A pulmonary early systolic sound was investigated in 50 patients. It may be mistaken for splitting of the first heart sound but is loudest in the pulmonary area, and it has been helpful in clinical diagnosis.Extra sounds in systole were known to Cuffer and Barbillon (1887). Potain (1900) described systolic gallop rhythm when the extra sound was loudest in the aortic area in cases of aortic atheroma and in typhoid fever, and he attributed this sound to the sudden checking of aortic expansion. Wolferth and Margolies (1940) came to the conclusion that this description concerned a rare midsystolic sound. Gallavardin (1913) described late, occasionally mid-systolic, clicking sounds, different in quality from the heart sounds, usually loudest at the apex and varying with the phase of respiration; he considered them of extracardiac origin and found pleuro-pericardial adhesions in three cases. Subsequent authors including Lian and Deparis (1933), Johnston (1938), andEvans (1943) confirmed that mid or late systolic clicks were of no significance except in differential diagnosis. An exception is the systolic clicking sound in cases of mediastinal emphysema and left-sided pneumothorax (Hamman, 1937;Scadding and Wood, 1939). Mid or late systolic clicks or sounds, or " gallops " will not be considered in this paper.An early systolic sound (claquement protosystolique) was heard and recorded by Lian and his collaborators (1937, 1941, 1951) at the pulmonary area in patients with pulmonary stenosis and with dilatation of the pulmonary artery, and at the aortic area with aortic valve disease. It had been described by Petit (1902). Wolferth and Margolies (1945) stated that they had recently become aware of a sound in early systole which they had either overlooked or mistaken for the second component of a split first sound, and attributed it to the opening of the semilunar valves. Arrilaga and Taquini (1941) had reported a similar sound in one case of pulmonary stenosis and called it the semilunar opening click.Method of Investigation. Routine diagnostic cardiac catheterization had been performed in all but 4 of 50 consecutive patients in whom an obvious early systolic sound was heard in the pulmonary area. A larger number of cases without this sound on clinical auscultation but showing some or all of the cardiac abnormalities found in the positive group, were used as control cases. The clinical examination in each case included special attention to the first sound and to added systolic sounds in the mitral, tricuspid, pulmonary, and aortic areas. The intensity of the pulmonary sound was graded from one to four in expiration and in inspiration, and in relation to upright and reclining postures. Enlargement of the main pulmonary arc (pulmonary trunk and left branch) and of the right pulmonary artery were separately graded from one to four by means of teleradiograms in anterior and oblique views. Electrocardiographic evidence of ventricular hypertrophy was also graded and, to obtain some indication of the degree of ventricular asyn...

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A clinical and phonocardiographic study has been made of the murmurs and heart sounds in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact septum and right-toleft interatrial shunt. A striking difference in the behaviour of the systolic mnurlmur was found in the two conditions and this affords a new, simple bedside method of diagnosis. Important differences in the behaviour of the heart sounds were also found, but these are usually more difficult to evaluate clinically and may require special study.