IviETHODS
Handy Heart Sound Simulator
J. NATHANIEL SANDERSON, MD
Washington, D.C.
From the Division of Cardiology, Department of
Medicine, Georgetown University Hospital,
Washington, D.C. This study was supported in
part by the Benjamin May Memorial Fund, Met-
ropolitan Heart Guild, Washington, DC. and
grants from the U.S. Public Health Service, Be-
thesda, Md. The paper was submitted while the
author was on active duty in the U.S. Air Force
as a Fellow in Cardiovascular Diseases at
Georgetown University Hospital, Washington,
D.C. Manuscript accepted April 23. 1975.
Address for reprints: J. Nathaniel Sanderson,
MD, MAJ USAF MC, Division of Cardiology,
David Grant Medical Center, Travis Air Force
Base, Calif. 94535.
A simple bedside technique of heart sound simulation using hand and
stethoscope is described. The technique utilizes tissue vibration and
sound conduction with the usual air column of a stethoscope to repro-
duce auscultatoiy events accurately without the distortion that often
accompanies electrical production of heart sounds.
With increasing awareness of the significance of auscultatory cardiac
findings, medical educators have utilized various techniques and ap-
paratus to reproduce and simulate heart sounds. These have ranged
from verbal imitation to expensive electronic heart sound simulators.
In addition, libraries of heart sound recordings have been developed
in some centers. Although not inordinately cumbersome, the elec-
tronic apparatus do not always readily lend themselves to instanta-
neous and impromptu bedside teaching. Smaller pocket-sized cas-
sette recording devices provide a source for instant and repeated re-
play of observed physical findings, but are limited to records of the
sounds of an individual patient or those in a library of recorded
sounds. The following simple technique can be utilized to expand the
availability of heart sound simulators and meet the needs of a greater
number of medical educators and students.
Technique
The basic technique involves grasping the stethoscopic chest piece with the
diaphragm against the palm (Fig. 1). Simple heart sounds can then be repro-
duced by tapping the back of the forearm or hand holding the chest piece
with the opposite index finger (Fig. 2). The frequency and intensity of the
sound are dependent upon the area tapped (distance up the forearm) and the
vigor of the tap. Crisper, more intense sounds are created by tapping the
back of the hand. Softer, lower frequency sounds are created by taps over the
forearm. The simulation of first heart sounds (Si), second sounds (Sz), physi-
ologic third heart sounds or ventricular diastolic gallops (Ss), atria1 diastolic
gallops (Sd), opening snaps (OS), ejections sounds and systolic clicks is de-
pendent upon selection of the proper frequency and timing.
Triple rhythms: The triple rhythm of a ventricular diastolic gallop is pro-
duced by rhythmically tapping the wrist and mid and proximal forearm (Fig.
2). The distance between the areas tapped helps to establish the timing inter-
vals. In close intervals, as in the splitting of the second heart sound, it may be
necessary to use the middle and index fingers of the tapping hand sequential-
ly as in thumbing the fingers on a desk (Fig. 3). This can easily be expanded
to the triple sound of the aortic and pulmonary components of the second
heart sound and opening snap by adding the ring finger (Fig. 4). The rhythm
of an atria1 diastolic gallop (SJ is simulated in a similar fashion but in re-
verse order (Fig. 5).
Murmurs: Murmurs are produced by rubbing the back of the hand in var-
ious ways depending upon the type of murmur desired. The murmur of mi-
tral regurgitation can be simulated by tapping with the middle finger, then
lightly dragging it across the back of the hand and terminating the murmur
with the second heart sound by tapping with the index finger (Fig. 6). If less
than a holosystolic murmur is desired, the whole sequence should be per-
formed by the index finger since lifting the finger to tap for the second sound
December 1975 The American Journal of CARDIOLOGY Volume 36 925
HEARTSOUND SIMULATOR-SANDERSON

bell down, or held by an observer to free the tapping finger

of the opposite hand. The thenar eminence is placed on the
diaphragm. The thumb is flexed as described after the pro-
duction of the first and second heart sounds and opening
snap. For the more nimble-fingered, a systolic murmur can
also he added. The rhythm of atria1 fibrillation can easily
be simulated by changes in the cycle intervals.
Friction rubs: Pericardial friction rubs are produced by
scratching the back of the hand with the index fingernail in
a rhythmic fashion to create the characteristic of three
FIGURE 1. The stethoscopic chest piece is held with the diaphragm components. The presystolic or atria1 component is closely
against the palm. followed by a louder ventricular systolic component and
then the ventricular diastolic component to produce a 1,
Z:i rhythm. The leathery sound of a pleural friction rub
can be produced by pinching the distal index finger and
terminates the murmur (bottom, Fig. 6). A late systolic
thumb of the fisted empty hand together, pushing the
murmur can be produced by lifting the tapping finger after
thumb up the distal phalanx. The sound is transmitted to
the first heart sound, before the onset of the murmur.
the closed hand holding the chest piece by simply touching
The harsh systolic murmur of aortic stenosis is simulat-
the hands together (Fig. 10). The reproducibility of these
ed in a different fashion. The thumb of the opposite hand
sounds varies with the oil and moisture of the hands since a
is pressed firmly against the back of the hand holding the
fair amount of friction is required. Often placing an index
chest piece to ensure increased friction. The thumb is then
card between the index finger and thumb while performing
pushed for approximately 2.5 to 5 cm depending upon the
the same maneuver will provide the desired effect.
duration of the murmur desired (Fig. 7). The addition of a
Thr unique sound of mediastinal emphysema can be
diastolic blowing murmur can be achieved by softly drag-
produced by touching the diaphragm to the cupped palm of
ging the thumb with less friction back to the original posi-
the left hand. The diaphragm will stick to the palm. As the
tion. The change in direction of the motion of the thumb
diaphragm is gently lifted and as it breaks contact with the
often produces a skin “pop” that conveniently simulates
skin, the characteristic “crunching” sound is produced
the second heart sound (bottom, Fig. 7). A continuous mur-
(Fig. 11). To create a more realistic effect, rhythmic light
mur is simulated by rubbing the back of the hand in a cir-
pressure and elevation must be employed to produce the
cular motion (Fig. 8). The crescendo effect is created by
typical three components similar to those produced by a
heavy and light pressure during alternate halves of the cir-
pericardial friction rub. Rales can be simulated by lifting
cle.
the chest piece very slowly to prolong releasing the skin-
The simulation of the rumble of mitral stenosis requires
diaphragm contact.
removal of the chest piece from the closed hand. The dia-
phragm is placed on the thenar eminence at the base of the Discussion
thumb. With the chest piece in this position, the thumb is
flexed, producing a muscle tremor that simulates the rum- The quality of’ reproduction is surprisingly good
ble (Fig. 9). The addition of the first and second heart especially if no electronic amplifiers are interspaced
sounds and the openingtsnap preceding the rumble re- between the stethoscope and the observer’s ears. The
quires that the chest piece be placed on a stable surface. “phonocardiograms” accompanying the figures were

FIGURE 2 (left). Sequential tap-

ping with the index finger pro-
duces the first (St) and second
(S,) heart sounds and a ventricu-
lar diastolic gallop (SB). The inten-
sity and quality of the sound pro-
duced depend upon the area
tapped and the vigor of the tap.

FIGURE 3 (right). Tapping first

with the middle finger and then the
SOFTER \ middle finger and index finger in
LOWER rapid succession produces the
FREQUENCY first heart sound and both the aor-
SOUNDS \ tic (A*) and pulmonary (P2) com-
ponents of the second heart
sound or the aortic component
and opening snap (OS), depending
upon the interval. Respiratory
variation of splitting of the second
sound is easily produced by
changing the interval between the
middle and index finger taps

926 December 1975 The American Journal of CARDIOLOGY Volume 36

 HEART SOUND SIMUl_ATOFl-SANDERSON

FIGURE 4 (lefl). The triple sound of the

aortic valve closure (As), pulmonary
valve closure (P2) and mitral opening
snap (OS) is produced by sequentially
tapping with the ring, middle and index
fingers.

FIGURE 5 (right). The rhythm of an atrial

diastolic gallop (S4) is produced by first
tapping sequentially with the middle and
index fingers over the upper forearm and
then giving a single tap over the wrist.

FIGURE 6 (left). A holosystolic mur-

mur (SM) is created by softly dragging
the middle and ring ringers across the
back of the hand and wrist, terminat-
ing the motion by tapping the index
finger (top “phonocardiogram”). A
less than holosystolic murmur is
created by performing the entire ma- SM SM
neuver with just the index finger (bot-
tom “phonocardiogram”). SM = sys-
tolic murmur.

FIGURE 7 (right). A harsh systolic

murmur (SM) is produced by pushing /
the thumb across the back of the / I ’ i 1
hand. A soft diastolic murmur (DM) is
produced by softly dragging the
thumb back to the original position.
The change in direction of the thumb
motion may, but does not invariably,
produce a skin “pop” that simulates
the second heart sound.

FIGURE 6 (left). A continuous

murmur (CM) is produced by
rubbing the hand in a circular
fashion with light and firm
pressure in alternating halves
of the circle. The alternating
pressure creates the crescen-
do and decrescendo portions
of the murmur.
FIGURE 9 (right). The diastol-
ic rumble (DR) of mitral steno-
sis is simulated by the muscle
tremor produced by flexing the
thumb. The addition of the first
and second heart sounds and
cm
opening snap (OS) is as shown
in Figure 3 and requires that
the chest piece be rested
upon a stable surface or held
by an observer. : I I

December 1975 The American Journal of CARDIOLOGY Volume 36 927

HEART SOUNO SIMULATOR-SANOERSON
recorded on a Cambridge physiologic recorder using
the techniques described and differ little from those
produced by actual heart sounds. The authenticity of
the simulated sounds produced is probably related to
the similarity between the tissue vibration and sound
conduction in this technique and those encountered
in the production of physiologic heart sounds. The
amount of practice required to master the method
varies. It may be necessary to experiment with the
described techniques and to modify them while lis-
tening to the sounds produced before transferring the
stethoscopic earpiece to the student. A stethoscope
928 December 1975 The American Journal of CARDIOLOGY
FIGURE 10 (left). A leathery pleural fric-
tion rub is produced by rubbing the
thumb and index finger together. The
sound is transferred to the hand holding
the stethoscope by touching the hands
together. Pinching the index card be-
tween the thumb and index finger while
performing the maneuver will provide ad-
ditional friction if necessary to produce
the desired effect.
FIGURE 11 (right). The sound of medi-
astinal emphysema is produced by allow-
ing the diaphragm to stick to the palm
then rhythmically applying light pressure
and elevation to break the diaphragm-
skin contact.
with multiple head sets provides the easiest means
for the person producing the sounds to monitor his
efforts.
In summary, the technique provides an inexpen-
sive versatile, highly portable heart sound simulator
readily available at any medical facility.
Acknowledgment
I thank Drs. Jack B. Taylor, William C. Roberts and W.
Proctor Harvey for their encouragement during the devel-
opment of this technique. I also thank Mrs. Trudy Nichol-
son for her skillful assistance in preparation of the illustra-
tions.
Volume 38