The Value of the Pulmonic Second Sound. 
Read in the Section on Practice of Medicine at the Forty'-seventh 
Annual Meeting of the American Medical Association held at 
Atlanta, Ga., May 5-8, 18%. 
BY J. N. HALL, M.D. 
PROFESSOR OF THERAPEUTICS AND CLINICAL MEDICINE, UNIVERSITY OF 
COLORADO, DENVER, COLO. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 
JUNE 27, 1896. 
CHICAGO: 
American Medical Association Press. 
1806. THE VALUE OF THE PULMONIC SECOND 
SOUND. 
BY J. N. HALL, M.D. 
My object in presenting this paper is to call atten- 
tion to a well-known but much neglected subject, the 
investigation, in diseases of the chest especially, of 
the character of the second sound at the orifice of the 
pulmonary artery. It appears to me that many physi- 
cians, although gauging quite accurately the tension 
in the systemic circulation, by means of the pulse and 
the character of the aortic second sound, pass over as 
almost unworthy of notice the examination of the 
pulmonic area. And yet, in a few seconds, with the 
stethoscope as much may be learned of the conditions 
of the circulation in the lungs as has been learned, at 
the aortic area, of the systemic circulation. 
In diseases of the mitral valve, whether obstructive 
or regurgitant, all authorities agree as to the import- 
ance of the accentuation of the pulmonic second 
sound, in deciding as to the degree of obstruction in 
the pulmonary vessels. One may probably, with 
safety, go even further than most authors go, in the 
case of an apical systolic murmur, which has existed 
for some time, and say, given such a murmur, not 
transmitted greatly to the left, without enlargement 
of the cardiac area, and without accentuation of the 
pulmonic second sound, that probably no serious 
change has taken place in the valve. In other words, 
it is a crucial test when one is in doubt as to the char- 
acter of an apical systolic murmur, and, I believe, not 
appreciated at its full value. 
This sound is equally available in case of a mitral 
obstructive lesion in forming a correct judgment as to 2 
the degree of obstruction, and the degree of compen- 
sation as well. In case of doubt as to whether a pre- 
systolic murmur at the apex were due to mitral ob- 
struction or to aortic regurgitation (Flint’s murmur), 
the absence of marked accentuation of the pulmonic 
second sound would weigh decidedly in favor of the 
integrity of the mitral valve, although I have not 
found this point mentioned in any of the treatises 
upon this subject. 
In chronic disease of the chest of whatever nature, 
a marked accentuation of the second sound at the 
pulmonic orifice is of grave prognostic import, indi- 
cating a decided obstruction to the circulation in the 
vessels involved, although indicating as well an 
hypertrophy of the right ventricle to meet the in- 
creased demand. Whether the obstruction be from the 
destruction of capillaries in emphysema, the contrac- 
tion of the interstitial tissue in fibroid phthisis, or the 
combination of destruction of tissue, infiltration of 
the new products and possibly other processes in ordi- 
nary tuberculosis, it indicates serious trouble. 
A knowledge of the value of this sign may at times 
save one from serious error, as in the following case, 
seen in consultation some years since: A girl, six 
years of age, had presented for five days all the 
rational signs of acute lobar pneumonia, but the 
attending physician had been unable, after repeated 
examinations, to locate the disease. Finally, fearing 
that some other trouble was setting in, he asked me 
to see the case with him. 
After hearing the history I confidently expected to 
find the signs of pneumonia in the left chest, and was 
surprised to find the fronts entirely normal, so far as 
I could determine. Because of the child’s weakness, 
it was proposed to me that the examination of the 
back be omitted, but, having noted a decided accentu- 
ation of the pulmonic second sound, and called the 
attending physician’s attention to it, I insisted upon 
the complete examination, confident that anything of 
sufficient gravity to cause a decided increase in the 3 
tension in the pulmonic artery, must be discoverable 
upon careful examination. The back was found nor- 
mal, however, with the exception of an area two inches 
in diameter near the lower angle of the left scapula; 
here very moderate dulness existed, but the auscula- 
tory signs were marked, namely, bronchial respiration, 
bronchophony and moist rales. It was evidently an 
acute pneumonia which approached the surface of the 
lung only at this point, and, to one not fairly expert 
in physical diagnosis, not easy to discover. I admit, 
of course, that no physician should overlook such 
signs, but they were overlooked by the attendant in 
this case, and by a previous consultant. If the two 
had appreciated the meaning of the decided accentua- 
tion of the sound in question, they would probably 
have been led to make a successful search for the 
cause of it. 
Other instances of somewhat similar nature might 
be quoted, but this one will suffice for illustration. 
I believe that most of the present generation of 
physicians in active practice were taught that the 
murmurs at the pulmonic orifice were not only rare, 
but of comparatively little importance. The effect of 
this teaching has been to lead many of us to entirely 
neglect all sounds at this orifice in ordinary examina- 
tions, for I have often seen its area passed by without 
so much as the touch of the stethoscope. Inasmuch 
as a proper idea of the amount of obstruction in the 
pulmonic circuit in pneumonia, and hence of the 
amount of wTork called for from the right ventricle—a 
most important factor in prognosis and in deciding 
upon the advisability of administering cardiac stimu- 
lants—can not be obtained without an examination of 
the sound in question; nor a correct judgment be 
formed, in a case of chronic bronchitis, as to whether 
there is beginning obstruction, and consequent hyper- 
trophy of the right heart, from emphysema which has 
not yet developed sufficiently to be patent to percus- 
sion, it would seem to be proven, when the evidence 
we have heretofore adduced is considered, that this 4 
sound should be investigated in every day practice 
exactly as other accessible chest sounds are, the ease 
with which such examination can be made being a 
powerful recommendation of the procedure.