A BRIEF HISTORY OF PHYSICAL DIAGNOSIS* By HORACE MARSHALL KORNS, M.D. IOWA CITY, IOWA

“The history of a science is the science itself.”

HE eponymous designation of to employ bedside methods extensively, a certain facies, abnormality of and after his death (1738) his pupil, the finger nails, and splashing Gerhard van Swieten, carried on his sound within the thorax makes work. In 1745, at the invitation of the it difficult for any student of medicineempress Maria Theresa, van Swieten Tto remain ignorant of the fact that the removed to Vienna, where he was in- golden age of physical diagnosis began trusted with the task of reorganizing with Hippocrates. If unbridled curios- medical education. In 1753 he opened ity and a suspicion that one should study a teaching clinic at the old Bürgerspital, subjects rather than textbooks drive with Anton de Haen, also a pupil of him further, he will learn that after the Boerhaave, in charge. The great success death of Hippocrates more than twenty- of this experiment established for all one gloomy centuries dragged out their time the superiority of practical bedside weary length before another important instruction over purely theoretical contribution was made. Despite this methods of teaching, but the manifold prodigious interim, a striking similar- possibilities of clinical medicine never ity of ideas links Hippocrates so closely could have been realized fully without to his remote heirs and successors that much better methods of physical ex- the ancient and modern epochs may amination than were available in the logically be regarded as consecutive eighteenth century. Anyone occupying phases of the same great era. The mod- a position such as de Haen’s might have ern period began auspiciously in 1761 been expected at least to welcome prom- with the publication of Leopold Auen- ising new methods, if not to originate brugger’s “Inventum novum ex per- them, but de Haen, in spite of his great cussione thoracis humani ut signo ability as a clinician and teacher, was an abstrusos interni pectoris morbos dete- egregious bigot who went out of his way gendi,” a little monograph of ninety- to hate all innovations. Notwithstand- five pages based on seven years’ experi- ing the fact that he himself practiced ence with a new method of physical percussion of the abdomen, because examination of the chest—immediate Hippocrates, whose passionate disciple percussion. The light which thus burst he was, had done so, he greeted Auen- upon almost total darkness was as brugger’s great invention with sneers, timely as it was brilliant. which was quite in keeping with his The eighteenth century was notable character. Even the more enlightened for the rise and spread of systematic and usually receptive van Swieten, to clinical instruction in medicine. Boer- whom the “Inventum novum” was vir- haave, at Leiden, was one of the first1 tually dedicated, ignored it completely. *Presented to the Medical History Club of the State University of Iowa, October 16, 1935. It is always easier to condemn than to service in 1762 he devoted himself en- test by actual experience, as Laënnec tirely to his practice, and became one observed. of the most sought after physicians of Joseph Leopold Auenbrugger was Vienna. Garrison characterizes him as born in 1722 at Graz, in Lower Austria. “grave, genial, inflexibly honest, unas- After graduating at Vienna he served suming and charitable, loving science from 1751 until 1762 as physician to the for its own sake, . . . a noble example Spanish Military Hospital, where his of the substantial worth and charm of work on percussion was done. There is old-fashioned German character at its no doubt that he appreciated the sig- very best.” He died in 1809 at the ad- nificance of his contribution, but the vanced age of 87 years. willful disregard and open hostility Great as was the impetus imparted to with which it was received neither physical diagnosis by Corvisart’s revival surprised nor disturbed him. The path of Auenbrugger’s neglected invention, along which it moved slowly toward it is doubtful whether the remarkable universal recognition and acceptance advances of the nineteenth century was not opened until 1776, when Maxi- would have followed each other so rap- milian Stoll was chosen to succeed the idly without the stimulus of another now defunct de Haen. Stoll, under famous invention, the stethoscope. Im- whose brilliant leadership the Old Vi- mediate auscultation had been prac- enna School reached its zenith, intro- ticed, presumably for the most part in duced percussion into the teaching desultory fashion, by Hippocrates, clinic and referred to it several times in Aretaeus, Galen, Harvey, de Sénac, von his writings. A paper on percussion by Haller, Boyle, Hooke, Bayle, Bichat, one of his pupils, Josef Eyerel, fell by Corvisart, and probably many others, chance into the hands of Jean Nicolas but no systematic attempt to explore Corvisart (1755-1821), the celebrated the manifold potentialities of ausculta- French clinician, and aroused his in- tion as a special method of physical di- terest to such an extent that he sought agnosis had ever been made. The great and obtained a copy of Auenbrugger’s merit of Laënnec’s invention lay not so monograph. Realizing at once that the much in the instrument itself as in the method was worthy of serious considera- fact that it served to focus the attention tion, he began to practice it diligently. of the entire medical world on the aus- Twenty years later (1808) he published cultatory method. Rolleston, in his the results of his studies, together with Harveian oration (1928), expresses this an unabridged translation of the “In- idea as follows: ventum novum,” in his “Nouvèlle méthode pour reconnaitre les maladies Though the stethoscope has some ob- internes de la poitrine par la percussion vious advantages over the naked ear, the de cette cavité.” It was this book, backed enormous advances that followed its in- troduction were not so much due to the by Corvisart’s great prestige, which res- stethoscope as a mechanical instrument cued percussion from oblivion and es- as to the psychological effect that this new tablished it securely as one of the most method exerted on Laënnec, who other- important methods of physical diagno- wise would not have so ardently pursued sis. Auenbrugger lived just long enough auscultation as a means of diagnosis. It to enjoy this striking confirmation of was much the same with regard to the his work. After he retired from hospital pleximeter introduced by Piorry . . . in 1828, which in itself, apart from its tem- two years had succeeded in accumulat- porary influence in stimulating investiga- ing the material for his great “Traité de tion, is inferior as a method of eliciting l’auscultation médiate” (1819). The la- physical signs to Auenbrugger’s direct bor of preparing this treatise exhausted percussion which it was intended to super- the author’s slender physical resources, sede. forcing him within a month after its Réné Théophile Hyacinthe Laënnec publication to give up his work and re- was born in 1781 at Quimper, in Lower tire to his native province. Two years Brittany. After a period of excellent later, apparently restored to health, he preliminary training at Nantes, under returned to Paris and immediately re- the wise tutelage of his uncle, who was sumed his duties at l’Höpital Necker. senior physician to the hospital and The great success of his book and his in- later professor of medicine, he enrolled vention had already made him an inter- at Paris under Corvisart (1800). Assidu- national figure. He declined the offer ous application of his great natural abil- of a position on the Royal Council of ity to the study of pathology and clinical Public Instruction to become professor medicine brought him prompt recogni- of medicine at La Charité (1823), tion. In 1803, a year before his gradua- where, followed by an admiring group tion, he began a course of lectures in of students from all over Europe, he pathologic anatomy which soon rivaled applied himself more diligently than that conducted by the famous Dupuy- ever to his teaching and research. Un- tren. He relinquished this course after dismayed by the already exigent de- three years only because his none too mands on his time, he undertook the robust physique was unequal to the in- additional task of preparing a new edi- creasing demands being made upon it. tion of the “Traité,” which was now out Laënnec invented the stethoscope to of print. This was no perfunctory revi- extricate himself from a dilemma. A sion, but a thorough reworking of the young woman who consulted him in entire subject. The first edition had 1816 because of symptoms referable to been essentially an analytic correlation heart disease was so obese that percus- of physical signs with anatomic lesions; sion and palpation availed little, and he in the second, the augmented material felt that her age and sex precluded im- was completely recast and presented in mediate auscultation. Thereupon, rec- the form of a synthetic clinical and ollecting that sound is transmitted well pathologic treatment of each individual through solid bodies, he rolled three disease. Noteworthy as much from the quires of paper into a cylinder and ap- pathologic2 as from the clinical stand- plied one end to the region of the heart point, this work “is the foundation and the other to his ear. He was “not a stone of modern knowledge of diseases little surprised and pleased” to discover of the chest” (Garrison). that he could hear the heart sounds In order to complete his second edi- much more clearly by this means than tion, Laënnec once more drove his frail by applying the ear directly to the pre- physique beyond the narrow limits of cordia. At l’Höpital Necker, where he its endurance, this time irretrievably. had just been appointed physician-in- For several years he had suffered from chief, he began at once to explore all tuberculosis, the disease which his own the clinical possibilities of his new studies did so much to illuminate, and method, and within the short space of in August, 1826, about six months after his book was published, he succumbed. especially by the younger clinicians. Laënnec’s character was cast in the same Some of the more prominent of these modest mold as Auenbrugger’s, and his early investigators were Piorry, Bouil- pupils were influenced as much by his laud, Bertin, and Andral in France, personality as by his teaching. Forbes, Hodgkin, Hope, Elliotson, and Napoleon Bonaparte’s chief claim to Williams in England, Stokes, Graves, fame may well be that he warmly sup- and Corrigan in Ireland, Schönlein and ported Jennerian vaccination (Hag- Krukenberg in Germany, Skoda in Aus- gard), and it is certain that Corvisart, tria, and Jackson, Gerhard, and Flint his favorite physician, is remembered in America, but there were scores of primarily today as the discoverer of others who rendered valuable assistance Auenbrugger, but in neither case in correlating clinical observations with should the man’s major achievement be anatomic lesions. The experimental allowed to obscure the merits of his method, although employed at an early less conspicuous contributions to the date by a few, notably Hope and Corri- advancement of science. Corvisart’s rele- gan, was not applied widely until much gation of hydrothorax, anasarca, cer- later. The stream of papers and mono- tain forms of dyspnea, and other sup- graphs to which these intensive investi- posed “diseases” to the category of gations gave issue soon became a flood symptoms marks the first serious effort whose waters, as might be surmised, to investigate what is still one of the were not always conspicuously limpid. most elusive of medical problems—the Piorry’s introduction of mediate per- pathologic physiology of cardiac failure. cussion, coming, as it did, in 1828, when A bare recital of Corvisart’s specific Laënnec’s new ausculatory method was contributions to physical diagnosis, being widely diffused, exerted an im- which would include his discovery of mense influence on the development of the thrill in mitral stenosis and aneu- physical diagnosis, for it succeeded in rysm, his attempt to differentiate hyper- creating a further revival of interest in trophy from dilatation by means of pal- percussion precisely at the time when it pation, the digital method of estimating would be most effective. Rolleston’s as- arterial pressure, and his investigation sertion3 that Piorry’s method was in- of aphonia and brachial pulse inequal- ferior to Auenbrugger’s does not make ity in aortic aneurysm, not to mention allowance for the fact that the imme- the numerous observations with which diate percussion of Auenbrugger and he so richly embellished Auenbrugger’s Corvisart seems to have degenerated invention, would not convey an ade- into assault and battery. Piorry declared quate impression of his greatness as a that immediate percussion was “painful clinician and teacher. Fittingly ranked and dangerous to the patient,” which as the “father of modern objective diag- was confirmed by Chevallier, one of his nosis” (Middleton), Corvisart stands at pupils, who added that even his col- the opening of the nineteenth century leagues refused to let him practice it as the connecting link between Auen- on them. The explanation is simple brugger and Laënnec, his towering enough. It is much more difficult to ob- figure adumbrating the unparalleled tain satisfactorily sonorous results with achievements which were to come. the immediate method than with the The ideas of Auenbrugger, Corvisart, mediate. Consummate masters of the and Laënnec were followed up eagerly, original method, such as Auenbrugger and Corvisart, must have surmounted Pierre Adolphe Piorry (1794-1879), this difficulty, whereas many less expert in his day one of the most popular examiners obviously did not. Thus it is teachers in Paris, was a conscious realist not surprising that mediate percussion and shrewd practical psychologist whose soon found many enthusiastic adher- hints on the practice of medicine have ents. The abuse of immediate percus- lost none of their cogency with the sion contributed greatly to the confu- passage of time. They are here quoted sion then prevalent concerning the from Handerson’s translation of Baas’ whole subject of percussion and its History of Medicine: aims. Chevallier4 goes on to say that The art of examining a patient de- . . . direct percussion with the palm of mands long study and extensive knowl- the hand sets such a large area into vibra- edge. The examination should generally tion and is attended with such adventi- be short, so as not to weary the patient. tious sounds from the impact of the hand To ask a question twice is better than that one can scarcely detect the character once, and to examine a patient a second of tone elicited from the underlying time, after an interval of twenty-four organ. A moderate dullness of slight ex- hours, is better than a single examination. tent and also very pronounced but lim- Emphasis and arrogance should be ited areas of dullness escape percussion avoided without becoming commonplace. with the flat of the hand. Questions must be answered, however useless they may be, for in the eyes of the As Hoover points out, this “criticism world they have a great value, and the against the Auenbrugger method which physician cannot neglect these little noth- we read in support of Piorry’s mediate ings when related to him by the patient. method is valid against the latter, The physician should behave with firm- namely, it is not definitive because too ness but with courtesy, unite cold-blood- large an area of the thoracic wall is in- edness with a certain amount of feeling, cluded in the pleximeter.” and in important matters stand firmly The original wooden pleximeter of upon what he regards as for the good of Piorry, as well as the percussion ham- the patient. Prejudices which he cannot mer, which was introduced formally in overcome he must know how to yield to (though always giving them his censure), 1841 by Max Anton Wintrich5 (1813- unless they are accompanied with danger. 82), underwent innumerable, and often These precautions the physician should fantastic, modifications of form and not neglect if he desires to make his for- substance, none of which added mate- tune in this world, where savoir faire rially to its usefulness. These instru- often commands more success than reason ments are still employed in many con- and sound understanding. tinental European countries, but British The fascinating story of the evolution and American clinicians abandoned of the stethoscope is too long to recite them long ago. As early as 1831, James in detail. Experiments with various ma- Hope and William Stokes, independ- terials and designs determined Laën- ently, began to use their fingers as plex- nec’s choice of a wooden cylinder an imeters, and thus, by reducing un- inch and a half in diameter and twelve desirable adventitious sounds to a inches long, with a bore about a quar- minimum, demonstrated that finger ter of an inch in diameter, hollowed out percussion is superior to all other at one end to the depth of an inch and a methods. half. The latter was the pectoral end; it was provided with a closely fitting poses are not of sufficient practical im- stopper, traversed by a small aperture, portance to warrant detailed consid- which was inserted for auscultation of eration.6 the heart. For convenience in carrying, Among the foremost students of and also to permit its use at half the physical diagnosis in the period imme- usual length, the cylinder was divided diately following Laënnec’s untimely into two identical portions, accurately death were Jean Baptiste Bouillaud joined together. This form prevailed as (1796-1881), James Hope, and Charles long as Laënnec himself made the cylin- J. B. Williams. As early as 1823, ders and supplied them to his cus- year of his graduation, Bouillaud was tomers, but after his death the modifica- writing on the diagnosis of aortic aneu- tions became so numerous that soon rysm, paying especial attention to the there were almost as many varieties as ausculatory signs, and a year later he there were users of the instrument. edited Bertin’s monograph on diseases With one exception—the substitution of the heart and great vessels. His own of flexible tubing for the rigid stem— treatise on the same subject, an out- most of these alterations were trifling. standing contribution, appeared in The first binaural stethoscope, a crude, 1835. He was “the first to draw atten- impractical contrivance consisting of tion in a decided manner to inflamma- flexible leaden ear pieces attached di- tion of the internal membrane of the rectly to a wooden bell, was constructed heart7 and great vessels, which had been in 1829 ty C. J. B. Williams. What this either overlooked or only cursorily instrument needed more than anything glanced at by Corvisart, Baillie, Burns, else was rubber tubing, and when it Kreysig, Frank, and Laënnec” (Hope), became available a few years later and he established beyond question the binaural stethoscopes not unlike those relationship between rheumatic fever in use today began to make their ap- and heart disease. Bouillaud gave the pearance in England. In 1850 George best early description of what we now Philip Cammann brought the new in- recognize as auricular fibrillation, dis- strument to America, where, thanks to covered reduplication of the second the influence of Austin Flint, its use heart sound, and was the first to point became general somewhat earlier than out the connection between aphasia and in England. Today, logically enough, lesions of the anterior lobes of the the monaural stethoscope survives only brain. His splendid record as teacher, in those European countries in which clinician, and investigator is marred some form of Piorry’s pleximeter is still only by therapeutic ideas which were employed. The modern binaural stetho- still more sanguinary than those of scope for ordinary clinical use is Broussais. equipped either with a funnel-shaped James Hope (1801-41), who was cut chest piece or a Bowles diaphragm. Its off by pulmonary tuberculosis even acoustic characteristics, like those of the more prematurely than Laënnec, im- violin, are determined more by tradi- mortalized himself by an astonishing tions of design and the manufacturer’s array of brilliant contributions to the caprice than by the principles of pathognomy of heart disease. Before he physics. The numerous and often com- left Edinburgh, where he was graduated plicated stethoscopes which have been in 1825, he became convinced that if a designed to serve various special pur- valve is rendered incompetent regurgi- tation must ensue, and several years ments were entirely overlooked by such later he furnished the experimental coryphaei of physical diagnosis as Skoda proof of this assumption. After a year and Gerhardt, and thus have escaped of surgery in London he went to Paris, the notice of physiologists and histo- where he enjoyed the privilege of work- rians generally. The recognition which ing under the wise guidance of Chomel. Hope’s work should have achieved was Returning to London a year later, he accorded instead to the partially incor- became affiliated with St. George’s Hos- rect theory propounded in 1832 by J. R. pital, which he continued to serve until de St. Pons Rouanet (1797-1865). The the time of his death. A comprehensive exquisite irony of this situation does not recital of Hope’s achievements would become apparent until it is learned that expand this unpretentious essay to the the theory was not Rouanet’s at all, but proportions of a monograph. What originated, as he himself frankly ad- Laënnec had done for the clinical recog- mitted, with Robert Carswell (1793- nition of pulmonary disease Hope did 1857), ^ie famous illustrator of gross for disease of the heart and aorta. His pathology. diligent inquiries illuminated so many Hope’s generalizations concerning aspects of the subject that all subse- the volume and contour of the arterial quent students of cardiovascular disease pulse in the various valvular lesions have been, wittingly or unwittingly, his were based on the observation of 10,000 beneficiaries. cases. He knew perfectly well that pulse In the early days of mediate ausculta- volume bears a quantitative relation- tion much confusion arose from the fact ship to aortic and mitral lesions, and that no one understood clearly the cause his description of the celer pulse of aor- of the first and second heart sounds. The tic regurgitation anticipated Corrigan’s old theory that they were of muscular classic account. Hope failed to appre- origin, which had been accepted by hend the presystolic murmur of mitral Galen, Harvey, de Sénac, von Haller, stenosis, the credit for which belongs Bichat, and Corvisart, reinforced by to Fauvel (1843), ^ut he was first to Wollaston’s demonstration (1810) that note the early diastolic pulmonic mur- the contraction of skeletal muscle causes mur, once called Hope’s murmur, sound vibrations, led Laënnec into the which later became associated with the error of attributing the second sound to name of Graham Steell. auricular systole. John William Turner Beginning in 1828, when, at the early (1789-1835) pointed out Laënnec’s mis- age of 23 years, he published “A Ra- take (1828) and offered another expla- tional Exposition of the Physical Signs nation which proved to be equally erro- of the Diseases of the Lungs and neous. Hope, who saw that the problem Pleura,” the name of Charles James would never be solved by theorizing, Blazius Williams (1805-89), a pupil of attacked it experimentally (1830-35), Laënnec, occupies a prominent place and succeeded so well that his principal in the annals of physical diagnosis. His conclusions have never been shaken by sound idea that the stethoscope should subsequent investigators.8 The omnipo- be binaural, embodied in the clumsy tent influence of the French School instrument which he constructed in throughout the early decades of the 1829 ancf developed by others in more nineteenth century possibly accounts practical form about ten years later, ex- for the fact that these crucial experi- ercised an incalculable influence on the progress of auscultation in England and servations was exceedingly obscure, and America. In 1838 Williams called at- there was no one in Vienna who could tention to the tracheal tone which is help him. This forced him to reinvesti- heard when the vibrations produced gate every phase of the entire subject, by percussion are transmitted through and, as Sigerist suggests, probably a dense, homogeneous medium directly prompted his attempt to reduce the to the tracheobronchial air column. sonorous phenomena of physical diag- Although this phenomenon has often nosis to simple and universally intel- been confused with the tympany which ligible terms. Skoda described in 1839, l^ey have in In this way he was enabled to plumb reality quite dissimilar origins, for the depths of physical diagnosis, and to Skodaic tympany occurs, not over dense render it far more objective. Before his media, but over relaxed lung adjacent day, auscultation and percussion had been to dense media. The tracheal tone and methods that were only at the disposal of tone change are well known to every those capable of a considerable measure clinician, but the fact that pulsus para- of imaginative insight. When Skoda had doxus was described by Williams made the physical causes of the phe- twenty-three years before Kussmaul ob- nomena clear, however, it was much easier served it seems to have been overlooked both to teach and to learn the new meth- as completely as has the definitive clini- ods (Sigerist). cal and experimental study of this sub- Skoda’s methods differed in no wise ject made by Gauchat and Katz in 1924. from those of his predecessors. Dili- Williams was perhaps less gifted than gently he correlated clinical observa- Hope, but his more catholic interests tions with anatomic lesions, and de- and superior urbanity earned him an vised experiments to elucidate obscure equally enviable reputation. points. He reported his results in a se- The New Vienna School, rising like ries of papers which began in 1836 and a phoenix from the ashes of the Old, culminated three years later in his made a brilliant record of achievement “Abhandlung über Perkussion und in almost every branch of medical sci- Auskultation,” a book which was to ence. In many respects it was the spirit- serve as the starting point for all subse- ual child of the scientific revolution quent investigations in its field. which originated in France during the First Empire. This was particularly Partly because of the rudimentary true of its leading clinician, Josef state of acoustics, which was yet to find Skoda (1805-81), whose lifelong devo- its Tyndall, Helmholtz, and Rayleigh, tion to the study of physical diagnosis Skoda did not meet with complete suc- may be traced directly to the influence cess in his endeavor to place all sono- of the French masters of percussion, rous phenomena on a simple physical auscultation, and pathology. At the out- basis, but once the all-important fact set of his career Skoda was beset with that it was eminently desirable had many perplexities. Although he was been established, the eventual attain- thoroughly familiar with the French ment became a foregone conclusion. literature on percussion and ausculta- The names of Wintrich, Flint, Hoppe- tion, the precise tonal connotation of Seyler, Gerhardt, Geigel, Weber, Sel- the somewhat poetical expressions with ling, von Müller, and Martini stand which the French had clothed their ob- out among those who have since added materially to our knowledge o£ this leadership of the Dublin School, is in- subject. separably linked with that of John The same contemptuous indifference Cheyne (1777-1836) and Robert Adams which was Auenbrugger’s portion in (1791-1875) in the eponymous designa- Vienna was at first manifested toward tions of periodic breathing and cardiac Skoda, but Skoda’s story has a different syncope, respectively. It may be some- ending. A brilliant diagnosis which he thing more than coincidence that made in consultation with Freiherr von Stokes, Corrigan, Hope, and Williams Türkheim, the minister of medical were students together at Edinburgh. education, so excited the latter’s ad- Williams was gradauted in 1824, the miration that he created a new depart- others in 1825. Obviously, Edinburgh ment for chest diseases at the Allge- was attracting good minds, but it is meines Krankenhaus and placed equally obvious that the same powerful Skoda in charge of it (1840). How thor- directing influence (perhaps the teach- oughly Skoda took advantage of this ing of William P. Alison) must have opportunity may be inferred from the been exerted on each of these young fact that within a year he was made men. Stokes’ first paper, on the use of visiting physician and director of a di- the stethoscope, appeared while he was vision. His appointment as professor still in Edinburgh. Back in his native of medicine followed in 1846. Skoda’s Dublin he became the colleague, mastery of physical diagnosis soon made friend, and collaborator of Graves at the him famous, and students of all ages Meath Hospital, and in 1845 he suc- and nationalities flocked to his clinics. ceeded his father, Whitley Stokes, as He wrote very little, but like Schön- Regius Professor of Medicine. Stokes lein, who wrote even less, he exerted a deserves great credit for insisting on the profound influence on the growth of paramount importance of the myo- scientific medicine. cardial factor in heart disease. Corvisart The well-known fact that clinical had emphasized this, and Laënnec, medicine and pathology are necessarily Hope, and Clendinning reiterated it, interdependent is strikingly illustrated but by 1850 the general preoccupation by comparing the New Vienna School with murmurs and valvular lesions had with its celebrated contemporary in become so profound that the myocar- Dublin. The profound and enduring dium was actually in danger of being significance of the former rests squarely forgotten. It is scarcely necessary to add on the genius of Carl Rokitansky, the that the admonitions of Stokes and greatest descriptive pathologist the others after him had absolutely no ef- world has ever known, whereas the fect. Not until large numbers of re- Dublin School, which had no first-rate cruits began to pass through the hands pathologist, failed to attain the same of medical examiners during the World high rank in spite of its galaxy o£ cli- War, and then largely at the insistence nicians (Cheyne, Adams, Corrigan, of Mackenzie, was the murmur hysteria Graves, Stokes). This is not an invidious replaced by a more rational point of distinction, for it reflects no discredit view. on the individual achievements of these Stokes’ reputation grew rapidly. He justly famous men. was an unusually able teacher, a keen The name of William Stokes (1804- observer, and a man of forceful person- 78), who shared with Graves the ality and broad human interests. His “Diseases of the Chest” (1837) and had gone to Paris to study the new “Diseases of the Heart and Aorta” methods at first hand were returning to (1854) were recognized at home and disseminate them. One of the most in- abroad as the work of a great master, fluential of these pioneers was William and the later years of his life were Wood Gerhard (1809-72), of Philadel- crowded with honors. phia, who distinguished himself early Even the casual student of medical in his career by completing the differ- history soon learns that “priority” is entiation between typhoid and typhus the name of the reward for doing some- fevers (1837). Gerhard was graduated thing which has been done previously, from the University of Pennsylvania in perhaps as well or better, by one or 1830. A year later he joined James Jack- more persons. It is at best an empty son, Jr., and C. W. Pennock in Paris, honor because it implies disregard for and shared with them the exceptional the uniformity and continuity of natu- advantage of private instruction under ral phenomena. Medical eponyms, Pierre Charles Alexandre Louis (1787- even when they connote substantiation 1872). At that time Louis was the great or amplification of previously incom- favorite of American students, who ad- plete observations, often serve no mired especially his idea of using the better purpose than to obscure the well- statistical method to elucidate problems known fact that inventions and dis- which are not susceptible of experi- coveries are as much a product of the mental study. Strange as it seems, Ger- past as of the present. Mention of hard never held a professorship, but he Stokes brings to mind what is probably was for thirty years the most esteemed one of the best of the numerous ex- teacher in Philadelphia. His treatise on amples which might be cited. Cardiac diseases of the chest, published in 1842, syncope, usually referred to as the was the first American textbook to in- Stokes-Adams syndrome, had been de- corporate the newer methods of physi- scribed no less than six times, namely, cal diagnosis, and held undisputed sway in 171g by Gerbezius, in 1761 by Mor- until the time of Flint. Gerhard and his gagni, in 1793 by Spens and Duncan, contemporaries knew, as does everyone and in 1827 by Burnett and Adams, be- who still practices immediate ausculta- fore Stokes gave his account of it in tion, that in its early stages pleural ef- 1846. Conversely, Stokes’ description fusion almost invariably produces high- of paroxysmal tachycardia antedated pitched tubular breathing, whereas Cotton’s by thirteen years, and both he most modern authors, presumably be- and Gerhardt observed the so-called cause they rely exclusively on mediate “diaphragm phenomenon” three or auscultation with the binaural stetho- four decades before Litten. scope, which is a very poor conductor The stimulating influence of the of high-pitched sounds, state that pleu- early nineteenth century renaissance of ral effusion suppresses the breath medicine in France spread to America sounds. Although Gerhard had a much almost as rapidly as it did throughout better grasp of pulmonary affections Europe. In 1821, James Jackson, Sr. than of cardiovascular disease, he was (1777-1868) introduced percussion and nevertheless familiar with two impor- auscultation at the Massachusetts Gen- tant methods of exploring the aorta, eral Hospital, and within a few years namely, thrusting a finger deep into the many of the American students who retromanubrial space, and palpating with the head over the upper sternum be acclaimed particularly for his in- for the systolic impulse. The use of the sistence on the importance of pitch in stethoscope had led Laënnec, Bouil- acoustic diagnosis (1852), thereby re- laud, and Hope to the accidental dis- vealing his allegiance to the Skodaic covery that palpation with the head is principle that if auscultation and per- a much more sensitive method of ap- cussion were to become universally ap- preciating the cardiac impulse than pal- plicable methods they would have to be pation with the hand, and Gerhard divested of romance. His explanation simply widened the application of this of the incidental diastolic-presystolic method by showing that it is even more mitral murmur in aortic regurgitation useful in the diagnosis of enlargement (Flint’s murmur), which he discovered of the aorta. Unfortunately, little atten- in 1862, has never been refuted. He was tion has been paid to this valuable the first to describe presystolic cardio- contribution. pulmonary murmurs and to make effec- It is generally conceded that James tive use of whispered pectoriloquy. But Jackson, Jr., who died at the age of 24, over and above these contributions, im- was destined for a brilliant medical portant as they are, looms the figure of career. His father’s personal loss could the man himself—tolerant, urbane, in- not be repaired, but he may have de- tellectually mature, always receptive to rived a certain measure of spiritual new ideas. consolation from the success of another The subject of cardiopulmonary of his pupils, the famous Austin Flint, murmurs has always been of great in- Sr. (1812-86), more especially because terest to the clinician. Laënnec be- this was one student who dispensed lieved that certain adventitious sounds with the customary Parisian sojourn. which he heard over the precordia were Flint’s remarkable talents, extraordi- produced in the lung by the motion of nary versatility, prodigious capacity for the heart, but the fact that they some- work, scientific achievements, public times persisted when the breath was spirit, and strength of character made held engendered doubts which explain him the greatest figure in American his elusive treatment of the subject in medicine between Benjamin Rush and the “Traité.” In 1839 Hope described William Osler. He held successive pro- a mesosystolic cardiopulmonary mur- fessorships in no less than six medical mur, assuming that “the violent beats colleges, one of which he helped to of the heart compressed the lung, and, found, left 16,922 folio pages of clini- by suddenly expelling its air, created cal notes written in his own hand, and a rnurmur”-an explanation which is was the author of scores of papers and correct as far as it goes. Hope referred monographs. His treatise on practice, to similar cases of Elliotson’s, and the best before Osler’s, passed through added the warning that the examiner six editions in twenty years. Flint’s de- should auscultate the heart both with votion to the study of percussion and the patent sitting up and lying down. auscultation not only greatly clarified Extracardial adventitious sounds were and enlarged the subject, but also com- described subsequently by Wintrich pleted the demonstration, so ably be- (“systolic vesicular breathing”), Skoda, gun in America by Jackson and Ger- and others. In 1868 Bernhard Naunyn hard, that physical diagnosis is the sine (1839-1925) asserted that certain sys- qua non of clinical medicine. He is to tolic murmurs heard over the pulmonic area are due to relative niitral regurgi- notcd first. I11 1705 Raymond Vieus- tation. Balfour supported this idea sens (1641-1716) observed it in asso- vigorously, even to the exent of deny- ciation with mitral stenosis. A century ing the existence of extracardial mur- later Corvisart again called attention murs. and Austin Flint just as vigor- to it, and in 1835 Bouillaud described ously opposed it. In 1876. Pierre Carl it as delirium cordis. It was discussed Potain (1825-1901) put an end to the in turn by Stokes (1854) and others, controversy by showing experimentally but 110t until the time of Mackenzie that relative mitral regurgitation is did the study of auricular fibrillation practically impossible in a normal pass from the descriptive to the inves- heart, but even as late as 1898 the fun- tigative stage. Our modern conception damental significance of Potain’s work of the cardiac arrhythmias began with on cardiopulmonary murmurs had the work of a busy country doctor, somehow escaped Balfour’s notice com- James Mackenzie (1853-1925), who pletely. and, although it has been re- somehow found time to observe and emphasized repeatedly (e.g., Butler, record for mankind. About 1890 his 1907), it is still not thoroughly appre- attention was first directed to auricular ciated. Charles Emile Frangois-Franck fibrillation as a distinct entity. The (1849-1921) dispelled once for all any simple cxpedient of arranging the doubts which may have remained con- sphygmograph to record arterial and cerning the existence of cardiopul- venous pulses simultaneously enabled monary murmurs when he discovered, him “to separate the great majority of while operating on a dog, that a systolic irregularities into definite groups, ac- murmur was audible over the heart. cording to the mechanism of their pro- Without opening the pleural cavity he duction.” Originally he held that au- inserted a tenaculum into the thorax ricular paralysis was responsible for and withdrew a portion of lung from the particular arrhythmia which was the anterior surface of the heart, where- characterized by the “ventricular form upon the murmur ceased immediately. of venous pulse” (1902), but when he After the lung was restored to its for- observed hypertrophy of the auricles mer position the murmur returned. in such cases post mortem he aban- The ease with which most of the im- doned this idea and assumed that the portant disturbances in the mechanism auricles and ventricles were contract- of the heart beat are recognized today ing simultancously in response to an affords an excellent example of the fact impulse which arose somewhere be- that clinical wits are often sharpened tween them, probably in the A-V node by the application of appropriate in- (“nodal rhythm,” 1908). With the hclp strumental methods to bedside prob- of Cushny, Edmonds, and Lewis, the lems. Reliable graphic methods of question was finally settled by corrc- studying cardiovascular phenomena are lating clinical and experimental data, of extremely recent origin, yet they and, in 1909, Lewis, and Rothberger have been pursued so intensively that and Winterberg, independently, estab- scarcely any detail remains unexplored. lished the fact that the arrhythmia This is particularly true of the cardiac which Mackcnzie had isolatcd as “nodal arrhythmias. Auricular fibrillation, rhythm” and Hering as pulsus irregu- which is by far the commonest of the laris perpetuus (1903) was auricular sustained arrhythmias, was naturally fibrillation. The final solution of this ancl other problems relating to dis- cause des bruits respiratoire per^us au turbances in the mechanism of the moyen de l’auscultation” (1834), and heart beat was renderecl comparatively have been recently restated and en- simple when Willem Einthoven (1860- larged by Bushnell (1921). Their pur- 1927) inventecl the string galvanometer pose is to show that all normal respira- and aclaptecl it to the study of carclio- tory souncls, both bronchial and electric phenomena (1903). It is inter- vesicular, are caused by the passage of esting to note that at the very time air through the rima glottidis. This when Einthoven was devising an in- theory was opposed in 1837 by Stokes strument which cleared away at one and Adam Raciborski (1809-71), and stroke the errors due to the inertia of in 1892 by Hermann Sahli (1856-1933). the capillary electrometer, Otto Frank The view that bronchial breath sounds was developing the principle of optical are the product of a labial system of registration to circumvent similar er- pipes has been maintained very con- rors in the sphygmograph and cardiac vincingly by Paul Martini (1889- ) manometer. Together, these contribu- and George Edmeston Fahr (1882- tions practically revolutionized cardio- ). One clifficulty which befogged vascular physiology. Frank’s method, the whole problem for almost a century as appliecl by Wiggers and others, was was the lack of a reliable objective the first to portray the contours of the method of recording sound vibrations, arterial pulse more accurately than they and the experimental studies of Mar- coulcl be perceived by the finger, and as tini (1920-23) and others after him, in a result the tactus eruditus of the clini- which such methods were utilized for cian underwent an overhauling. the hrst time, are therefore particularly Perhaps nothing pertaining to physi- noteworthy. Although in many respects cal cliagnosis has given investigators the labial pipe theory is superior to all more trouble than the cause of the others, the laryngeal factor has not been breath sounds, particularly the so- excludecl entirely, ancl the question of called vesicular murmur of normal vesicular participation still wants a sat- breathing. No sooner had Laënnec de- isfactory answer. scribed these sounds and their patho- Proficiency in the art of detecting logic modifications than the theories enlargement of the thoracic aorta is began to form. Most of them start inversely proportional to the clegree of either with the assumption that the enlargement, which epitomizes the respiratory apparatus acts as a reed pipe long struggle to attain it. The first diag- system, or as a labial pipe system. nosis of aneurysm to be confirmed by Among the prominent proponents of necropsy was made in 1555 by Andreas thc reed pipe theory, which was the Vesalius (1514-64), who basecl it on the first to make its appearance, were Au- observation of a pulsation along the guste Fran^ois Chomel (1788-1858), dorsal spine. At that time, ancl for more Joseph Honoré Simon Beau (1806-65), than 250 years thereafter, only the Robert Spittal (1804-52), Johann Her- enormous aneurysms which had eroded mann Baas (1838-1909), and George the chest wall were recognizable, but Ensign Bushnell (1853- )• The with the rise of physical diagnosis as a principal arguments on which it rests scientific method sui generis, Corvisart, were presented most cogently by Beau, Hodgson, Bertin, Corrigan, Skoda, and beginning with his “Recherches sur la others began to detect enlargement of the aorta before it reached the terminal aneurysm of the ascending and trans- stage. The distinctive physical signs verse aorta comparatively easy would accumulated slowly. Corvisart discov- have been largely futile had it not ulti- ered the systolic thrill (1806); Bertin mately brought to light the means of emphasized the value of auscultation recognizing syphilitic aortitis in its (1824), which Laënnec had underesti- early stages. Hope referred to aortitis mated; and Corrigan called attention in 1839 as “a disease so obscure that it to the expansile pulsation. Carswell might well be supposed theoretical.” (1831) and Henderson (1836) noted the Fifteen years later Stokes recorded the accentuated aortic second sound, and a fact that accentuation of the aortic sec- few years later Gerhard pointed out ond sound, with or without an aortic the important signs already referred to, systolic murmur, appears long before namely, the increased accessibility to any other sign, which practically solved palpation with the head over the aortic the problem, but the significance of area and with the finger behind the this observation was not appreciated manubrium. Unilateral diminution of even by those who took notice of it brachial pulse volume, first recorded (e.g., Balfour, 1898). As late as 1906 by William Harvey in 1628, was stud- Broadbent was saying that “it is diffi- ied in greater detail by Corvisart in cult to arrive at a diagnosis [of acute 1806 and Hope in 1831; the aphonia aortitis] with any degree of certainty referable to encroachment on the re- during life, and, in the absence of an- current laryngeal branch of the left gina, it can rarely be made.” Even to- vagus was mentioned first by Corvisart day, notwithstanding the obvious fact (1806) and investigated more fully by that antisyphilitic therapy is ineffective Stokes in 1854 and Semon in 1898; unless instituted long before the aneu- Oliver described the tracheal tug in rysmal stage, the signs whicli betray 1878; Gerhardt, in 1866, correctly as- early syphilitic aortitis are not gener- cribed accentuation of the aortic sec- ally known. To Henri Huchard (1844- ond sound to enlargement of the aorta 1910), whose numerous noteworthy and tympanicity of the sound to athe- contributions to our knowledge of ar- roma of the arterial wall; and Broad- terial disease so richly adorn his great bent emphasized the importance of “Traité clinique des maladies du coeur the diastolic impact as a means of dis- et de l’aorte” (1889),10 much credit is tinguishing between aneurysm and due for directing attention to the im- other pulsating mediastinal tumors portance of aortitis, but it remained (1897). Balfour accepted Gerhardt’s for Charles Franklin Hoover (1865- conclusion that accentuation of the 1927) to apply thc finishing touches in aortic second sound is due to increased a classical paper (1920) which stands accessibility of the aorta9 (1875), and out as the definitive contribution to observed that a normal aorta, if uncov- thc subject. ered and displaced from beneath the Hoover was a graduate of Harvard sternum, simulates aneurysm. The (1892), and a pupil of Edmund Neus- etiology of aneurysm remained obscure ser, Friedrich Kraus, and Pierre Marie. until 1876, when F. H. Welch showed Very early in his career he manifested that syphilis plays the dominant röle. that passionate devotion to physical The long quest which culminated diagnosis which was to make him pre- in making the clinical diagnosis of eminent in thc art of unaided clinical observation. His papers on the bedside external intercostals were expiratory study of air hunger, syphilitic aortitis, and the internal intercostals inspira- definitive percussion, and the respira- tory held sway for nearly fourteen cen- tory movements of the thorax were a turies. Vesalius (1543) declared that blast of fresh air in the miasma of pre- both groups serve the same purpose; as occupation with dubious new pro- Baas somewhat nai’vely expresses it, cedures which was arising all around “that the intercostal muscles merely him. His wise insistence on the clini- separate the ribs from each other, with- cian’s right to final judgment in all out either expanding or contracting the matters pertaining to the diagnosis and thorax.” John Mayow (1643-79) “dis- treatment of disease, and his thor- covered the double articulation of the oughly sound contention that the prin- ribs with the spine, and discussed the cipal service rendered by so-called function of the intercostal muscles in methods and instruments of precision an entirely modern spirit” (Garrison), is to sharpen the clinician’s powers of and Thomas Willis (1621-75) regarded observation and broaden his viewpoint the external intercostals as inspiratory exercised an exceedingly wholesome in- and the internal as expiratory (1673). fluence on students who were finding Prerequisite to the rational investiga- it difficult to adjust themselves to the tion of intercostal function were the radically changed conditions of the fundamental principles, hrst enun- twentieth century. The fire of his gen- ciated in 1680 by Giovanni Alfonso ius burned brightest at the bedside, Borelli (1608-79), that inspiration is where he was literally indefatigable in accomplished by muscular action and pursuit of the truth. There was noth- expiration simply by muscular relaxa- ing of the intuitive or mystical about tion, and that the lungs themselves are his method; it was characterized rather purely passive and still contain air at by rigorous objectivity and ruled al- the end of expiration. Had Georg Er- ways by healthy skepticism. No one hardt Hamberger (1697-1755) not dis- who ever watched him at work—search- regarded Borelli, he might not have ing out significant features which were formulated the erroneous theory con- hidden from everyone else, calling cerning the mechanism of respiration upon his seemingly inexhaustible re- which Albrecht von Haller (1708-77) sourcefulness to elicit the last relevant so promptly challenged and effectively historical detail, making physical diag- demolished. Haller first investigated nosis itself a delicate instrument of the intercostal muscles experimentally, precision capable of nuances such as and Hamberger constructed a model only the virtuoso can evoke—could to illustrate their action, but not until doubt that he was the supreme embodi- Henry Newell Martin (1848-96) and ment of the clinician’s art. Edward Mussey Hartwell (1850-1922) Hoover’s originality was manifested published the results of their experi- in countless ways, but in none more ments in 1879 did the actual facts be- conspicuously than his investigation of gin to emerge. By means of animal the diagnostic significance of inspira- experiments and acute clinical obser- tory movement of the costal margins. vations, Hoover not only succeeded The action of the intercostal muscles (1922) in rounding out our knowledge had long been a subject of speculation of intercostal function, but showed and controversy. Galen’s view that the how it is synchronized and integrated with that of other intrinsic and acces- etiological theorizing . . . which tend sory muscles of respiration to insure to mcrge bedside medicine into thc smooth and efficient ventilation of the ancillary devices it utilizes, to enslave lungs. His study of diaphragmatic func- thc mind of the physician by making tion was equally fruitful. The same in- him dependent upon artificial aids and, vestigative method and sound inductive in extremis, to turn the patient himself reasoning enabled him to brush aside into a laboratory animal. Between the the flimsy theories of Galen, Vesalius, two lies thc Golden Mean, the via Columbus, Borelli, and Magendie, and media followed by all practitioners of to harmonize the apparently discord- sound sense, ripe judgment, and varied ant experiments of Beau and Maissiat experience” (Garrison). Never before (1843), Brou (1843), and Duchenne has it been so diflicult, or so important, (1853). The result was a much clearer for the young student of medicine to conception of thoracic excursion, to- learn that “not all thc chemistry and gether with a new clinical method of physics in the world can make a good great value in the diagnosis of thoracic diagnostician or a good practitioner or and upper abdominal disease. a good teacher of him who is not at There is every indication that the home by the bedside” (Thayer). great modern age of physical diagnosis, Moreover, physical diagnosis has ushered in by Auenbrugger 175 years helped to encompass its own downfall. ago, has come to an end. The reasons Supinely it has allowed itself to be are not far to seek. As medicine passed pushed into the background by inno- gradually from the descriptive to the vations which, however useful they may experimental stage, the alluring poten- be, can never replace it. It has not even tialities of the laboratory drew the phy- realized its own potentialities, much sician so far away from the bedside that less taken advantage of progress in the famous prophecy uttered by Skoda upon his retirement in 1871, “Now the other fielcls. In spite of the well-known microscope and chemistry may take fact that diagnostic endeavor is always their turn,” has become a miserable stultified by reducing it to a formula, underestimate of the fabulous meta- physical diagnosis still clings so tena- morphosis which has actually taken ciously to otiose formalism that it often place. What would Skoda have said if seems to be more of a ritual than a he could have foreseen the clinical reality. It must shed its intolerable applications of roentgenology? “The burden of outworn clothing, and no time-honored Hippocratic reliance on longer obscure its simple truths with the natural powers of the mind and the irrelevant and immaterial “refine- five senses in diagnosis (without which ments,” if it is to take its proper place the physician is nothing)” has been re- as a major factor in shaping the broader placed to a disquieting extent by “an clinical horizons which the inevitable almost bewildering array of laboratory reaction against overemphasis on acces- tests, instrumentation, specialism, [and] sory laboratory methods will bring.

Tex t Refe rf .nce s 1. The Leidcn tradition of bedside teach- about 1543. Aftcr della Monte’s death ing was a heritage from Padua, where the practice lapsed (1551). Revived by it had been introduced by Giovanni Albcrtino Bottoni and Marco degli Battista dclla Monte (Montanus) Oddi about 1578, the idea was carried to Leiden by a Dutch student at 7. For which lie coined the term “endo- Padua, Jan van Heurne, and ulti- carditis.” mately placed on a solid footing (1636) 8. Hope’s claim to priority in this investi- by van Heurne’s son Otto and by gation was disputed by C. J. B. Wil- Ewald Scrivelius (Garrison). 2. It is perhaps fortunate that Laënnec liams. Apparently because the sig- never wrote the treatise on morbid nificance of tlie experiments was at anatomy which he had planned many first somewhat obscured by this con- years earlier, else the “Traité,” want- troversy and by confficting interpreta'- ing its rich pathologic background, tions, the British Association for the might not have attained such prompt Advancement of Science appointed a recognition. committee in Dublin and another in 3. See page 3. London (of which Williams was a 4. Quoted by Hoover, C. F. J.A.M.A., 75: member) to reinvestigate the motions 1626, 1920. and sounds of the heart. Both com- 5. In 1658 Johannes Jacobus Wepfer (1620- mittees reached the conclusion that 95) reported that the Swiss veterina- the original work was fundamentally rians and butchers used a small ham- sound. Although Williams never re- mer to percuss the skulls of cattle as linquished his claim, the credit clearly a means of detecting the presence of belongs to Hope. cysticerci, which makes tliem forerun- 9. Paradoxically, he attributed accentua- ners of both Lancisi and Auenbrug- tion of the pulmonic second sound to ger. David Barry (1781-1836) percussed high pressure in the pulmonary ar- with a little ebony hanimer, the head tery. of which was covered with oxgut and leather (Piorry). Laënnec was in the 10. It is surprising that George William Bal- habit of using his stethoscope as a per- four (1823-1903), in the third edition cussion hammer. of his “Lectures on Diseases of the 6. In this connection it is interesting to re- Heart and Aorta” (1898), does not once call Austin Flint’s prediction that the refer to Huchard, although his many principle of the telephone would one references to other foreign authors day be adapted to the transmission of show that he was not hindered by respiratory and cardiac sounds. linguistic barriers.

Additio nal Ref ere nces Baas , J. H. History of Medicine. Trans. zur Geschichte dcr mittelbaren Perkussion. from the German by H. E. Handerson, Ibid., 6:245, N. Y., 1889. Ebst ein , W. Einige Bemerkungen zu der Balf our , G. W. Clinical Lectures on Dis- Geschichte des Stethoskops. Deutsches eases of the Heart and Aorta. Ed. 3, Lon- Arch. f. klin. Med., 69:488, 1901. don, 1898. (Ed. 1, 1875) Edens , E. Lehrbuch der Perkussion und Bro adb ent , W. H., an d Bro adb ent , John Auskultation. Berlin, 1920. F. H. Heart Disease and Ancurysm of the Fahr , G. E. The acoustics of tlie bronchial Aorta. Ed. 4, N. Y., 1906. (Ed. 1, 1897) breath sounds. Arch. Int. Med., 39:286, Bush nei .l , G. E. The ntode of production of 1927- the so-called vesicular niurmur of respira- Garris on , F. H. History of Medicine. Ed. 4, tion. J.A.M.A., 77:2104, 1921. Phila., Saunders, 1929. ------. The discoverer of the mode of pro- Gerha rd , W. W. The Diagnosis, Pathology, duction of breath sounds. Ibid., 80:895, and Treatment of the Diseases of the 1923- Cliest. Ed. 2, Phila., 1846. (Ed. 1, 1842) Ebs te in , E. Das Plessimeter. Ein Beitrag zur Ger har dt , C. Lehrbuch der Perkussion und Geschichte der mittelbaren Perkussion. Auskultation. Ed. 6, Tiibingen, 1900. Arch. f. Gesch. d. Med., 4:43, 1911. Heri nghau s , F. J. Austin Flint, J. Michigan ------. Der Perkussionshammer. Ein Beitrag M. Soc., 31:126, 1932. A Brief Histor y of Physi cal Diagno sis

Hope , J. Diseases of the Heart and Great Majo r , R. H. Classic Descriptions of Disease. Vessels, edited by C. W. Pennock. 2iid Springfield, Thomas, 1932. American from grd London ed., Phila., Midd le to n , W. S. A biographic history of 1846. physical diagnosis, Ann. M. Hist., 6:426, Hoo ver , C. F. Definitive percussion and in- 1924. spection in estimating size and contour of ------. William Wood Gerhard. Ibid., n.s. 7:1, the heart, J.A.M.A., 75:1626, 1920. ------. Aortitis syphilitica. lbid., 74:226, 1920. ]935------. Diagnostic signs from the scaleni, in- Moon , R. O. Growth of Our Knowledge of tercostal muscles, and the diaphragm in Heart Disease. New York and London, lung ventilation. Arch. Int. Med., 20:701, Longmans, 1927. Plsc hmann , T. Die Medizin in Wien währ------. The functions and integration of the end der letzten 100 fahre. Wien, 1884. intercostal muscles. Ibid., 30:1, 1922. Rolle st on , H. D. Cardio-Vascular Diseases ------. Cardiopulmonary murmurs, AT. F. Since Harvey’s Discovery (Harveian Ora- Med. J., 68:185, 1898. tion). Cambridge, 1928. Huchar d , H. Traité clinique des maladies Sige ris t , H. E. The Great Doctors. Trans- du coeur et de l’aorte. Ed. 3, Paris, 1899. lated from the German by Eden and Cedar (Ed. 1, 1889) Paul, New York, Norton, 1933. Kell y , H. A. A cyclopedia of American med- ical biography. Phila., Saunders, 1912. Williams , C. J. B. Lectures on the Physiol- Laën nec , R. T. H. Treatise on Diseases of ogy and Diseases of the Chest. London the Chest and on Mediate Auscultation. Med. Gaz., n.s. 2:1, 1838. Trans. from the French by John Forbes, Williams , C. T. Laënnec and the evolution New York, 1830. of the stethoscope. Brit. M. J., 2:6, 1907.