10 January 2015

LAENNEC His Life & Times Dr.Roger KERVRAN Oxford: Pergamon Press; 1960. Translated from the French by Diana C ABRAHAMS-CURIEL

Editor

Professor Seamas Donnelly
Published on behalf of
The Association of Physicians

Alas, poor Laënnec!


DOI: http://dx.doi.org/10.1093/qjmed/hcq215 275-277 First published online: 12 November 2010

‘Je l’ai entendu désigner sous divers noms, tous impropres et quelquefois barbares … . Je lui ai donné, en conséquence, le nom de stéthoscope, qui me paraît exprimer le mieux son principal usage.’ Thus Laennec in his book, Traité de l’auscultation médiate, of 18191 named his invention, the instrument that came to symbolize his very profession and that illuminated the path to an understanding of the outward signs of disease in pathological terms.
As a medical student in the 1950s, I was confused by the terms used to describe the sounds heard through the stethoscope, râle and rhonchus, which meant little in English and seemed in their original languages to mean the same thing, a rattle. Yet, they were used apparently to denote different sounds. It was therefore my good fortune to become a student of Dr John Robertson in Liverpool who referred me back to the original text and showed me a copy of his paper with Robert Coope in the Lancet, Rales, rhonchi and Laënnec.2 It is still well worth reading. My interest in Laënnec and the origins of clinical examination was fired, and on graduating in 1962 I bought myself a copy of his most recent biography3 and hitch-hiked down to Brittany to visit his birthplace in Quimper and his grave near Douarnenez.
René-Théophile-Hyacinthe Laënnec, named for his grandfather, father and god-mother, did not have an easy life. Born in 1781, he lost his mother 5 years later and his father proved to be a feckless if intelligent and charming lawyer who managed repeatedly to lose all his money. However, Théophile did have two pieces of good fortune, first being sent to live with his uncle Guillaume, a physician and a constant support in his endeavours and, second, being possessed of an intelligence not short of genius. He played the flute, sang Breton songs and became a scholar of Celtic tongues and a devoted farmer, but these were secondary to his career in medicine, relaxations and ways of coping with his chronic ill-health, asthma, gout and tuberculosis; the last of these eventually killed him at the age of 46 years. He survived the awfulness of the Revolution and the terror of 1793 in Nantes. His apprenticeship to his uncle started as an army surgeon third class at the age of 15 years. With five years of military surgery behind him, he made his way to Paris in 1801 to enrol in medical school where he quickly distinguished himself and started publishing original observations. He does, however, seem to have attracted the opposition and perhaps enmity of several of his seniors, notably Dupuytren, and was repeatedly passed over for senior appointments – it is possible that his brilliance attracted some jealousy. His financial survival depended on his ability to attract wealthy patients but his academic work required a hospital base. He achieved a position first at La Salpêtrière (where he was heavily involved in the care of soldiers returning from the Russian campaign) and then, in 1816, the Hôpital Necker. It was here that he finally established his international reputation. He records that in 1816 he was consulted by a plump young woman with symptoms of heart disease in whom it seemed indelicate and difficult to listen to the precordium by direct application of the ear, a method occasionally used though little commented upon at the time. His mind was prepared, as an advocate of Hippocratic medicine and of the recently rediscovered studies of Auenbrugger on percussion, and he wrote: ‘ … je vins à me rappeler un phénomène d’acoustique fort connu: si l’on applique l’oreille à l’extrémité d’une poutre, on entend très distinctement un coup d’épingle donnè à l’autre bout.’ Being thus aware of the acoustic properties of solid material, in this case in conducting the sound of a pin scratch along a wooden beam, he used as a substitute readily to hand a tightly rolled bunch of papers and was convinced that this made the heart sounds more readily audible.
This single observation led Laënnec to a series of studies both of the properties of different materials and shapes of device in conducting sound and also of the pathological correlates of the sounds he heard in his patients’ chests and hearts. In this he differed from all his predecessors, relying on combining meticulous clinical and post mortem observations of patients with lung disease. He made the first stethoscopes himself, being (inevitably) a skilled wood turner, and the first editions of his book came with a stethoscope for an additional 3 francs. The publication made an instant impact and within a few years distinguished physicians from all of Europe and indeed America came to study under him in his final hospital appointment at La Charité. His work was translated into English by Forbes, though subsequent commentaries led to some confusion as to the use of his terminology. In fact, Laënnec had been quite clear about râles and rhonchi, only using the former term in his book to describe the various added sounds heard in the lung; in his own words: ‘Je crois devoir engager les médecins qui se livreront à l’auscultation à ne jamais prononcer devant les malades et les personnes étrangères à la médecine les noms des signes stéthoscopiques. Cela n’est jamais nécessaire; et déjà je me suis aperçu que la valeur de certains signes graves était connue de quelques malades, dont les médecins avaient parlé devant eux avec trop peu de prudence. Par cette même raison, je substitue habituellement au nom de râle celui de rhonchus, qui n’effraie person, si par inadvertance on vient à le prononcer.’ Thus he was clear that the two words were synonymous and that the Latin (a language in which he commonly lectured) provided a less frightening substitute for the French with its connotations of the death rattle when speaking in front of his patients. It is unfortunate that this was misunderstood in 1876 by Latham, who taught that râle meant a moist sound and rhonchus a dry sound or wheeze. This aberrant usage persisted and confused students until the 1970s.
Laënnec’s teaching, in spite of misunderstanding and some downright opposition, formed the basis of pulmonary and, to a somewhat lesser extent, cardiac diagnosis until the introduction of radiology and the increased understanding of cardiac physiology in the early 20th century. The stethoscope was modified as a bi-aural instrument, helping to exclude extraneous noise,4 and the use of rubber then plastic tubes substituted, but the sounds we hear are those described by Laënnec. He was aware of the different sound frequencies and that different configurations of stethoscope allowed better conduction of higher and lower frequencies, and this was incorporated in the use of bell and diaphragm from the mid-20th century. Laënnec was not of course completely correct in all his suggestions as to the genesis of the sounds, searching as he was for anatomical correlates. Only in the late 1960s did the innovative work of Nath, Capel and Forgacs explain the origin of breath sounds and crackles in physical and physiological terms5 (and for discussion of this, see Ref.6). But, these modifications aside, what matters is the connection the instrument makes between the patient and the brain of the listener.
The retired doctor, chancing inadvertently or from ennui on Holby City or Casualty on television, or waiting patiently to be seen in the Out Patient department of his local hospital, will have noticed the principal use of the stethoscope nowadays seems to be to denote the trade of the individual who hangs it round his or her neck. Occasionally we see it removed and applied briefly to the upper chest under the shirt prior to its owner issuing reassurance or a worried look. Even I have been examined in this cursory manner. In many cases, it appears that the mystique of the stethoscope has hypnotised some doctors into using its application as a substitute for a careful examination involving observation, palpation, percussion and auscultation as urged by Laënnec and his followers. Observations of candidates for the MRCP over several decades has suggested to me that skill in clinical examination among UK graduates has deteriorated, perhaps a consequence of over-reliance on more sophisticated methods of examination. This has coincided with the sad decline of the post mortem examination as a vital component of teaching and as a final audit on our care of our patients.
One of Laënnec’s pupils, Charles Williams, described him thus: ‘His great talents are known to the public through the medium of his writings; but those who attended his clinique can only appreciate the wonderful acuteness of his perception, and faculty for observation, that enabled him to carry his discovery to the degree of perfection in which he left it; and they above all witnessed, felt, and profited by the solicitous interest which he showed to make others partake of its inestimable advantages. They felt in his death the loss of a friend.’7 Laënnec was the man who taught us to think about what is going on inside a patient’s chest. Are we forgetting what he taught? Alas, poor Laënnec!

References