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During the past century, perhaps the most characteristic symbol associated with
physicians has been the stethoscope. It replaced the urine glass, the symbol which
had prevailed since medieval times. Today’s physician acquires his first stethoscope
during his second year in medical school. From then on, employment of percussion
and auscultation in his study of patients becomes as automatic as counting pulse
or taking temperature. Yet it required three generations of medical men and lifelong
efforts of two physicians dedicated to research to introduce these methods of medicine,
to instruct physicians in their use, and to overcome resistance and prejudice of
contemporaries to whom change was offensive.
Percussion was introduced to medicine by an Austrian, Leopold Auenbrugger (1722-1809).
Appointed physician to the Spanish Military Hospital, then Vienna’s finest,
in 1751. Auenbrugger had exceptional opportunity to observe the processes of disease,
especially disease of the chest. He noted that, when the thorax of a healthy person
is struck lightly, a sound resembling that of a drum muffled with a thick woolen
cloth is produced. In sick persons, such sounds vary in accordance with the nature
of underlying change, its location, and its extent. Auenbrogger spent seven years
testing his idea, especially checking opinions formed while examining moribund patients
with conditions found at autopsy. In 1761, he published his epochal contribution.
On percussion of the Chest, in a small volume of 95 pages.
Though a second edition appeared in 1775, Auenbrugger’s work was unappreciated
until 1808, when Jean Nicolas Corvisari, physician to Napoleon I and leader of medical
thought in France, translated On Percussion of the Chest into French and gave unstinted
praise to the discoverer of percussion, 47 years after Auenbrugger’s little
volume first appeared in Austria. Corvisart became one of the Laennec’s teachers,
providing the link between Auenbrugger and percussion, and Laennec and indirect
auscultation. As the career of the Austrian physician was drawing to a close, that
of the young Frenchman was just beginning.
Laennec’s embarkation upon a career in medicine closely coincided with recognition
of Paris world capital of medicine between 1800 and 1850. The foundations had been
well laid, Morgagni of Padua and Richat of Paris had established the importance
of anatomic pathology and of autopsy. Pinel had proved the value of statistical
compilations from patient’s records. Corvisart the clinician emphasized need
for adequate physical examination, including employment of Auenbrugger’s methods
of percussion. To these advances, Laennec was to add mediate (indirect) auscultation.
This combination of clinical and diagnostic procedures revealed basic characteristics
of diseases prevalent at the time, such as tuberculosis, typhoid fever, and diphtheria.
Rene Theophile Hyacinthe Laennec was born at Quimper, Lower Brittany, France, February
17, 1781. He was not quite 5 years of age when his mother died of pulmonary tuberculosis,
a disease prevalent in the area. His father, an advocate with considerable education,
preferred literature to law, and accepted practically no responsibility for his
children. Early in life Theophile Laennec went to live with an uncle, Guillaume
Francois Laennec, a professor on the faculty of medicine at Nantes, who had studied
at Montpellier, and under Hunter, in London. This uncle saw to it that young Theophile
received a sound basic and classical education, despite the turbulent times. The
French Revolution was under way, with its rioting and political brutalities. In
his fifteenth year, Theophile was given the little of military surgeon, third class,
and set to work as an apprentice, assisting his uncle in military hospitals at Nantes.
After preliminary studies in local educational institutions, Laennec, at 19 years
of age, was able to go to Paris to complete his medical education. Shortage of funds
and poor living conditions did not improve his already delicate health. He immediately
enrolled in the Ecole de Medicine, and attended clinics at I’ Hospital de
La Charite under Corvisart and his assistant, Bayle. Corvisart stressed bedside
instruction , and trained his students thoroughly in autopsy examinations. Laennec
studied carefully and methodically; during his first three years at LaCharite he
wrote up careful histories of more than 400 patients whom he had seen. Driven by
his inborn intensity, Laennec won two governmentally sponsored first prizes in surgery
and in medicine by competitive examination and while still an undergraduate student
published papers on heart disease and on the capsule of the liver. His memoir in
1802 on peritonitis was particularly valuable in clarifying this age-old problem.
Theophile Laennec received his doctorate, June 11, 1804, at age23. For five years
after graduation he was editor-in-chief of the Journal de Medecine. At the same
time he lectured on pathologic anatomy. Paper after paper flowed from his pen. Tuberculosis
in particular attracted his attention, and percussion was one of his favorite diagnostic
methods.
In 1816, at 35 years of age, Laennec was appointed visiting physician to Hospital
Necker. This provided him the opportunity of his lifetime. Likely his name would
have found its place in history because of his publications on pathology and methods
of correlating clinical observations with post-mortem findings; but the clinic at
Necker Hospital, in his first year there, presented Laennec the challenge that led
to his greatest discovery.
Laennec was familiar with palpation and percussion; and from his friend and former
teacher, Bayle, he had learned of immediate, or direct, auscultation (listening
to sounds in the thorax by placing the physician’s ear directly on the patient’s
chest was). Many patients were not accustomed to bathing and some even were verminous,
so many physicians were reluctant to use this diagnostic method. Layers of fat that
sometimes obstructed transmission of sounds, and modesty of women patients were
further deterrents.
One day, in 1816, while walking through a littered yard pondering the problem of
a very obese young woman suspected to be suffering from heart disease, Laennec noted
a group of children at play about a pile of beans. One would put his ear against
the end of a beam, while another would scratch or tap the opposite end. To their
childish amazement the sounds were conveyed from one end to the other. Laennec,
grasping the physical principle involved, hurried back to Necker and his overweight
patient.
“I rolled a quire of paper into a kind of cylinder,” says Laennec in
the introduction to his great book, “and applied one end of it to the region
of the heart and the other to my ear, and was not a little surprised and pleased
to find that I could thereby perceive the action of the heart in a manner much more
clear and distinct than I had ever been able to by immediate application of the
ear. From this moment I imagined that the circumstance might furnish means for enabling
us to ascertain the character, not only of the action of the heart, but of every
species of sound produced by the motion of all the thoracic viscera and consequently
for the exploration of the respiration, the voice, the rhoncus (rale), and perhaps
even the fluctuation of fluid extravasated in the pleura or the pericardium. With
this conviction I forthwith commenced at the Hospital Necker a series of observations
from which I have been able to deduce a set of new signs of diseases of the chest…to
render the diagnosis of the diseases of the lungs, heart, and pleura, as decided
and circumstantial as the indications furnished to the surgeon by the introduction
of the finger or the sound, in the complaints wherein these are used.”
Laennec then set about experimenting with various forms of the instrument, which
be named stethoscope. First he tried a compact roll of paper, then a wand with no
aperture. This he found would convey heart sounds, but a cylinder with a central
aperture and a funnel-shaped opening at the applied end proved best suited for chest
examinations. He finally settled on a cylindrical instrument made of light wood,
about an inch and a half in diameter and a foot long, perforated longitudinally
by a quarter-inch bore, hollowed out to funnel shape at the end for application.
He fitted this end with an insertable perforated plug that would convert the device
to a simple cylinder. The instrument was divided into two portions of about equal
length that would slip or screw together. This had the double advantage of being
more convenient for carrying in a pocket, and, when desired, of providing a shorter
instrument by use of only one segment. Various adaptation of this form of instrument
continued in use by physicians until the binaural stethoscope was developed by Dr.
George Philip Cammann, of New York, in 1855.
For the next three years, 1816 to 1819, Laennec intensively studied sounds heard
through his stethoscopes, and like Auenbrugger, checked his impressions with autopsy
findings. He presented reports to the Societe de I’Ecole, and to the academy
of Sciences, describing use of his instrument in diagnosis and sounds encountered
in patients with such conditions as pneumothorax, bronchial dilatation, pulmonary
emphysema, edema, gangrene, and tuberculosis. He also described significant attributes
of voice transmission through the chest wall, which he termed “pectoriloquy”
and which he interpreted as indicative of serious tuberculosis lesions. He thereafter
set about publication of his findings in book form. In 1819, A treatise on the Diseases
of the Chest and on Mediale Auscultation appeared in two thick volumes.
Laennec’s health again broke down (likely he was already suffering from tuberculosis)
and he retired to his forms at Kerlouarnce for two years. He returned to Paris in
November, 1821, this time to be welcomed with many honors. He was appointed personal
physician to the Duchess of Berry; and in 1822 he was appointed professor of practical
medicine at the college de France, to succeed Vorvisart as clinical professor one
year later. Physicians from all over Europe and America came to hear lectures by
the discoverer of auscultation, who had resigned his position at Necker and had
taken over to clinic at La Charite. In 1824 he was made a Knight of the Legion of
Honor. The emaciated asthmatic little physician plunged again into an intensive
work schedule, which included preparation of second, enlarged edition of his treatise
on auscultation. Again he was defeated by poor health. He contracted a cold, and
his dry cough became more severe. At the end of May, 1826, Laennec returned once
more to Brittany, hopeful for relief. One of his pupils, called to care for him,
on examining him heard the telltale pectoriloquy, harbinger of death from tuberculosis.
Laennec’s condition worsened, and on August 13, 1826, the dread consumption
that had claimed his mother and many of his patients took the life of the little
physician in his forty fifth year.
Tribute to Laennec as a man of medicine may be found in Sigerist’s writings:
“Laennec was something much more than the discoverer of auscultation. He was
a distinguished anatomist and a great clinician. The invention of the stethoscope
was remarkable, but even more remarkable was what he himself did with the instrument.”
As a man among men, Ackerknecht described Laennec as: “Incredibly many-sided:
a good philologist, musician, hunter, draftsman, woodcarver, and administrator,
besides being a medical genius and a good man. But he exhibited a façade
of coldness and few persons recognized his true value during his short life –
so full of tribulations, so poor in joys, yet so rich in accomplishments.”
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