René-Théophile-Hyacinthe Laënnec

Inventor of the stethoscope

Most people interested in the history of science will probably concur with Louis Pasteur’s words: “When it comes to observations, nature only favours the mind that is prepared.” But how many scientists are prepared that what to observe is children’s play?

René-Théophile-Hyacinthe Laënnec's mother died in her early thirties, probably from tuberculosis. His father, a lieutenant at the admiralty in Quimper, being unable to care for his children, Théophile was sent to his uncle, the physician Gauillaume-François Laënnec (1748-1822) at Nantes; there he was introduced to medical work. The French Revolution struck Nantes fiercely, and Laënnec worked in the city hospitals. In 1795 he was commissioned a third surgeon at the Hôpital de la Paix and shortly afterward at the Hospice de la Fraternité. It was at the latter that Laënnec became acquainted with clinical work, surgical dressing, and treatment of patients. His health was not good, for he suffered from lassitude and occasional periods of pyrexia. He found consolation in music and spent his spare time playing the flute and writing poetry.

Laënnec’s father wished him to abandon the study of medicine, and during a period of indecision Laënnec spent time at Quimper, dancing, taking country rambles, and playing the flute, with occasional study of Greek. In June 1799 he returned to his medical studies and was appointed surgeon at the Hôtel-Dieu in Nantes. From there he entered the École Pratique in Paris and studied dissection in Guillaume Dupuytren’s (1777-1835) laboratory. The following year, in June 1802, he published his first paper in Journal de médecine, Observations sur une maladie de coeur. It was followed in August, in the same journal, by Histoire des inflammations du péritoine. His colleagues at this time were Gaspard Laurent Bayle (1774-1816), Marie Francois Xavier Bichat (1771-1802), Jean-Jacques Leroux de Tillets (1749-1832), and Jean-Nicolas Corvisart des Marest (1755-1821), Napoleon’s life physician.

Bayle’s death from tuberculosis caused Laënnec much sorrow; and this, coupled with his dislike for Dupuytren, nearly resulted in his leaving Paris. Bichat persuaded him not to go and together they published a number of papers on anatomy in Journal de médecine in 1802 and 1803.

In 1803 Laënnec was awarded the prize for surgery and shared the prize for medicine awarded by the Grandes Écoles of Paris. His reputation increased, and he began to give private instruction in morbid anatomy to supplement his meagre income. Although suffering from asthma, he worked hard and announced his classification of anatomical lesions into encephaloid and scirrhous types. He also found that the tubercle lesion could be present in all organs of the body and was identical with that which had previously been thought to be limited to the lungs; he did not, however, realize that the condition was infectious. His thesis Propositions sur la doctrine d’Hippocrate relativement à la médecine-pratique, was presented and accepted in July 1804; he thereby became an associate of the Société de l’École de Médecine.

Family troubles, the death of his uncle from tuberculosis, and financial difficulties, coupled with his break with Dupuytren, disturbed the continuity of Laënnec’s work and caused his health to fail. He recovered by going to Brittany, and on his return to Paris he became an editor-shareholder of the Journal de médecine. Private practice increased; but he was disappointed in not being appointed assistant physician at the Hôtel-Dieu in Paris, physician to the emperor’s pages, or head of the department of anatomical studies. Taking the initiative himself, in 1808 he founded the Athénée Médical, which merged with the Société Académique de Paris. Shortly afterward he was appointed personal physician to Cardinal Joseph Fesch (1763-1839), the uncle of Napoleon I, but the cardinal was exiled after the fall of Napoleon. After failing to be elected to the chair of Hippocratic medicine and rare cases, Laënnec began preparing articles on pathological anatomy and ascarids for the Dictionnaire des sciences médicales. At this time (1812-1813) France was at war, and Laënnec took charge of the wards in the Salpêtrière reserved for wounded Breton soldiers.

On the restoration of the monarchy, Laënnec settled down to routine work but failed to obtain the chair of forensic medicine; reluctantly he accepted the post of physician to the Necker Hospital in 1816. It was here that he became interested in emphysema, tuberculosis, and physical signs of the chest. Although auscultation had been known since the days of Hippocrates, it was always done by the «direct» method, which often was very inconvenient. Still, this method had gained some popularity through Baron Jean-Nicolas Corvisart des Marest's (1755-1821) translation of the work of Josef Leopold Auenbrugger (1722-1809).

It was in 1816 Laënnec got the idea for the stethoscope from some children playing near the Louvre. The children applied their ears to two ends of long pieces of woods to listen to the transmission of sounds of pin scratches etc.

The following day he rolled up a piece of paper, tying it with some string, and applied it to a patient's heart. Being an excellent carpenter, he next made an instrument out of a wooden cylinder 30 cm long. In placing this instrument to the patient's chest he could hear various sounds from the heart and lungs. For three years he studied the chest sounds of his patients and compared them with the diseases found during autopsy.

Laënnec introduced what he called the «mediate» method, using a hollow tube for listening to the lungs and a solid wooden rod for heart sounds; by February 1818 he was able to present a paper on the subject to the Académie de Médecine. His poor health obliged him to live in Brittany as a gentleman farmer for some time; but by the end of 1818 he returned to Paris and soon was able to classify the physical signs of egophony, rales, rhonchi, and crepitations, which he described in detail in his book De l’auscultation médiate. The work was published in August 1819 and was acknowledged to be a great advance in the knowledge of chest diseases. Laënnec named his instrument stethoscope, which is Greek for examining the chest.

Again increasing asthma, headaches, and dyspepsia forced Laënnec to return in October 1819 to his estates at Kerlouarnec, Brittany, where he assumed the role of a country squire; however the possibility of election to the chair of medicine in Paris led him back to his clinic at the Necker Hospital. Owing to personal animosities, it was not until July 1822 that he was appointed to the chair and a lectureship at the Collège de France, replacing Jean-Noël Hallé (1754-1822). After this honours came rapidly to Laënnec. In January 1823 he became a full member of the Académie de Médecine and professor at the medical clinic of the Charité, and in August 1824 he was made a chevalier of the Legion of Honour. His private practice increased and included many distinguished persons. As a lecturer he became internationally famous; at times as many as fifty doctors awaited his arrival at the Charité Hospital, to which he had transferred his clinical work from the Necker.

Laënnec’s health at this time was fairly good. Feeling the need of help in his domestic affairs, he engaged as housekeeper a Mme Argon, whom he married in December 1824. The happy union helped him to publish a new edition of his book and enter the competition for the Monthyon Prize in physiology, but the extra work caused a return of his chest symptoms and forced him to leave Paris in May 1826, never to return. The climate of Brittany brought a temporary improvement in his health, but he died on August 13 that year.

Laënnec was the first to describe the sub-deltoid bursa and studied the fibrous capsule of the liver and gave a clear clinical and anatomical description of peritonitis. He also first described and named melanoma (melanose) during his anatomical dissections. He realized the black spots in the lung were metastatic melanoma, not soot or tuberculosis.

He wrote two books which were masterpieces of description of diseases of the chest and heart, although the section on the heart in both books was not nearly as significant as that of the chest because so little of the physiology of the heart was understood at the time (Laënnec attributed the 2nd sound to auricular function after the closure of the pulmonary and aortic valves).

Laënnec's studies on tuberculosis were monumental. He first recognised the unity of this condition, which had previously been thought to be a number of different diseases. He wrote the first descriptions of bronchiectasis and cirrhosis, and classified pulmonary conditions. He introduced many terms still used today; for example, pectoriloquy, rales and aegophony, and described bronchial and vesicular breathing. In short, he perfected the art of physical examination of the chest.

"Do not fear to repeat what has already been said. Men need [the truth] dinned into their ears many times and from all sides. The first rumour makes them pick up their ears, the second register, and the third enters."

"I risked my life, but the book I am going to publish will be, I hope, useful enough sooner or later to be worth the life of a man."

De l'auscultation médiate. Preface.
"In 1816 I was consulted by a young woman labouring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [direct auscultation] being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, . . . the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder 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 do by the immediate application of my ear."
Translated by John Forbes.

• Josef Leopold Auenbrugger:
  Inventum novum ex percussione thoracis humani ut signo abstrusos interni pectoris morbos detegendi.
  (A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest).
  Vindobonae, J. T. Trattner, 1761, 1763, 1775.
  First German translation in Vienna, 1843.
  First French translation by Rozière de la Chassagne:
  
• Manuel des pulmoniques, ou traité complet des maladies de la poitrine. On y a joint une nouvelle méthode de rennoitre ces mêmes maladies par la percussion du thorax, traduite du Latin.
  2 parts in one volume. Paris, Humaire, 1770. 319 pages.
  French annotated translation by Jean-Nicolas Corvisart:
  
• La nouvelle méthode pour reconnaître les maladies internes de poitrine par la percussion de cette cavité. Paris, 1808. Works by Laënnec:
• Observations sur une maladie de coeur.
  Journal de médecine, Paris, June 1802
• Histoire des inflammations du péritoine.
  Journal de médecine, Paris, August 1802.
• Note sur l’arachnoïde intérieure, ou sur la portion de cette membrane qui tapisse les ventricules du cerveau.
  Journal de Médecine, Paris, 1803, 5: 254-263.
• Note sur une capsule synoviale située entre l’apophyse acromion de l’humerus.
  Journal de Médecine, Paris, 1803, 5: 422-426.
• Lettre sur des tuniques qui enveloppent certains viscères et fournissent des gaines membraneuses à leurs vaisseux.
  Journal de Médecine, Paris, 1803; 6: 539-575.
• Propositions sur la doctrine médicale d’Hippocrate, relativement à la médecine pratique.
  Doctoral thesis, presented June 11, 1804, at the École de Médecine, and accepted in July.
• Mémoire sur les vers vesiculaires et principalement sur ceux qui se trouvent dans le corps humain.
  Mémoires de la Société de la Faculté de médecine, 1804: 176.
• Constitution médicale, observée à Paris pendant les six premiers mois de l’année 1807.
  With Jean-Jacques Leroux de Tillets, Gaspard Bayle, and Louis-Aimé Fizeau (1775-1864)
  Journal de médecine, chirurgie, pharmacie, etc. Paris, T. XIV.
• Mémoire sur le distomus intersectus, nouveau genre de vers intestins.
  Mémoires de la Société de la Faculté de médecine, 1809: 1-281.
• Constitution de l’année 1813.
  Journal de médecine, chirurgie, pharmacie, etc. Paris, 1813.
• De l'auscultation médiate, ou traité du diagnostic des maladies des poumons et du coeur, fondé principalement sur ce nouveau moyen d’exploration.
  2 volumes. Paris 1819; 1826; 1831 by Mériadec Laënnec; 3 volumes 1836.
  German translation, 1822; 1823.
  Also by Friedrich Ludwig Meissner (1796-1860) under the title of:
  
• Abhandlung von den Krankheiten der Lungen und des Herzens und der mittelbaren Auscultation als eines Mittels zu ihrer Erkennung. Leipzig, 1832. Various:
• K. Denkler and J. Johnson:
  A lost piece of melanoma history.
  Plastic and Reconstructive Surgery, Baltimore, December 1999, 104 (7): 2149-253.