Stethoscopic auscultation is by no means the simple operation which many physicians believe it to be. It is an art which must be learned through long practice, and is attainable to its fullest extent only by those who possess, in the first place, a thorough knowledge of the anatomy of the organs contained within the thoracic cavity,—both the gross anatomical relations of the different organs and the minute structure of the different subdivisions of the pulmonary mass. A good knowledge of the mode of action of all this vascular and respiratory machinery, under normal conditions, is also necessary. He who really becomes an expert in the art of successful auscultation must necessarily be equipped with a knowledge of the different acoustic phenomena that present themselves to the examiner’s hearing under the various pathological states to which both the heart and the lungs are liable. All these facts are brought out with great fulness of detail by Laënnec in the second edition (1826) of his treatise. (I have not examined the English translation of Laënnec’s treatise, but presumably all these details have been accurately reproduced in that version.) A man without a delicate sense of hearing and a well-trained imagination,—which latter gift may truly be said to be possessed by comparatively few of those who practice medicine,—will soon confess to himself that he is able to gain only a very meagre modicum of satisfactory information from the practice of the art of auscultation.

Laënnec reports a large number of cases in which various pulmonary and pleural disorders developed as complications of the original affection, and in each such case he mentions in full detail all the phenomena that were discovered on auscultation and percussion of the chest. Some of these histories are extremely interesting; they constitute a rich mine of clinical data from which the practicing physician may draw a great fund of useful information. A mere list of the headings of these reports would fill several of the pages of this treatise. From the statements already made the reader is likely to infer that Laënnec is particularly strong in his presentation of the facts relating to the pathological anatomy of pulmonary and cardiac diseases, as well as in his treatment of the subject of auscultation in all its phases; and in drawing this inference he would be wholly in the right. Laënnec’s treatise furnishes an exhaustive and thoroughly practical discussion of the various diseases of the heart and lungs, and stands for all time as a glorious monument in his honor.

Magendie, speaking before a class of medical students at Hôtel-Dieu about the difficulties which the physician occasionally encounters in his efforts to interpret correctly the significance of certain sounds heard during auscultation, narrates the following experience:—

Here, gentlemen, is the heart of a young woman who recently died in this hospital. I believe that I have already published an account of her case, which is one of exceptional interest; but, however this may be, I remember perfectly well all the details of the results ascertained (during life) by a careful auscultation of her heart. The first sound was heard without any difficulty, but the second one was entirely lacking. What, it will be asked, was the cause of this phenomenon? At first I was disposed to believe that she was affected with hydrothorax, but, when I came to make a more careful examination, I was obliged to reject this hypothesis; and, although I suspected that the absence of the second sound was due to an obstacle of a mechanical nature,—one that nullified the stroke communicated by the heart to the sternum,—I was unable to form any idea as to the real nature of this obstacle. The present autopsy furnishes the desired explanation. As a result of a former attack of pericarditis the anterior surface of the heart was covered with a thick layer of false membranes; ... the tip of the organ, on the other hand, still preserved its usual smooth and polished aspect.... In my judgment the interposition of false membranes, which had been deposited upon the surface of the heart, acted as a cushion, thus preventing the transmission of the sound by annulling the shock which would otherwise result from the blow upon the sternum. Lower down, at the tip of the organ, where no false membranes had been deposited, the blow upon the thorax, caused with each systole of the heart, produced the normal degree of noise.

(From Magendie’s “Leçons sur les Phénomènes Physiques de la Vie.”)

I should perhaps add here the statement that Laënnec’s researches into the question of auscultation of the chest were made at the Necker Hospital in Paris, and extended over a period of eighteen years.

The Faculté de Médecine and the Cathedral at Montpellier, France.
(Courtesy of Monsieur le Pasteur Paul Barnaud, of Sainte Foy la Grande [Gironde], France.)

Paul-Joseph Barthez, one of the most distinguished physicians of France during the eighteenth century, was born at Montpellier on December 11, 1734. His father, who was a civil engineer and well known as a clever mathematician, practiced his profession at Narbonne, and it was there that the son spent the first years of his life. At a very early age he manifested a decided love for study, and his parents took great pains with his education. During the period of youth he displayed two marked characteristics—sincerity and very little inclination to indulge in social pleasures. On more than one occasion he submitted to chastisement rather than to tell a lie. As he advanced in age he showed a marked tendency to choose an ecclesiastical career, but his father was not at all disposed to encourage him in such a choice, and finally induced him to give the preference to medicine. Accordingly, Paul-Joseph, during the month of November, 1750, was enrolled as a medical student at the University of Montpellier. Three years later he passed the required examinations with great credit and was given the degree of Doctor of Medicine. In 1761 he made his first appearance at Montpellier as a lecturer and met with a fair degree of success. Up to this time he had experienced a good deal of anxiety caused by his pecuniary troubles, but during the succeeding years his practice steadily increased and he was soon relieved from this source of trouble. In 1781, after the death of Dr. Tronchin, he was called to Paris to take the doctor’s place as the private physician of the Duke of Orleans. In the meantime, despite the greatly disturbed condition of political affairs in Paris, and also despite the persistent efforts of his enemies to drive him out of the capital, Barthez managed to accumulate a fortune amply sufficient for all his reasonable needs. In 1802 the First Consul, Bonaparte, appointed him and Corvisart Government Physicians,—Barthez for Montpellier and the southern part of France, and Corvisart for Paris and the northern part; and, a little later, Barthez was appointed Bonaparte’s Consulting Physician.