
c .p.s. AC, and of three different frequency bands J.A .M .A ., 84 : 1794, 1925 .
simultaneously recorded from same area (80 to 160 ; 2 . WILLIAMS, H . B . and DODGE, H. F . Analysis of
heart sounds . Arch . Int . Med., 38 : 658, 1926 .
160 to 320 ; 320 to 640) . Sweep : 5 cm . per second .
Center, high speed (2 .4 M . per second) harmonic analysis 3, BUTTERWORTH, J . S ., CH.ACslN . .M . and MCGRATH .
R . Cardiac Auscultation. New York, 1955 .
of diastolic murmur . Bottom : high speed (2 .4 M. per
Grune and Stratton .
second) harmonic analysis of diastolic murmur . Am-
4 . MANNHRIMER, E . Calibrated phonocardiography .
plification of frequency bands 160 to 320 and 320 to
Acta Paediat. Scaadinav ., suppl . 2 : 28, 1940 .
640 . Detailed description in text .
5 . MAAss, H . and WEBER, A . Herzschalt Registrienulg
mittels differenzierender Filter . Cardiologia, 21 :
773 . 1952 .
6 . LuisxnA, A . A., RICHMOND, L . and ARAVANIS, C .
characteristic of certain val ular diseases and
Selective phonocardiography . Am . Heart J., 51 :
not of others, so that determination of the basic 221, 1956 .
frequency can have diagnostic value . 7 . McKusucx, V. A . Spectral phonocardiography :
High speed phonocardiography supplies more current status as a research, clinical and teaching
precise information concerning the frequency of tool . Circulation, 12 :744,1955 .
8 . LUISADA, A. A . Symposium on phonocardiography .
a sound than that derived from conventional
Introduction . Am . J. Cordial ., 4 : 1, 1959 .
phonocardiography . For example, the dias- 9 . Z.ALTER, R ., HODARA, H . and LmsxoA, A . A.
tolic murmur has a higher average frequency in Phonocardiography . i . General principles and


High Speed Phonocardiography 71

problems of standardization . .Nn . J. Cardiol ., 4 : 13 . CANIOGIA, A ., BERTELLI, G. and LODONE, M .

3, 1959 . Analisi armonica dci rnmori cardiaci condotta
10 . CANIGGIA, A., BERTELLI, G . and LODONE, M . con la fonocardiografia ad alta velocitA . Cuore e
Fonocardiografia ad alta velocitA . Boll. Soc . ital . circolaz ., 44 : 103, 1960 .
biol, spec., 35 : 218, 1959 . 14 . CANIGCIA, A., BERTELLI, G- and LODONE, M .
11 . C.ANloriA . A . Analisi dei rnmori cardiaci musicali High speed phonocardiography in aortic in-
con la fonocardiografia ad alta velocitA . Boll . sufficiency . Cardiologia . In press .
Soc . ital . cardiol ., 4 : 321, 1959 .
12 . CANIGGLA . A., and BERTELLI, G . Fonocardiografia 15 . CANIGGIA, A . and BERTELLI, G . High speed
ad alta velocitA : analisi dclle vibrazioni com- phonocardiography : analysis of the vibrations
ponenti i tool ed i sof l cardiaci . Minerva cazdio- of the heart sounds and murmurs. Panminerva
angiol . 8 : 249, 1960 . Med. In press.

JULY 1961