Makers of Modern Medicine Part 8

With this conviction I forthwith {146} commenced at the Necker Hospital a series of observations from which I have been able to deduce a set of new signs of the diseases of the chest. These are for the most part certain, simple and prominent, and calculated perhaps, to render the diagnosis of the diseases of the lungs, heart and pleura as decided and circ.u.mstantial as the indications furnished to the surgeons by the finger or sound, in the complaints wherein these are of use."

This is the una.s.suming way in which Laennec announces his great discovery. He did not in modern fashion immediately cry "Eureka!" and announce the far-reaching importance of his method of diagnosis. For two years he devoted himself to the patient study of the application of his method and the appreciation of its possibilities and its limitations. Then he presented a simple memoir to the French Academy of Sciences on the subject. A committee of three, then distinguished members of the Academy, Doctors Portal, Pelletan and Percy were named to investigate the new discovery.

It is rather interesting to notice, though almost needless to say, that the names of these men would be now absolutely unremembered in medical history but for the fortuitous circ.u.mstance that made them Laennec's investigators. Such is too often the ephemeralness of contemporary reputation. Fortunately for the committee, they reported favorably upon Laennec's discoveries. It is not always true of new and really great advances in medicine that they are received with proper appreciation upon their first announcement. Even Harvey said of his discovery of the circulation of the blood that he expected no one of any reputation in his own generation to accept it. It is not very surprising to find then in the matter of the Laennec investigators that there is a cautious reserve in their report, showing that they were not too ready {147} to commit themselves to a decided opinion on the importance of the new discovery, nor to any irretrievable commendation.

The important part of the discovery was supposed to consist in the use of the wooden cylinder which Laennec came to employ instead of the roll of paper originally used. This wooden cylinder, now familiar to us under the excellent name invented for it by Laennec himself is the modern single stethoscope. This instrument is of great service. The really important part of Laennec's work, however, was not the invention of the stethoscope, but the exact observation of the changes of the breath sounds that could be noted with it in various forms of chest diseases.

Laennec succeeded in pointing out how each one of the various diseases of the heart and lungs might be recognized from every other. Before his time, most of the diseases of the lungs, if accompanied with any tendency to fever particularly, were called lung fever. He showed the difference between bronchitis and pneumonia, pneumonia and pleurisy, and the various forms of tuberculosis and even the rarer pathological conditions of the lung, such as cancer, or the more familiar conditions usually not a.s.sociated with fever, emphysema, and some of the forms of retraction.

With regard to heart disease, it was before Laennec's discovery almost a sealed chapter in practical medicine. It was known that people died from heart disease often and, not infrequently, without much warning.

The possibility that heart conditions could be separated one from another, and that some of them could be proved to be comparatively harmless, some of them liable to cause lingering illness, while others were surely a.s.sociated with the probability of sudden fatal termination, was scarcely dreamed of. It is to Laennec's introduction of auscultation that modern medicine owes all its exacter knowledge of heart lesions and their {148} significance. He himself did not solve all the mysteries of sound here as he did in the lungs; indeed, he made some mistakes that render him more sympathetic because they bring him down to the level of our humanity. He did make important discoveries with regard to heart disease, and his method of diagnosis during his own life was, in the hands of the Irish school of medicine, to prove the key to the problems of disease he failed to unlock.

Almost at once Laennec's method of auscultation attracted widespread attention. From Germany, from Italy, from England, even from the United States, in those days when our medical men had so few opportunities to go abroad, medical students and physicians went to Paris to study the method under the direction of the master himself and to learn from him his admirable technique of auscultation. Those who came found that the main thing to be seen was the patient observation given to every case and Laennec's admirably complete examination of each condition. The services to diagnosis rendered by the method were worthy of the enthusiasm it aroused. Only the work of Pasteur has attracted corresponding attention during the nineteenth century. Physicians practice auscultation so much as a matter of course now that it is hard to understand what an extreme novelty it was in 1820, and how much it added to the confidence of pract.i.tioners in their diagnosis of chest diseases.

Bouilland said, with an enthusiasm that does not go beyond literal truth, "A sense was lacking in medicine and I would say, if I dared, that Laennec the creator, by a sort of divine delegation of a new sense, supplied the long-felt want. The sense which medicine lacked was hearing. Sight and touch had already been developed in the service of medical diagnosis. Hearing was more important than the other two senses, and in giving it to scientific medicine Laennec disclosed a new {149} world of knowledge destined to complete the rising science of diagnosis."

Henri Roger said: "Laennec in placing his ear on the chest of his patient heard for the first time in the history of human disease the cry of suffering organs. First of all, he learned to know the variations in their cries and the expressive modulations of the air-carrying tubes and the orifices of the heart that indicate the points where all is not well. He was the first to understand and to make others realize the significance of this pathological language, which, until then, had been misunderstood or, rather, scarcely listened to. Henceforth, the pract.i.tioner of medicine, endowed with one sense more than before and with his power of investigation materially increased, could read for himself the alterations hidden in the depths of the organism. His ear opened to the mind a new world in medical science."

The freely expressed opinions of distinguished German, English and American physicians show that these enthusiastic praises from his French compatriots are well deserved by Laennec for the beautifully simple, yet wonderfully fecund method that he placed before the medical profession in all its completeness.

The first employment of the stethoscope by rolling up sheets of paper is of itself a sign of his readiness of invention. He made his own stethoscopes by hand and liked to spend his leisure time fashioning them carefully and even ornately. One of the stethoscopes certainly used by him and probably made by himself is to be seen at the Museum of the College of Physicians of Philadelphia.

After three years of study and patient investigation of the use of auscultation in pulmonary and cardiac diagnosis, Laennec wrote his book on the subject. This is an immortal work--a true cla.s.sic in its complete treatment of the subject. {150} We have had thousands of books written on the subject since Laennec's time, and yet no physician could do better at the present moment than study Laennec's two comparatively small volumes to learn the art of physical diagnosis.

It is a characteristic of genius to give a completeness to work that endows it with an enduring independent vitality. Almost innumerable disciples follow in the footsteps of a teacher, and each thinks that he adds something to the fulness of the revelation made by the master.

At the end of a century the fourth generation finds that scarcely anything has been added and that the master's work alone stands out, not merely as the great central fact of the new theory or doctrine, but as the absolute vital ent.i.ty to which the other supposed discoveries are only advent.i.tious and not entirely indispensable accessories.

Dr. Austin Flint, the elder, admittedly one of the greatest diagnosticians in pulmonary and heart diseases that we have ever had in America, said on this subject: "Suffice it to say here that, although during the forty years that have elapsed since the publication of Laennec's works the application of physical exploration has been considerably extended and rendered more complete in many of its details, the fundamental truths presented by the discoverer of auscultation not only remain as a basis of the new science, but for a large portion of the existing superstructure. Let the student become familiar with all that is now known on this subject, and he will then read the writings of Laennec with amazement that there remained so little to be altered or added."

Laennec's unremitting devotion to his hospital work finally impaired his health. He was never robust and strangers who came to Paris and saw him for the first time wondered that he should be able to stand the labor he required of himself. The portraits of him give a good impression of {151} his ascetic delicacy; they convey besides a certain wistfulness, the look of one close to human suffering, and unable to do all that he would wish to relieve it. Long before his discovery of the mysteries of auscultation, he had accomplished results that of themselves, and without his subsequent master discovery, would have given him an enduring name in medical literature. Laennec's genius enabled him to make a really great discovery, but Laennec's talent, the princ.i.p.al part of which was an inexhaustible faculty for untiring labor, an infinite capacity for taking pains with all that he did, enabled him to make a number of smaller discoveries any one of which would have given a great reputation to a lesser man.

Some idea of the amount of work that he did in preparing himself for the observations that were to result in his discovery may be gathered from details of his earlier career. During the first three years of his attendance at La Charite Hospital in Paris he drew up a minute history of nearly four hundred cases of disease. As early as 1805 he read a paper on hydatid cysts. These cysts were formerly thought to be hollow tumors formed within the tissues themselves somewhat as other cystic tumors are formed. Laennec showed conclusively that their origin was entirely due to certain worms that had become parasites in human beings. The cysts instead of being tumors were really one stage of the worm's existence, and had an organization and an independent existence of their own. He gave an exact description of them and even showed that there were several types of the parasite, and described the different changes that various forms produced in the human tissues. This study of the hydatid parasites remains a remarkable contribution to medicine down even to our own day.

During these early years Laennec devoted himself particularly to the study of pathology. Like all the men who {152} have made great discoveries in medicine he understood that all true medical advance must be founded on actual observation of the changes caused by disease in the tissues, and that this knowledge can only be obtained in the autopsy room. For years he devoted himself to the faithful study of the tissues of patients dead from various forms of disease. He wrote as the result of this work a treatise on peritonitis that was a distinct advance over anything known before his time and which, in the words of Benjamin Ward Richardson, "as a pathological study was shrewdly in antic.i.p.ation of the later work of one who became his most formidable rival, the famous Broussais."

From the peritoneum his attention was attracted to the liver. As early as 1804 he wrote a description of the membranes of the liver.

Pathological changes in the liver continued to occupy his attention for some time, and it is to him we owe the name cirrhosis of the liver, as a term for the changes which are produced by alcohol in this gland. Alcoholic cirrhosis is often spoken of as Laennec's cirrhosis of the liver, and he was the first to point out the significance of the changes in the organ, their etiology and the reason for the symptoms that usually accompany this condition. This work alone would have been sufficient to have made Laennec's name a permanent fixture in medical literature.

During the early years of Laennec's career at Paris, the French Anatomical Society was founded and Laennec became a prominent member of it. Corvisart, who was the moving spirit in the society, was at this time--the early years of the nineteenth century--doing his great teaching at the medical school of the University of Paris. He was Laennec's master, and was at the height of his glory. It was a constant source of surprise to his students to note how well the master's diagnosis agreed with postmortem findings. This is, after {153} all, the only true criterion of scientific diagnosis. It is not surprising that the strict application of this practical method of control of medical theory soon gave rise to a series of distinct advances in medical knowledge of the greatest importance.

Discussions of cases were frequent and Laennec took a prominent part in them. His knowledge of medicine was broadening in this great field of practice, and he was chosen as one of the contributors to the _Dictionnaire des Sciences Medicales_. His articles for this work contained much original matter of great value and suggestive views of notable importance. Laennec was the first to give a description of carcinoma encephaloides and certain especially malignant forms of cancers. He showed the distinction between pigmented spots of benignant character and those that were due to malignant disease.

"After all, however," says Benjamin Ward Richardson, "the grand reputation of Laennec must rest on his one immortal work. It is not too much to say that any man of good intelligence could have written the other memoirs. No one less than Laennec could have written the 'Treatise on Mediate Auscultation and the Use of the Stethoscope.' The true student of medicine, who never wears out, reads this original work of Laennec once in two years at least, so long as he is in practice and takes a living interest in the subject of which it treats. It ranks equally with the original works of Vesalius, Harvey and Bichat and as a section of medical literature is quite equal to any section of Hippocrates." [Footnote 3]

[Footnote 3: The full t.i.tle of this work of Laennec's is "De l'auscultation mediate ou traite du diagnostic des maladies des poumons et du coeur par R. T. H. Laennec." Its modest motto is the Greek sentence: [Greek Text], (The most important part of an art is to be able to observe properly.) The book was published in Paris by J. A. Brosson et J. S. Chande, rue Pierre-Sarrazin, No. 9, 1819.]

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Some quotations from the Latin preface to the book will serve to show that Laennec appreciated the value of the discovery he had made for the diagnosis of chest diseases, yet that he did not expect it to be taken up enthusiastically at once, and in his modest way he adds that he shall be satisfied if it should serve to save but one human being from suffering and death. [Footnote 4]

[Footnote 4: "Imo neminem hanc methodum expertum deinceps c.u.m Baglivio dicturum esse spero: O quantum difficile est diagnoscere morbos pulmonum."

"Nostra enim _aetas incuriosa_ quoque _suorum_ (the italics are Laennec's own); et si quid novi ab homine coaevo in medio ponitur, risu ut plurimum ineptisque cavillationibus excipiunt; quippe facilius est aspernari quam experiri."

"Hoc mihi satis est quod bonis doctisque viris nonnullis acceptam aegrotisque multis utilem, hanc methodum fore confidere possim; hominem unum ereptum orco dulce dignumque meae atque etiam majoris operae pretium praemium fore existimem."

"I may say that no one who has made himself expert with this method will after this have occasion to say with Baglivi, Oh! how difficult it is to diagnose disease of the lungs."

"For our generation is not inquisitive as to what is being accomplished by its sons. Claims of new discoveries made by contemporaries are likely for the most part to be met by smiles and mocking remarks. It is always easier to condemn than to test by actual experience."

"It suffices for me if I can only feel sure that this method will commend itself to a few worthy and learned men who will make it of use to many patients. I shall consider it ample, yea, more than sufficient reward for my labor, if it should prove the means by which a single human being is s.n.a.t.c.hed from untimely death."]

Unfortunately, as we have said, Laennec's untiring devotion for nearly twenty years to medical investigation caused his health to give way.

It is painful to think that in the full tide of the success of his great labors, when the value of his work was only just beginning to be properly appreciated and when he had attained a position which would satisfy even lofty ambitions, his nerves gave way and he had many {155} of the typical melancholic symptoms that disturb the modern neurasthenic. Fortunately, his habits of life, always extremely abstemious, and his liking for outdoor sports had been a safeguard for him. He retired to the country and for nearly two years spent most of his time in the open air.

It was not long before surcease from intellectual labor and indulgence in field sport restored him to health and to activity. He foresaw, however, that to go back to the city and to his scientific work would almost surely lead to another breakdown. One of his biographers states that it was the great regard which he had for his family and the powerful influence of his religious principles which alone had sufficient weight to make him leave his retreat in the country. After an absence of two years, he returned to Paris and once more took up his hospital duties.

Soon after his return he received the appointment of physician to the d.u.c.h.esse de Berri. One of the main objections to this position in Laennec's mind seems to have been the necessity for occasionally wearing court dress with a sword and regalia. Ordinarily he went dressed very plainly, and it was noted that, when men of much less authority and much less practice used their own carriages, he usually took a hired cab. His position at court gave him enough influence to bring about the proper recognition of his merit as a teacher. At this time his lectures on auscultation, though he held no regular professorship, were crowded by students from all nations. The year after his return to Paris he was appointed Professor of Medicine in the College of France, and afterward of clinical medicine at the Hospital La Charite where he had made his own studies as a medical student.

About this time he was offered a position of importance as a member of the Royal Council of Public Instruction. This he refused, however, because it would deprive him of {156} some of the precious time that he wished to devote to the further investigation of important subjects in clinical medicine and especially to the elaboration of his method of auscultation.

One of the most striking features of Laennec's character was his absolute placidity and lack of personal ambition. His life was pa.s.sed in the most complete calm. He devoted himself to his work, and had the supreme joy of duty accomplished, seeming to look for no other enjoyment in life. Those who knew him best said that they had never seen him angry or even impatient. In the midst of his discussion with Broussais, it might have been expected that there would occasionally have been some flashes of impatience, for the great protagonist of medical theory was a man of satiric character, and his supposedly scientific discussion was stained by some very bitter personalities.

In spite of all Broussais' sarcasm, Laennec remained absolutely unmoved. Occasionally his friends saw a smile at some of Broussais'

emphatic a.s.severations, but Laennec simply continued at his work, and looked straight ahead, convinced that what he was doing was for the cause of truth, and the truth would finally prevail.

He was known for the kindness of his disposition, and his readiness to help his friends whenever it was possible. He was never known to injure anyone, and a certain quiet elevation of spirit preserved him from all conceit. One of his most intimate Breton friends, Kergaradec, said, "I have never heard Laennec express by a single word, or even by the slightest insinuation, anything that might seem to indicate pride in what he had accomplished or that might provoke a listener to say something in praise of him." The friends he made were bound to him with hoops of steel. They were not many, for he had not the time to waste on many friends. He was too devoted to his work, and too {157} deeply interested in the great problem whose solution he foresaw meant so much for the good of humanity, to have much time for anything but his studies and his patients.

With regard to Laennec's personal character, his most recent biographer Dr. Henri Saintignon, has said: [Footnote 5]

[Footnote 5: Laennec, Sa vie et son oeuvre. Par Dr. Henri Saintignon. Paris, J. B. Bailliere et Fils, 1904.]

"I have shown in the course of this life just what was the character of Laennec and his intellectual and moral qualities, so that it will not be necessary for me to dwell at length on this subject, in concluding. His great piety, which had never been abandoned from his earliest infancy, was his main guide during all his life. Without ostentation, yet without any weakness, absolutely ignoring human respect, he obeyed with utter simplicity the prescriptions of his faith. While he did not conceal his convictions when during the first empire they might have proved a source of lessened esteem, or positive prejudice, he made no noise about them when under the Restoration they might have proved the means of advancement and of fortune. He had not in the slightest degree what is so often objected to, in devoted persons, namely, the love of making proselytes. The words of Prof. Desgenettes might very well have been applied to him: as he did not believe himself to have any mission to lead others to his opinions, he limited himself to preaching by example. The reproach of being rabidly clerical or propagandist, which was urged against him, when he first became a member of the faculty of medicine, was absolutely unjustified. Laennec never occupied himself with politics nor with religion in public. As a physician he devoted himself exclusively to his profession, receiving at his clinic all those who desired to follow his teaching, whatever might be their opinions or their beliefs."

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It was not long, however, before Laennec's many labors in Paris began to tell on his health once more. His practice after his return to health and his attachment to the court became large and lucrative. It is characteristic of the man and his ways that he frequently refused, owing to lack of time, to go to see wealthy patients, from whom he would have received large fees, but it is said that he never refused to go to see a poor patient. His hospital patients always received the most solicitous attention, and his time was almost entirely at their disposal. It was not long before Laennec himself, who had taught modern physicians so much about the diagnosis of pulmonary diseases, began evidently to suffer from pulmonary disease himself. There seems no doubt now that almost constant a.s.sociation with tuberculous patients in an overworked subject inclined naturally to be of underweight, and therefore especially susceptible, led to the contraction of the disease.

After about four years in Paris, a dry, hard cough developed insidiously, gradually increased in annoyance, and finally grew so serious as to demand a return once more to his native Bretagne. He lost flesh, became subject to intermittent attacks of fever and suffered from some pleuritic and pulmonic pains. For some time after his return to his native air he improved. He was treated by the usual method employed at the time whenever fever accompanied any ailment.

Venesection was the main part of what was then called the antiphlogistic treatment. It is needless to say he did not improve. He was suffering from exhausting disease and the treatment became really an accessory to further exhaustion.

At last there could be no longer any doubt that the end was approaching. The old cure of the village came often to visit him, and brought him all the consolations of religion. {159} With his sincere Christian faith and firm conviction, it was not hard for Laennec to find the moral force and the calm necessary to secure an easy death.

Finally one day, on August 13th, his wife saw him take off his fingers one after another the rings he wore, and place them softly upon the table. When she asked him why he did so, he replied, "It will not be long now before someone else would have to do this service for me, and I do not wish that they should have the trouble." Even in death he was thinking of others rather than of himself, and he was calmly facing the inevitable, thoroughly prepared for it. Two hours afterward, at five o'clock in the afternoon, without there having been at any time the slightest loss of consciousness, Laennec pa.s.sed away.

How faithfully his family had watched over him, and how simple was the feeling of Christian confidence in all of them, may very well be gathered from the letter of his cousin Ambrose to Laennec's brother Meriadec in Paris.

"My dear Meriadec:--Poor Rene is no more. His life was pa.s.sed in the midst of labor and of benevolence. While he had all the virtues of the true Christian, and a wisdom far beyond what was usually granted to men, they have not sufficed to obtain for him the grace of a longer life. Somehow it was ordained that this glory and ornament of our family was not to remain with us. What a sad reflection it is on our restless eagerness in this life, and on the vanity of our hopes, that a genius like this must perish just when it was about to receive the fruit of its labors! He leaves to us a name, a name difficult to sustain and the example of virtues that it will not be easy to imitate. Let us hope that he will watch over us in the future as he has done in the past, and that he will still continue to aid us after his death. Although I have been prepared for this sad event, I could not suspect how much grief I was to experience in losing my {160} second master, my friend from earliest infancy, and him whom I had become accustomed to consider as my eldest brother. I must confess that for some years now we have all had to pay dear for the short intervals of happiness that it has pleased heaven to accord to us."