Friday, March 11, 2016

1761: Avenbrugger introduces chest percussion to medical profession

Joseph Avenbrugger (1722-1807) was not
the first physician to use chest percussion,
although he was the first to officially introduce
it to the medical profession in 1761. 
Hippocrates mentioned chest auscultation and succussion as far back as 400 B.C. thus introducing them to the medical profession. These techniques remained the only means of diagnosing diseases of the chest for greater than 2,600 years.

A new method called chest percussion was not described in 1761 by Joseph Leopold Avenbrugger, and still not generally accepted until 1807, a year before Avenbrugger's death.

Auscultation is the process of listening to sounds within the body.  To hear lung and heart sounds, the physician would place his ear upon the patient's chest, a task that was gross on large sweaty people, especially women, uncomfortable for both the physician and patient, and which may place the physician at risk of catching the victim's disease.

Succussion is the process of shaking the patient.  This was described by Hippocrates around 400 B.C. as a method of hearing puss move around in the lungs, thus allowing him to diagnose pleurisy.

Percussion is the process of tapping on a patients chest with a finger
to listen to the sounds emitted.  Physicians of today use the technique
as shown above, as it is gentler on the patient.  The presence of an
ongoing asthma attack, or air trapping, can be heard by the resonant
sound emitted.  
Percussion is the process of of gently tapping on the patient's skin to listen to the sounds emitted.  This would help the physician determine the size of an organ, and whether or not it was enlarged or diseased.

Percussion is Latin for to beat or to strike, and may have originally been used to describe the beating or striking of the first man-made instruments.  The technique may have been used as far back as the 17th century B.C. in Ancient Egypt. (1)

So while auscultation, succussion and percussion were taught in the ancient world, they were not routinely practiced until Avenbrugger learned about them by studying ancient accounts.  He then spent the next seven years silently and laboriously working on research to prove its usefulness. (1)(2, page 19)

Avenbrugger was born in Graets in Syria in 1722 to a hotel keeper who made sure his son received a good education at the University of Vienna.  At the age of 22 he became a physician at the Spanish Military Hospital where he worked for 10 years. (1)(2, page 19)

It was here he spent doing "observational and experimental studies (that) enabled him to discover that by tapping on the chest with the finger much important information with regard to diseased conditions within the chest might be obtained." (1)

In one experiment he inserted fluid into the lung of a corpse and then tapped on the chest to confirm if a dull sound was heard over the area the fluid was entered.  His studies confirmed his findings.  (1)

In other experiments he would tap on the chest to come up with a diagnosis, and when that patient died he would perform an autopsy to confirm his diagnosis.

So he learned that fluid, tumors, organs or other solid substances inside the body produced a dull sound, such as tapping over the heart or liver.  By tapping around an organ he could determine how large it was, and whether or not it was diseased.

He determined that fluid filled areas of the lungs also produced a dull sound, such as would be produced in pneumonia.  By using percussion he could not only determine that pneumonia was present, but where in the lung it was present. 

He also determined that hollow areas of the chest produced a high pitched sound, or what later physicians referred to as tympanic or resonant sound.  The removal of part of a lung would produce a high pitched sound when percussion was performed over that part of the lung. Emphysema and asthma may cause air to become trapped in the lungs, and therefore percussion of their chest will produce a high pitched sound.  So a skilled physician could diagnose asthma by percussion.

In 1761 he published his work in a 95 page booklet written in Latin called Inventum Novum ex percussione thoracis humani, ut signo abstrusos interni pectoris morbos detegendi, or "A new invention for discovering thoracic diseases by percussion of the chest."  In the book he credited his discovery to his father who would tap on kegs to determine how full they were.  (1) (2, page 19)(5, page 243)

A. Sakula, in his 1979 biography of Pierre Adolphe Piory, a man who would later help perfect the art of percussion and auscultation, quoted Avenbrugger's description of how he performed his procedure.  He described the technique of percussion as follows: (4, page 576)
"Observation 2: Of the Method of Percussion.
IV. The thorax ought to be struck, slowly and gently, with the points of the fingers brought close together and at the same time extended.
V. During percussion the shirt is to be drawn tight over the chest, or the hand of the operator covered with a glove made of unpolished leather. Scholium: If the naked chest is struck by the naked hand, the contact of the polished surfaces produces a kind of noise which alters or obscures the natural character of the sound." (4, page 576)
His booklet was translated into French, and then other languages, although, perhaps because he was a little known and modest physician, his idea was not well accepted by the medical community. (3, page 38)

Regardless, the idea of percussion was officially introduced to the medical profession, and there was just enough interest aroused by his booklet to keep his idea alive.

Avenbrugger was later described as "a simple minded, kindly and unassuming junior physician at the Vienna Hospital.  (5, page 242)

Forty-six ears after his booklet was published, a physian several years younger than him by the name of Jean Nicolas Corvisant learned about Avenbrugger's work on percussion, and he performed experiments of his own on his patients.  He learned, as did Avenbrugger, that it was very useful in diagnosing diseases of the chest.

In 1807 he republished Avenbrugger's Inventum Novum, an this time the booklet was well received, perhaps because Corvisant had a good relationship with the dictator of France, Napoleon Bonaparte.  While not obligated, he humbly and modestly gave credit for the discovery to Avenbrugger.

Yet while Corvisant helped gain fame for Avenbruger's discovery of percussion, Corvisant's former student, Rene Laennec, helped further establish the discovery in the minds of physicians, first in France, and then throughout the world, by his 1819 book Mediate Auscultation.

In this book, Laennec wrote about how great a discovery chest percussion was. He said:  (6, page 3-4)
Nay, will go so far to assert, and without fear of contradiction from those who have been long accustomed to the examination  of dead bodies, -- that before the discovery of Avenbrugger, one half of the acute cases of peripneumon and pleurisy, and almost all the chronic pleurises, were mistaken by practitioners; and that, in such instances as the superior tact of a phsician enabled him to suspect the true nature of the disease, his conviction was rarely sufficiently strong of prompt and justify the application of very powerful remedies. The percussion of the chest, according to the method of the ingenious observer just mentioned, is one of the most valuable discoveries ever made in medicine. (6, page 3-4)
So Avenbrugger lived long enough to see his discovery accepted by his peers in France in 1807.  Of this, Laennec said:
He died without  ever perhaps dreaming of the celebrity which his discovery was destined to obtain"
Avenbrugger passed away in 1808. Yet his discovery of percussion would become a common procedure performed by physicians in order to help them diagnose and treat their patients.  (6, page 19)

Further reading:
  1. Laennec, history of chest percussion
  2. Corvisant re-introduced chest percussion to medicine
  3. Percussion and stethoscope fine tuned
  1. "The Catholic Encyclopedia, "Leopold Auenbrugger," (1)
  2. Andral, G., notes to the works of Rene Laennec, "A treaties on the diseases of the chest, and on mediate auscultation," translated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company (10
  3. Williams, Henry Smith, "The Century's Progress in Scientific Medicine," Harper's Magazine, 1899, page 38
  4. Sakula, Alex., "Pierre Adolphe Piorry (1794-1879): pioneer of percussion and pleximetry," October, 1979, Thorax ( 34(5): 575–581).  (11)
  5. Dally, J.F. Halls, "Life and times of Jean Nicolas Corvisart" (1755-1821)," Proc R Soc Med., March, 1941, 34 (5), pages 239-246 (8)
  6. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," translated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company (9)
  7. Sakula, Alex., "Pierre Adolphe Piorry (1794-1879): pioneer of percussion and pleximetry," October, 1979, Thorax ( 34(5): 575–581).  
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