1808: Corvisart re-introduces chest percussion to medicine

Jean Nicolas Corvisart (1755-1821) was the
mentor and teacher of two men who would go
on to gain fame studying diseases of the chest:
 Matthew Baillie and Rene Laennec.
Another pupil of his was Marie-Francois-
Xavier Bichat, the founder of biology. 

Joseph Avenbrugger introduced the medical community to chest percussion in 1761, although his idea was flat out rejected by many and rarely used by those who learned of it.  It would be another 53 years before his idea would be accepted, and it would take the efforts of a famous physician by the name of Jean Nicolas Corvisart des Merets (1755-1821). 

J.F. Halls Dally, in a 1941 article, said Corvisart was born February 15, 1755, to Pierre Corvisart, an advocate and attorney to the Parliament of Paris. For part of his childhood he lived with an uncle who was a priest at Vimille.  He then started college at Sainte-Barbe at the age of 12, where he was a "mediocre pupil who favored of outdoor sports. (1, page 239)

Of Corvisart's childhood education, Dally said: 

He is said to have left the college almost as ignorant as when he went in, with no reputation but that of an incorrigible idler. Thus the childhood of Corvisart gave no promise of his brilliant future. (1, page 239)

Later on he started as a law student, but after spending time at medical clinics of Paris he became interested in medicine. He became particularly interested in the speeches of Dr. Anthony Petit, a professor of anatomy and medicine. It was this reason "the young Corvisart recognized the profession for which he was designed. He longed to study the animal economy, and for this purpose he determined to be a physician," said Baron Cuvier in his 1830 memoir of Corvisart. (2, page 81) (1, page 23)

Surreptitiously, as he didn't want his father to be disappointed, he attended the lectures of the most famous physicians of the day, including Petit and Pierre Joseph Desault, said Cuvier. His father ultimately found out and approved of his transfer to the medical profession. (2, page 81)

Dally said he paid his way through medical school by becoming a male nurse at at Hotel Dieu, the oldest hospital in Paris.  It was here he became greatly influenced by the surgeon Pierre Joseph Desault, chief surgeon of the Hotel Dieu. Corvisart observed diseases with him and and examined bodies.  He also delivered his own lectures on anatomy and physiology, and these were well received.  He soon became well liked by his fellow students and physicians. (1, page 239)(2, page 81)

He was offered a job as physician at Necker, although he declined this position because all who held it had to wear a particular wig that had been handed down for decades.  Other clinics had given up this tradition, but it was still alive at Necker.  When he was offered a choice of taking the job and wearing the wig, or keeping his hair, he said he'd prefer to keep his hair.  This was a minor set back, however, because other opportunities awaited him. (1, page 240)(2, page 81)

It's interesting to note that while medicine in other areas of Europe had moved forward by leaps and bounds, Cuvier said medicine in France remained much as it was in the middle ages when the Faculty of Paris was formed. He said:

Besides, there were no public lectures at the beds of the sick. In order to see a few patients, the students accompanied the elder physicians in their visits; afterwords, when these physicians were unwell, or too much busied with practice, they acted for them, and thus they continued, till at length they, too, slowly attained their professional rank. (2, page 81)

Desbois de Rochfort (1750-1786)

In 1788 he became elected as physician at Necker hospital. His predecessor was Desbois de Rochfort, (Rochfort had passed away) chief physician at Le Charite, who was the...

...real creator of clinical medicine in France.  The pupil thus succeeded the master, and the glory of the master gained added lustre. Corvisart took over the clinical teaching and from that moment his reputation, already established among his colleagues and students, began to spread outside the confines of the hospital." (1, page 240)(2, page 81)

However, unlike his predecessors, he believed it was best to diagnose diseases by their signs and symptoms and pathological anatomy, as opposed to guessing what might be found on autopsy.  (1, page 240)

Then things change for the worse in France. Although the end result would benefit the medical profession of France.  Dally said:

In 1793 the Reign of Terror began.  The medical schools were shut, anyone could call himself a doctor and treat the sick.  Medical education was three centuries behind the times. But out of the Revolution grew modern medical education.  In the new schools of Paris laboratories were instituted for scientific study; students were taught at the bedside in hospital after the manner of Sydenham.  And it was Corvisart -- formerly rejected because he wore no wig, who taught, who for he had now become the leading professor in France. He acquired the natural history of disease by collecting observations, and when possible, following the example of Morgagni, he noted from dissection and from autopsy the changes in the body that caused symptoms of disease.  His chief lectures were given at the Necker hospital, and subsequently over a term of fifteen years at Cochin Hospital." (1, page 240)

Corvisart, whose reputation increased daily, lived in close contact with the most illustrious men of the time.  In 1795, on the criterion of the first school of medicine in Paris, he was unanimously elected to fill the Chair of Clinical Medicine, for the first time included as part of public education in France. Two years later, in 1797, he was made Professor of Medicine at the College de France. (1, page 240-241) 

While Corvisart was professor of medicine at the Charite Hospital in Paris, he studied the works of Auenbrugger and found the technique of percussion useful in diagnosing his own patients.

He championed for percussion when he re-published Abenbrugger's booklet about percussion Inventum Novum in 1808.  While he didn't have to, he humbly gave credit for the discovery of percussion to Avenbrugger.

He wrote:

"I could have raised myself to the rank of an author by remodeling the work of Auenbrugger and publishing a work on percussion.  But by that I would sacrifice the name of Auenbrugger to my own vanity; that I do not wish to do: it belongs to him, it is his beautiful and rightful discovery which I wish to bring to life." (1, page 242-243)

While Corvisant supported Avenbrugger's general technique, he adjusted it slightly so that "he used the palmar surface of the extended and approximated fingers," said Alex Sakula. (6, page 576)

Corvisart used the technique to help diagnose patients with tuberculosis and other diseases of the chest.  Based on the sounds emitted he would be able to tell how large or small the tubercles inside a patient were, along with their locations. (3)

Corvisart and his students -- one of whom was Rene Laennec -- were believed to be the only physicians in the world who used percussion. Perhaps this was because Corvisart was among the few physicians who studied Auenbrugger's work.

The use of percussion was among the diagnostic techniques used by Corvisart.  He used percussion, took a pulse, listened to the patients lung sounds by placing his ear on his patient's chest, watched the patient's breathing, felt for a temperature, observed sputum and perspiration, color of the patient's skin, changes in the voice, etc.  (2, page 81)

This was the new medical diagnostic practice that had already engulfed the medical profession throughout much of Europe, all but for the exception of chest percussion and, maybe also, vocal fremitis (vibration felt by the hand on the chest when a person speaks.  Different diseases would produce different sounds, according to the Free Dictionary by Farlex).

The Catholic Encyclopedia notes that Corvisant may have been the first to describe the technique of vocal fremitis, which is where a hand is placed over the patient's chest, and the patient is asked to make a sound, such as "a" or "e."  The physician then notes the vibratjions (fremitis) felt as the person made these sounds. Corvisart found this to be another very useful procedure in diagnosing diseases of the chest.  (5)

So, in this way, Corvisart was able to add to the list of diagnostic tools used by European physicians of his era.  By using these tools, Corvisart, and based on his studies of bodies, was able to match changes on the outside of the body with changes that might be occurring inside the body.  He was, therefore, able to use observation and science to diagnose.

In this way, he was able to use observation and science to diagnose patient, as opposed to using theory and just guessing.  Perhaps it was this that most impressed the emperor of France.

Napoleon Bonaparte was a famous military leader and
emperor of France. In these days, the best,
and perhaps only, means of adapting new ideas
was to earn the respect of the ruling party.

The technique of chest percussion may not even have been adapted by the medical profession at all if not for Emperor Napolean Bonaparte (1769-1821) selecting Corvisart as his own personal physician.  (4)

Dally said Corvisart was recommended as physician to Bonaparte because he was impressed that Corvisart used a scientific technique instead of simply guessing what was wrong, as other physicians of his era did.

Some speculate it was Boneparte who convinced Corvisart to write his first book, a treaties on diseases of the heart. This work was significant to our history of asthma because it was among the essential steps needed for future physicians to pluck cardiac disorders that caused dyspnea out from under the umbrella term asthma. (1, page 243)

Of this, Dally said:

It is said that cardiology as such did not exist prior to Corvisart's work. He really created cardiac symptomatology, and established differential diagnosis between cardiac and pulmonary disease, as well as between functional and organic heart disease." (1, page 243)

Corvisart later wrote his commentaries on Auenbrugger, which was also well received by his peers. (1, page 241)(2, page 82)

Thanks to the writings of Corvisart, and later Rene Laennec, Auenbrugger's discovery would become readily accepted shortly after his death in 1807, and Auenbrugger would eventually go down as one of the great minds in medical history.

Auenbrugger did, however, live "just long enough to witness the beginning of a proper recognition of his discovery," said Dally. (1, page 243)

Of course Corvisart himself would also go down as one of the great minds in medical history, not just because he re-introduced chest percussion to medicine, but because was a great physician overall who left an indelible impression on the medical profession.

He developed apoplexy (stoke symptoms) that took away his ability to perform his job, but not his mind.  He then suffered a cardiac arrest on September 18, 1821. He left behind no family, although he left much to his family of physicians.  (2, page 82)

Further reading:

1. Laennec, the inventor of the stethoscope
2. Auenbrugger introduced chest percussion to medical profession

References:

1. Dally, J.F. Halls, "Life and times of Jean Nicolas Corvisart (1755-1821)," Proc R Soc Med., March, 1941, 34 (5), pages 239-246
2. Baron, Cuvier, "Biographical Memoir of M. Corvisart," Literary Port Folia, Thursday, March 18, 1830, No. 11, Philadelphia, pages 81-82
3. "The Catholic Encyclopedia, "Leopold Auenbrugger," http://www.newadvent.org/cathen/02072a.htm
4. Williams, Henry Smith, "The Century's Progress in Scientific Medicine," Harper's Magazine, 1899, page 3
5. "The Catholic Encyclopedia, "Leopold Auenbrugger," http://www.newadvent.org/cathen/02072a.htm
6. Sakula, Alex., "Pierre Adolphe Piorry (1794-1879): pioneer of percussion and pleximetry," October, 1979, Thorax ( 34(5): 575–581).  

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1800-1900: The scientific revolution and the age of progress

Charles Darwin's "Origin of Species" may have helped
to spark the scientific revolution 

Perhaps among the most important centuries in the evolution of medicine wisdom was the 19th century. The great historian Fielding Hudson Garrison explained that this was the century that put an end to old dogmatic theories, thus opening the door for medicine and science to move forward. (1, page 424)

Respiratory diseases, particularly those looped under the umbrella term asthma, benefited greatly as pathology (the study of disease) and internal medicine (diagnosis and treatment of disease) were advanced during the course of the 18th century.  This brought us a greater understanding of the physiology of respiration,  setting the stage for what would transpire in the 19th century.

For instance, Mark Jackson, in his book "Asthma: A Biography, explained the following:

Eager to reject older irrational, mystical models of health and sickness, prominent Enlightenment physicians, such as Thomas Sydenham 1624-1689), George Stahl (1660-1734), Friedrish Hoffmann (1660-1742), and Herman Boerhaave (1668-1738), not only increasingly emphasized the importance of careful observation of the patterns and presentations of disease, but also strove to develop 'a simple and logical synthesis of medical knowledge designed to replace increasingly obsolete humoral conceptions inherited from antiquity' and to alleviate and conquer ill health.  (2, page 70)

Investigations of the human body, and new ideas such as "careful observation of patters and presentations of disease" brought about a better understanding not just regarding diseases, but the treatments to remedy them.  However, old theories persisted, thus acting as fetters to the furthering of wisdom.

Such theoretic fetters holding back great minds did not exist in the 19th century, wrote Fielding Hudson Garrison in his book "An Introduction to the history of medicine,"  mainly due to such works as: (1, page 424, 426)

• Friedrich Schelling's "Natural Philosophy" in 1797, "which aimed at establishing a subjective and objective identity of all things." (1, page 425)
• Hermann von Hemholtz,'s "Conservation of Energy" in 1847, which established the idea that no energy was lost in muscle movement, and that there was no vital force that causes muscle movement (wikepedia)
• Charles Darwin's "Origin of Species" in 1859, which established the idea that living creatures, including humans, evolve over time as changes in their environments occur. 

These works were met with much reservation and controversy by a dogmatic society, although they had a significant impact on both science and medicine, helping to open up the doors for scientific progress. As the ideas put forth by these works were accepted, great minds were no longer limited by theories made by famous men of the past, thus opening up a whole new world for them. (1, page 424)

Hermann Hemholtz shot down the age old theory that
'there was a vital force responsible for muscle movement.
His scientifically proven idea helped spark a revolution.

As noted by Garrison:

"It took a long time to demonstrate that the advancement of internal medicine as a science can never be accomplished by hugging some pet theory out of a regard for it's author's personality, but only through the performance of a vast amount of chemical, physical, and biological research by thousands of willing workers." (1, page 426)

Yet even though medical theories were no longer existent, "the modern scientific movement did not attain its full stride until well after the middle of the century. The medicine of the early half was, with a few noble exceptions, only part and parcel of the stationary theorizing of the preceding age," wrote Garrison.  (1, page 425)

A good example of this we can find in our own asthma history.  Dr. Robert Bree, who was the preeminent asthma expert in the first half of the 19th century, continued to believe in old humoral theories.  On the other hand, Dr. Henry Hyde Salter, who was the preeminent asthma expert in the second half of the 19th century, devised modern conclusions regarding asthma based on scientific investigations. 

Friedrish Schelling encouraged the subjective and the objective
review of patients. His ideas helped spark the scientific revolution.

We have to under stand, however, that the fact Bree did not use science and Salter did does not mean that Salter's conclusions were flawless, because they weren't.  The fact that pure asthma left behind no scarring in the lungs caused him to deduce, as experts before him had, that asthma must be nervous in origin.  Surely he was wrong, but he also didn't know about the immune system. 

The term asthma went through an amazing transformation during the course of the 19th century, with many physicians hunting for answers, and each coming to his own conclusion.  Some were right, thus leading investigators in the right direction.  Some were wrong, thus leading investigators in the wrong direction.  Regardless, all such investigations benefited our disease, thus setting the stage for what would transpire in the 20th century. 

References:

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company
2. Jackson, Mark, "Asthma: A biography," 2009, New York, Oxford University Press; reference quoted by Jackson: Guenter B. Risse, "Medicine in the age of Enlightenment," in Andrew Wear, editor, Medicine in Society: Historical Essays, (Cambridge, 1992), pages 149-95

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1768: Bosier de Sauvages classifies asthma

Francois Boissier de Sauvages (1706-1767)

One of the key figures in the early days of nosology was the French physician and nosologist Francois Boissier de Sauvages (1706-1767). He worked with the disease classification system created by Thomas Sydenham, and divided diseases into ten categories based on symptoms in his 1763 book, "Nosologie Methodique (diagnostic methods)."  (1)(2)

De Sauvages, like Sydenham, was from the vitalist school of medicine in Montpellier. It is Sauvages who is often given credit for making vitalism popular among the medical community in the 17th century.

Vitalism was an ancient system of medicine that was started by the ancient Greeks (if not earlier) and perhaps first described through the writings of Hippocrates and Aristotle.  It was a belief that a vital spirit, or a soul, was responsible for maintaining the balance of health and sickness.

They believed that the vital spirit within the body was determined by the opposing humours within the body: black bile, yellow bile, phlegm, and blood.  As noted earlier in this history, even the Chinese had a system regarding the balance of substances in the body, such as Qi.  So systems of vitalism, of sorts, existed from an earliest moments of civilization.

Vitalism was revitalized, so to speak, by George Ernest Stahl (1660-1734).  He believed a significant difference between living organisms and inorganic bodies was that living organisms possess a vital spirit.  This view was worded well by the authors of Encyclopedia Britannica:

From his observation that organic bodies decompose rapidly after life ceases, while inorganic bodies remain chemically stable, he concluded that the strong corruptibility of organic matter must result from its material nature (that is, chemical composition) and that there was an immaterial reason that kept a living body from its natural decomposition. Stahl identified this reason with the principle of life, which he sometimes called “natura” (nature) and sometimes “anima” (soul). This natural reason of anima was the source of the remarkable self-healing power of the organism, and when misled, such as by emotions, it produced illnesses. This double character of the vital principle made it the foundation of physiology and pathology, and it dictated that physicians should work to facilitate or restore its healing power based on attentive observation. (6)

Stahl, like most vitalists, understood that the body was a complex system, but he rejected the idea that it was purely mechanical, (6) or consisted of a system of "pulleys and levers" that worked together to maintain health. He did not believe that health could be explained by physical or mechanical means. (5)

Stahl believed it was this soul, or anima, or vital spirit, that made the difference between living organisms like human beings and inanimate objects. The vital spirit was the vital principle of life, health, and healing. (6)

Following the beliefs of Stahl and his vital principle were Sydenham and then Sauvages.

Dr. John Charles Thorowgood, in 1879, said during a lecture on asthma to the Medical Society at London, that by the mid 17th century physicians started to take notice of the periodicity of asthma, or the fact that asthmatics tend to go long periods between episodes. (3, page 5)

Thorowgood said that Sauvages, In his 1768 book Genera Morborum, defined  asthma as "Difficultas spirandi periodice recurrens, chronica (difficult breathing that recurs periodically and is chronic)."  (3, page 5)

In 1879, Francis Ramadge said Sauvages used the term suspirium (sigh) instead of the term asthma.    However, Ramadge said that Sauvages made the same error as the ancients "by giving to asthma a sense almost as extensive as that which belongs to dyspnoea. (4, page 5)

References:

1. "Francois Boissier de Sauvages," encyclopedia.com, http://www.britannica.com/EBchecked/topic/525610/Francois-Boissier-de-Sauvages, accessed 10/12/13
2. "Francois Boissier de Sauvages," neuroportraits.eu, http://neuroportraits.eu/portrait/fran%C3%A7ois-boissier-de-sauvages, accessed 10/12/13
3. Thorowgood, John Charles, "The Lettsomian Lectures delivered at the medical society at London, 1879, on on bronchial asthma: its causes, pathology and treatment," 1879, London, Bailliere, Tindall, & Cox
4. Ramadge, Francis Hopkins, "Asthma, its species and complications," 1835, London, Longman, Rees, Orme, Brown, Green, and Longman
5. "Vitalism," Dictionary.com, http://www.merriam-webster.com/dictionary/vitalism, accessed 10/12/13
6. "George Ernst Stahl," encyclopedia britannica.com, http://www.britannica.com/EBchecked/topic/562520/Georg-Ernst-Stahl, accessed 10/12/13

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