How Laënnec invented the stethoscope

International Journal of Cardiology 118 (2007) 281 – 285 www.elsevier.com/locate/ijcard

Editorial

How Laënnec invented the stethoscope Tsung O. Cheng ⁎ Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Avenue, N.W., Washington, D.C. 20037, United States Received 10 June 2006; accepted 28 June 2006 Available online 12 October 2006

Abstract Although it is well known that Laënnec invented the stethoscope, the story of how he invented it is less well known. This article discusses the many theories behind the story as well as the impact of Laënnec's discovery on the practice of cardiology in the 21st century. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Laënnec; Stethoscope; Auscultation

It is a well established fact that René Théophile Hyacinthe Laënnec (1781–1826), a French physician at the Necker Hospital in Paris, invented the stethoscope. However, how Laënnec discovered this remarkable diagnostic instrument has been the subject of many stories. The most frequently quoted story was that one of Laënnec's cardiac patients was a young lady; propriety forbade Laënnec from placing his ear against her bosom without causing embarrassment as he would normally do to listen to a male patient's heart. To sidestep this problem, Laënnec placed one end of a rolled piece of paper on the patient's heart region and the other to his ear. Laënnec found this makeshift instrument allowed him to hear the heart more clearly [1]. Another version was that this young female patient was rather obese. The obesity of the patient prevented Laënnec from getting the chest to produce adequate sounds. As reported by Bynum and Porter [2], Laënnec wrote, “I rolled a square of paper into a sort of cylinder and applied one 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

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and distinct than I had ever been able to do by the immediate application of the ear.” A third version was that Laënnec was afraid of contracting pulmonary tuberculosis when examining too closely to a tuberculous patient. The famous portrait of Laënnec listening to the chest of a tuberculous patient (Fig. 1) seemed to support this version. However, this story was not very acceptable, because Laënnec suffered from pulmonary tuberculosis early in his life before he invented the stethoscope [3]. The story how Laënnec contracted tuberculosis is interesting. The literature seemed to suggest that Laënnec contracted it from his mother who suffered from tuberculosis. But Laënnec's mother did not suffer from tuberculosis according to Laënnec [4]. Webb [4], in his very informative book, stated that Laënnec frequently pricked his fingers at autopsy; in 1803 he injured his finger at an autopsy on a case of Pott's disease, accidentally cutting it with a saw, and in 1819 he received a slight infection following an autopsy on a case of empyema. He died from tuberculosis on August 13, 1826 at the age of 45 [5]. The most convincing account was that recently revived by Markel [6]. One day in the fall of 1816, Laënnec was scheduled to examine a young woman with cardiac disease. He was running late and so took a shortcut through the courtyard of the Louvre, where a group of playful youngsters played atop a pile of old timber. Webb [4] in his book,

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Fig. 1. (A) Portrait of Laënnec auscultating his patient while his left hand was holding his stethoscope (Courtesy National Library of Medicine). (B) This famous portrait is now displayed in the Great Hall of La Sorbonne in Paris (Courtesy J.J. Boutaric).

Fig. 4. Laënnec using his stethoscope in mediate auscultation (Collection KHARBINE-TAPABOR with permission).

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entitled “René Théophile Hyacinthe Laennec. A memoir”, described the incident as follows: “In walking through the Gardens of the Louvre about this time Laënnec came upon a pile of litter which had collected as a result of the political chaos and the attendant neglect. Here a joyous crowd of urchins played. Their amusement was to divide into two groups, one at each end of a wooden beam, and while one group scratched and tapped at one end, the second group, their ears pressed to the other end, listened in childish amazement to the sounds. Laënnec looked and understood. He set out for the Necker at a fast gait. Reaching the room of his adipose patient, he seized a paper-covered book, rolled it into a tight cylinder, and to the amazement of the onlookers, he placed one end of this crude instrument against the patient's heart while he applied his ear to the other end. He could hear the heart sound and also the respiratory murmur.” Although Laënnec never referred to this incident directly in his book [7], he did say: “Then I remembered a well-known acoustic fact, that if the ear be applied to one end of a plank it is easy to hear a pin's scratching at the other end. I conceived the possibility of employing this property of matter in the present case. I took a quire of paper, rolled it very tight, and applied one end of the roll to the precordium; then inclining my ear to the other end, I was surprised and pleased to hear the beating of the heart much more clearly than if I had applied my ear directly to the chest” [3].

Fig. 2. The original stethoscope that Laënnec constructed from a rolled paper journal (Courtesy J.J. Boutaric).

Fig. 3. The original wooden stethoscope that Laënnec invented following the one he made from a rolled paper journal that was shown in Fig. 2 (Courtesy J.J. Boutaric).

Fig. 2 depicts such a cylindrical roll of paper devised by Laënnec which is now exhibited in the Medical Museum in Paris. After numerous designs, Laënnec finally developed the wooden stethoscope that is shown in Fig. 3. The following translation is excerpted from Talbott [8]: “Substances of medium density such as wood and cane are preferable…. As a consequence, I used a wooden cylinder 16 mm. in diameter, one foot in length, with a lumen of approximately .25 inch in diameter, and connected at one end to a bell about 1 1/2 inch in size…. At first I did not feel it was necessary to give a name to such a simple instrument. Since others felt differently I created several names, each of them improper, such as sonometer, pectoriloque, pectoriloquie, thoraciloque. medical cornet, etc. Finally I called it “stethoscope” which I thought best expressed the principle of its use. We hoped it can be applied to other uses aside from exploration of the chest.” Although the word ‘stethoscope’ was invented by Laënnec, his uncle Guillaume originally suggested the name ‘thoraciscope’ [4]. But Laënnec was too much of a purist to accept a name that combined Latin and Greek. So he changed the name to ‘stethoscope’ [4]. The word ‘stethoscope’ is made of two Greek words: stethos =chest, skopein = to view or to see [9]. Though Laënnec coined the term stethoscope, he never employed it, preferring to style his invention a baton or cylinder [4]. Laënnec also created the term ‘rales’ [4,10]. Laënnec called his method “auscultation” from the word ‘auscultare’ (to listen) [10]. He also named it “mediat” to indicate the use of the stethoscope [4], in contrast to immediate or direct auscultation which has been the

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technique used until that time [3]. Fig. 1 shows Laënnec utilizing direct auscultation on a patient while holding in his left hand his stethoscope for use in mediate auscultation. This famous portrait is now hung in the Great Hall of La Sorbonne in Paris (Fig. 1B). Fig. 4 shows Laënnec using his stethoscope in mediate auscultation. Boutaric [11] in his fascinating book, entitled “Laennec, Balzac, Chopin et le stéthoscope. ou la diffusion de l'auscultation médiate durant la première moitié du XIXe siècle”, also conjectured that it was Laënnec's stethoscope that made possible the correct diagnoses of congestive heart failure associated with hypertension in Honoré de Balzac (1799–1850) and of possible pulmonary tuberculosis and autopsy-proven adhesive (constrictive) pericarditis in Frédéric Chopin (1810–1849). Laënnec, at one point, was devoted to playing the flute, practicing 6 h a day at times [12]. He also found time to write poetry, using the pseudonym Cenneal (Laënnec spelled backwards) [12]. But his love was in medicine. We should be eternally grateful to him for switching from flute-playing and poetry-writing to the practice of medicine which led to the invention of the stethoscope which in turn revolutionized the technique of cardiac and pulmonary auscultation forever. Of interest was the fact that, by the irony of fate, Laënnec's name in medical terminology is attached, not to any of the afore-mentioned cardiopulmonary accomplishments, but to a short account in a description of the hobnail liver in cirrhosis [13]. It was Laënnec, who proposed the name ‘cirrhosis’ (χιρρός in Greek, meaning “tawny colored”) on account of the characteristic yellow color of a cirrhotic liver [14]. Although he was not the first person to have described this condition, Laënnec's name has always been eponymously affixed to alcoholic liver cirrhosis [14]. As a matter of fact, when I used ‘Laënnec’ as a search word in PubMed, I came up with 5651 citations, all of which dealt with alcoholic liver cirrhosis. Among other things, Laënnec also gave such an excellent description of pneumonia that Osler frequently recommended it to his students to study [13]. Present-day cardiologists rely too much on gadgets and too little on clinical skills such as auscultation [15]. The use of a stethoscope is an art of medicine that is being lost amid growing reliance on gadgets such as echocardiography, computed tomography, magnetic resonance imaging, cardiac catheterization and angiography. But a stethoscope weighs less than a pound, does not need an electric outlet or a videorecorder, is not radioactive, has no adverse side effects, and fits easily into a coat pocket that can go anywhere [16]. I also see many medical students and housestaff in my hospital carrying different styles of stethoscopes, more to impress their sweethearts or patients than actually use them for auscultation [17]. Auscultation remains a low cost, but still sophisticated procedure that immediately connects the physician to the patient and transfers that all-important clinical power known as the “laying on of the hands” [9]. When used with skill, it may correctly determine whether more expensive testing should be in order. In this way, the stethoscope deserves our

continued respect and more attention as an indispensable aid for the evaluation and management of our patients in our everyday practice [9]. It is hoped that the proper use of the stethoscope will continue to serve as a model for the decision making criteria applied by Laënnec to the resolution of many medical problems [18]. On the other hand, one should not rely every cardiac diagnosis on the stethoscope. Laënnec was such a devotee to cardiac auscultation as a necessary tool for diagnosis of all heart diseases that for him persistence of normal heart sounds and absence of any abnormal sounds implied the absence of organic changes [19]. Therefore, he described angina as a nervous “lesionless” disease, or “névrose”, because no objective physical sign could be found for detecting angina [19]. Finally, the stethoscope itself has evolved from a simple monoaural baton or cylinder made first of paper and then of wood by Laënnec in the 18th century to fancy biaural stethoscopes with gold-plated double-headed or tripleheaded chest pieces with or without electronic amplification capabilities in the 21st century. Some have long and thin tubings that can go around twice the neck of the examining physician; others have tubings so short that during auscultation the physician can look directly into the eyeballs of the patients. But it is not these fancy accessories that make the difference. It is what lies between the two earpieces that counts [20]. Acknowledgment I wish to express my sincere appreciation to Drs. Boutaric and Walusinski for their invaluable advices and assistance throughout the preparation of this article. References [1] Harding AS. Milestones in Health and Medicine. Phoenix, Arizona: Oryx Press; 2000. p. 192–3. [2] Bynum WF, Porter R. Companion Encyclopedia of the History of Medicine, vol. 2. London: Routledge; 1994. p. 828. [3] Acierno LJ. The History of Cardiology. London: The Parthenon Publishing Group; 1994. p. 468–72. [4] Webb GB. René Théophile Hyacinthe Laennec. A Memoir. New York: Paul B. Hoeber; 1928. p. 79–101. [5] Duffin J. To See with a Better Eye. A Life of R.T.H. Laennec. Princeton, NJ: Princeton University Press; 1998. p. 282–3. [6] Markel H. The stethoscope and the art of listening. N Engl J Med 2006;354:551–3. [7] Laënnec RTH. A Treatise on Diseases of the Chest. J. Forbes, Trans. London: Underwood; 1821. [8] Talbott JH. A Biographical History of Medicine. Excerpts and Essays of the Men and Their Work. New York: Grune & Stratton; 1970. p. 495–7. [9] Hanna IR, Silverman ME. A history of cardiac auscultation and some of its contributors. Am J Cardiol 2002;90:259–67. [10] Bing RJ. Cardiology. The Evolution of the Science and the Art. 2nd ed. New Brunswick, NJ: Rutgers University Press; 1999. p. 337–40. [11] Boutaric JJ: Laennec, Balzac, Chopin et le stéthoscope. ou la diffusion de l'auscultation médiate durant la première moitié du XIXe siècle, Paris: Glyphe and Biotem Editions 2004, pp 281–326 and pp 327–390.

T.O. Cheng / International Journal of Cardiology 118 (2007) 281–285 [12] Stone J. René Laënnec. In: Hurst JW, Conti CR, Fye WB, editors. Profiles in Cardiology. Mahwah, NJ: The Foundation for Advances in Medicine and Science; 2003. p. 89–90. [13] Castiglion A. A History of Medicine. New York: Jason Aronson; 1975. p. 701–2. [14] Duffy J. To See with a Better Eye. A Life of R.T.H. Laennec. Princeton, NJ: Princeton University Press; 1998. p. 70–2. [15] Cheng TO. Hyposkillia: deficiency of clinical skills. Texas Heart Inst J 2005;32:623–4.

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