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Auscultation of the heart is the last step in cardiac physical examination, but it is by no means of the least importance. The information obtained by inspection, palpation and percussion is differentiated, extended and more definitely authenticated by auscultation.

The object of auscultation is to determine the character of the heart sounds at the various valves, the cardiac rhythm, and the presence or absence of adventitious sounds.

Technic. As in auscultation of the lungs, two methods are practiced, viz., mediate and immediate.

Immediate auscultation. The immediate method is seldom used; the only excuse for employing the unaided ear in auscultating the heart is the lack of a stethoscope, or to verify a faint aortic diastolic murmur.

Mediate auscultation. The stethoscope should generally be employed for the examination of the heart, as with its aid the various valve areas can be definitely located, and the area of transmission is more easily followed.

In ambulatory patients it is often necessary to have them walk across the floor, the heart being auscultated both before and after the exertion.

With the patient in proper position, the following areas are examined.

Mitral area. The stethoscope is placed over the apical area (fifth interspace near the nipple) so that the character of the heart sounds may be noted. If the sounds seem normal, the second area is then auscultated, but if an adventitious sound is heard over the mitral area, the character and time should be noted, and the sound followed toward the left axilla to the angle of the left scapula.

Pulmonic area. The second area of auscultation is in the second intercostal space at a point close to the left sternal line. The character of the sound, the presence or absence of adventitious sounds, and the presence or absence of an accentuation of the normal sound, should be noted. Should an adventitious sound be heard here, its time and character should be investigated, and the stethoscope placed over the veins of the neck to determine the transmission of the adventitious sound.

Aortic area. The third area to be investigated is the second intercostal space to the right of the sternum. The strength of the sound there heard should be carefully studied, noting especially whether it equals in strength the one heard at the left second intercostal space, or whether it is weaker or stronger. Any adventitious sound heard at this orifice should be studied as to quality and time, and then followed either over the carotid artery (when the murmur is systolic in time) or down along the sternum, gradually approaching the apex (when the murmur is diastolic in time).

Tricuspid area. The fourth area to be auscultated is the lower part of the sternum near its junction with the ensiform cartilage. If an adventitious sound is heard at this orifice, it should be followed toward the liver. The clinical areas for listening to the valve sounds do not correspond to the anatomic positions of the heart valves, because the sounds produced at the various points are carried along the course of the blood stream, and are best heard at the different areas above indicated, their audibility being due to the acute change in the course of the blood stream which occurs at these points.