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The Chronic*Ill Issue 9 Auenbrugger and Laënnec Figure 1: Two pioneers who have Leopold Auenbrugger demarcated the development a musical ear and this undoubtedly of Western thoracic medicine helped him unravel the dullness and resonances which he elicited through Roger Ellul-Micallef MD(Malta), PhD(Edin), FRCP(Edin), FRCP(Lond) the percussion of the chest and correlate them to underlying Department of Clinical Pharmacology & Therapeutics pathological processes. He published University of Malta, Msida, Malta his findings in 1761,5 as a modest Email: [email protected] little volume of 75 pages, ‘Inventum novum in percussione thoracis ut signo With the publications in 1761 of Giovan Battista Morgagni’s abstrusos interim pectoris morbis detegendi thoracis’. (Figure 2) (1682-1771) ‘De sedibus et causis morborum’ (On the Sites Auenbrugger established that by and Causes of Diseases),1,2 pathological anatomy became a percussing the chest wall a careful science in its own right. Morgagni’s aim was to try and clinician could obtain almost as much correlate the symptoms of a disease as it developed with information about underlying pathology 3 findings at post mortem. Although this found immediate as if he were looking through the chest. application in surgical disorders, where lesions were often It was thus possible to diagnose visible and palpable, it was not thought to be equally useful in abscesses, areas of collapse, cases of internal ailments as long as physicians were unable to consolidation of the lung, air in the explore what was happening to internal organs during life.4 pleural cavity, pleural effusion and This was made possible with the clinical diagnostic procedures different kinds of enlargements of the pioneered by Leopold Auenbrugger (1722-1809) and by René heart.6,7 Théophile Hyacinthe Laënnec (1781-1826). He was also an accomplished musician and at the Emperor’s request wrote the libretto for a comic opera, Auenbrugger, (Figure 1) senior of percussion after he had observed his Der Rauchfangskehrer (The Chimney physician to the hospital of the Holy father tapping wine barrels in his cellar. Sweep) for the court composer Salieri. Trinity and the Spanish Military Leopold studied medicine in Vienna Its first performance was reported to Hospital at Vienna, introduced during the time that the medical school have been ‘ein Kolossales Succes’! percussion of the chest as a diagnostic there was being reformed along the Although he was ennobled in 1784 his tool. It is said that this son of an lines of the Leyden school by the new method of clinical examination was Austrian innkeeper from Graz first Dutchman Gerhard van Swieten (1700- not immediately widely accepted. latched on to the diagnostic potential 1772). Auenbrugger was blessed with Indeed it is said to have been given Issue 9 Respiratory Supplement 2005 the chronic✱ill 7 gave full credit to the Austrian physician. The first English translation by Sir John Forbes (1787-1861), ‘A new invention for Percussing the Human Chest to Detect Hidden Signs of Disease’ had to wait for a further 16 years before being published.6 Auenbrugger’s method was further improved upon by Pierre Adolphe Piorry (1794-1879)10 and Josef Skoda (1805- 1881).11,12 Both Auenbrugger and Corvisart are considered to be important forerunners of the greatest medical revolutionary of the nineteenth century, Laënnec (Figure 3). The latter was born in Quimper, in Brittany, and lost his mother when he Figure 3: Figure 2: was only five years old. René spent his René Théophile Hyacinthe Laënnec Auenbrugger’s Monograph on percussion later childhood first with an uncle, a curé, who had to flee to England from 15 only a muted reception by his the Revolution and subsequently with distinctly’. As with Auenbrugger, a contemporary, Anton de Haen (1704- another uncle, a medical practitioner at simple boyhood observation led 1706), one of Herman Boerhaave’s Nantes who subsequently became Laënnec to a discovery that was to (1668-1738) star pupils, who as Rector of the University.13 Laënnec’s deeply affect the practice of medicine. Professor of Medicine in Vienna did a name is forever linked with the Laënnec performed a number of lot to introduce thermometry. invention of a simple diagnostic aid, experiments to establish the best Auenbrugger was well aware that it was the stethoscope.14 The word, a material to use and to determine the not easy for innovations to be accepted combination of two Greek words, ‘chest’ right length, the correct internal by one’s professional colleagues, for in and ‘to view’ is curiously a misnomer measurements and most convenient the introduction to his book he wrote: because whilst it aids in the shape. He produced a hollow wooden ‘... it has always been the fate of those auscultation of sounds emanating from tube about 30cm long and 5cm in who tried to improve their arts or inside the chest it certainly does not diameter, widening into a funnel at one sciences to be beset by envy, malice, permit the viewing of any thoracic end and fitting into the doctor’s ear at hatred, detraction and calumny’.8 He organs. the other (Figure 4). His observations, was being perhaps a little paranoid but Laënnec described what led to his reported to the Paris Académie des not totally so. invention during the examination of a Sciences, were at first met with The importance of percussion as a somewhat buxom patient, Mlle de disbelief. Within a few years however bedside skill in the clinical examination Surenne, in 1818: ‘As I realised that the use of the stethoscope had become of a patient was however fully both percussion and direct auscultation widespread not only in France but also appreciated by Jean Nicolas Corvisart were almost useless through the layer (1775-1821), Napoleon’s personal of fat, I recalled from boyhood a physician. As the first professor of familiar fact of acoustics, namely that medicine at the Hôpital de la Charitè he if one places one’s ear at the end of a had plenty of opportunity to introduce piece of timber one can hear very this clinical method of examination to distinctly the scratch of a pin at the his many students among whom was other end ... I therefore took a paper Laënnec.9 In 1808 he published an notebook, rolled it up tightly, applied annotated translation in French, one end to the precardiac region and ‘Nouvelle Méthode pour reconnaitre les listened at the other. I was as maladies internales de la poitrine’ of surprised as I was pleased to hear the Figure 4: Auenbrugger’s monograph in which he heartbeats much more clearly and Laënnec’s own design for a stethoscope 8 the chronic✱ill Issue 9 Respiratory Supplement 2005 in a number of other European He could not have been more wrong! de la plupart des maladies dont il s’agit countries. Forbes, who had earlier Laënnec’s medical and scientific aussi sûr que celui de certaines translated Auenbrugger’s work, became achievements were many. Based on maladies chirurgicales, telles que les an admirer of Laënnec. He translated clinical and postmortem findings he fracturis et les luxations entre autres’. into English his work, first published in described many respiratory ailments (... in diseases of the heart and lungs, Paris in 1819 as ‘De l’auscultation ranging from tuberculosis and asthma the ear, if I may so express myself, médiate, ou traité du pronostic des to bronchiectasis, a condition he called ‘seeing’ and ‘touching’ these organs, by maladies des poumons et du coeur’.16 ‘bronchorrhées purulentes’. He was means of an attentive examination picks Forbes was however sceptical as to eventually appointed to the Chair of up signs which, as Laënnec said, render whether this ‘ingenious instrument’ Medicine at the Collège de France in the diagnosis of most of the ailments in would ever ‘come into general use’ in succession to Corvisart. Laënnec died question as certain as that of certain England ‘because its beneficial of tuberculosis almost certainly picked surgical conditions such as fractures application requires a good deal of up in the post mortem room.18 and dislocations).19 trouble and skill but also because its Percussion and auscultation helped Decades would have to pass before whole character is utterly foreign’. In the physician obtain an objective view radiography would make the next addition Forbes felt that ‘To Englishmen into a patient’s illness. It may well be significant contribution to the there will always be something worth quoting here what one of diagnosis and follow up of diseases.20 ludicrous in the image of a grave Laënnec’s students, Jean Baptiste It was in fact on the night of November physician listening to a chest through a Bouillaud (1797-1881) had to say in 11th 1895 that Wilhelm Conrad Röntgen long wooden tube as if the disease his book ‘Essai sur la philosophie (1845-1923), professor of Physics at the were a living thing in communication médicale et sur les généralites de la University of Würzburg in Bavaria, while with him ....’ This Scottish physician clinique médicale’ published in Paris in investigating the passage of an electric had something even more damning to 1836: ‘C’est ainsi, par exemple, que current through a vacuum tube, say about English clinicians: ‘there is dans les maladies de poumon et du discovered X-rays.21 Chest X-rays were in this method’, Forbes wrote, ‘a sort coeur, l’oreille, s’il m’est permis de to transform the diagnosis of pulmonary of bold faith in the physical parler de la sorte, voyant et touchant diseases especially tuberculosis, but examination of patients wholly alien to ces organes, receuille, au moyen d’un Auenbrugger’s and Laënnec’s English medicine, more accustomed to examen attentif, des signes qui, comme introductions still form an integral part calm cautious philosophical musings’.17 l’a dit Laënnec, rendent le diagnostic of every clinical examination.
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