LAËNNEC AND THE INVENTION OF THE MODERN METHOD OF AUSCULTATION; PAUL-JOSEPH BARTHEZ

RenÉ ThÉophile Hyacinthe LaËnnec (1781–1826) was born at Quimper in Brittany, France. I am not able to furnish any details concerning his early history. His subsequent career as a physician, however, and especially his writings, show very clearly that he must have received a very careful and thorough education. Previous to 1816 auscultation of the chest was carried out in the same manner as it was in the time of Hippocrates,—that is, by applying the examiner’s ear, either directly or through an interposed piece of linen, to the surface of the skin overlying the particular part which he was desirous of examining.

In 1816 I was consulted [writes LaËnnec] by a young woman who presented certain general symptoms that pointed to the existence of some disease of the heart, and in whom, by reason of her embonpoint, simple palpation and percussion could scarcely be expected to furnish satisfactory information in regard to the nature of the disorder. The age and sex of the patient not permitting me to make such an examination as I have just mentioned I was compelled to adopt some other measure; and I then recalled to mind the acoustic phenomenon with which everybody is familiar, to-wit: if the ear be applied to one end of a wooden beam it will perceive with perfect distinctness the sound made by the scratching of a pin’s point on the opposite end of the beam. From this circumstance I inferred that in the present case I might advantageously utilize the principle underlying this phenomenon. Accordingly I rolled up into a cylinder-shaped, stiff-walled tube several sheets of writing-paper, and, resting one end of the cylinder on the skin of the precordial region, I applied my ear to the other end of the tube. I found to my surprise and pleasure that I was now able to hear the pulsations of the heart much more distinctly than I had ever before heard them when I applied my ear directly to the chest-wall.

This first experience made such a deep impression on the mind of LaËnnec that he promptly instituted a series of experiments which had for their object (1) the determination of the form of instrument that would best answer the desired purpose, and (2) the discovery of the various cardiac and pulmonary conditions that might advantageously be studied by the use of this instrument. Such were the first steps taken in one of the most useful medical discoveries of which we have any record. Auscultation, the importance of which had been dimly foreseen by Hippocrates the Great, became now for the first time, in the early part of the nineteenth century, one of the most effective aids to the physician in ascertaining the true nature and extent of certain diseases located in the cavity of the chest, in watching their progress, and in regulating their treatment in accordance with the physical conditions revealed by the aid of the method. The history of medicine has few more important events to record than this discovery made by LaËnnec, one of France’s greatest physicians.

As a result of the experiments to which I have just referred there was soon substituted for the crude thin-walled paper cylinder a solid column of light wood, hollowed out centrally throughout its length by a narrow tubular channel. To this new instrument the name “stethoscope” was given. It would require too great an amount of space to give here the full and very explicit instructions supplied by LaËnnec regarding the manner in which this instrument is to be employed in actual practice; and, furthermore, they are to be found in the best modern textbooks which deal with diseases of the chest.

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.

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.

Toward the end of his life Barthez suffered a great deal from bladder trouble, which proved eventually to be dependent upon the presence of a calculus. Instead of submitting at this time to a surgical operation, the only measure that offered him any chance of permanent relief, he put his faith in the use of lithontriptics; and then, when these proved to be impotent to give him relief, he expressed his willingness to submit to an operation. But by that time his general condition had become so unfavorable that it was not considered safe to operate. His death occurred on October 15, 1806, after he had passed through several weeks of very great suffering.

In order that one may form a correct estimate of Barthez’ professional career it is necessary that certain facts should be borne in mind. In the first place, he was endowed with a prodigious memory, a remarkable capacity for grasping facts, unlimited patience in studying their different aspects, great ability in ascertaining their relations to one another, and wonderful facility in following out the connections between abstract ideas. Then, in addition, his acquaintance with both ancient and modern languages made it easy for him to familiarize himself with the sayings of the philosophers and scientific men of all times and countries.

In 1785, after the death of Imbert, who at that time occupied the important position of Chancellor of the University of Montpellier, the highest medical office in the southern half of France, Barthez was chosen his successor.

Were it not for the difficulty presented by the lack of space I should be glad to add here, by way of example, a reproduction, in English, of one of Barthez’ “Consultations,” some of which are most instructive, and which furnish at the same time an excellent picture of the manner of procedure followed by this celebrated French diagnostician and teacher of the science and art of medicine. Merely to furnish a rÉsumÉ of one of these chapters would not serve a sufficiently useful purpose, and I must therefore abstain from making any attempt whatever to supply the desired portrayal. To those, however, who are interested more particularly in the subject of syphilis I will venture to suggest the perusal of Consultation XXXVI. (pp. 381–396), in which Barthez gives a very complete report of the infection, with that disease, of an entire family (father, mother and several children). This report is well worth reading. In addition to the “Consultations de MÉdecine,” which was published in 1820 by Lordat, Barthez wrote the following treatises:—

“Nouveaux ElÉments de la Science de l’Homme,” Montpellier, 1778 (1 vol.); Paris, 1806 (2 vols.); “TraitÉ des Maladies Goutteuses,” Paris, 1802 (2 vols.); “Nouvelle MÉcanique des Mouvements de l’Homme et des Animaux,” Carcassonne, 1798; “Discours sur le GÉnie d’Hippocrate,” Montpellier, 1801.^[23]