At the present time the most interesting development in medicine is
the gradual reduction of the death rate from tuberculosis. This is
entirely due to the fact that the disease can now be recognized very
early in its course, and that, as a consequence, the treatment may be
begun before serious damage has been inflicted on the lungs. Under the
circumstances, the disease formerly supposed incurable has become
according to all the best modern authorities one of the most tractable
of infectious diseases. In their recent lectures in Philadelphia,
before the Phipps Institute for the Prevention and Cure of
Consumption, such distinguished medical authorities as Dr. Trudeau, of
Saranac; Professor Osler, of Johns Hopkins, and Professor G. Simms
Woodhead, of Cambridge, England, insist on the absolute curability of
tuberculosis when it is taken in time. Professor Woodhead particularly
asserts that there has been entirely too much pessimism in this
matter, even among physicians.
This present confidence with regard to the successful treatment of
pulmonary consumption is due to the fact that the diagnosis can be
made early. The glory of this early recognition depends entirely on
two men--Auenbrugger, of Vienna, and Laennec, of Paris. To
Auenbrugger, whose work was done nearly half a century before that of
Laennec, must be given the credit of having first approached the
problem of differentiating diseases of the lungs from one {56} another
by methods which were so objectively practical that every practitioner
of medicine could, after having become expert in their employment, use
them with absolute confidence in his diagnosis.
Modern medical science and practice acknowledges very gratefully its
deep obligations to what is known as the Vienna school of medicine. It
is not a little surprising to find that it was the practical side of
medicine particularly which was developed at Vienna, since the
inhabitants of the Austrian capital, while supposed to have artistic
tastes far above the average, are usually considered to be among the
most impractical people in Europe. For over one hundred and fifty
years, however, the medical department of the University of Vienna has
always ranked among the first in the world. Many of the Viennese
professors of medicine have been acknowledged as the greatest teachers
of their time. Beginning with Van Swieten and De Haen during the
second half of the eighteenth century, the medical department of the
University of Vienna has scarcely ever been without at least one of
the leading lights of medicine in Europe. Wunderlich, Rokitansky and
Skoda were, in the middle of the nineteenth century, the greatest
medical men of their time. Hebra, Billroth and Nothnagel worthily
continued the tradition of medical greatness in the Austrian capital.
Even at the present time, notwithstanding the great advance in
medicine and medical teaching that has come over all Europe, it is
generally conceded that the best place in the world to study clinical
medicine--that is, to study illness at the bedside of the patient--is
the famous Allgemeines Krankenhaus, the General Hospital of Vienna.
The clinical teaching of medicine developed much later in the history
of medical education than might naturally have been expected. There is
a tradition of bedside instruction {57} in medicine in old Grecian
times at the various shrines of AEsculapius, but this is not well
authenticated. Early in the sixteenth century came the modern birth of
clinical medical instruction at St. Francis's Hospital, in Padua, in
connection with the University there, which in every line did so much
for modern medicine. The first clinic that attracted widespread
attention, however, did not come until Boerhaave's time, at the end of
the seventeenth and the beginning of the eighteenth century. The
bedside instruction in medicine by this distinguished master drew
hosts of students to the hitherto comparatively unimportant University
of Leyden, in Holland. Two rulers--just the two who, to modern minds,
would perhaps appear least likely to do so--at once recognized the
immense practical value of this innovation in medical teaching and
immediately set about securing its benefits for their people. Pope
Benedict XIII and the Empress of Austria put themselves in
communication with Boerhaave, and the Pope was the first to avail
himself of the advice in the matter which the great Dutch master gave.
The Roman clinic became, in the first half of the eighteenth century,
under the direction of the distinguished Lancisi, one of the best
known in Europe.
The Austrian Empress, Maria Theresa, interested in everything that
could prove to be for the benefit of her people, invited the
distinguished pupil of Boerhaave, Van Swieten, to become her family
physician, and encouraged him in the foundation of a clinical medical
school at Vienna. Van Swieten soon came to occupy a very prominent
place at Court. When he was invited from Holland, on the
recommendation of the sister of the Empress, there was no heir to the
Austrian crown, though one had been anxiously looked for for several
years. Heirs to the number of sixteen in all blessed the imperial
family in the next twenty-five years, {58} and Van Swieten became the
confidential adviser of the reigning monarchs in polity as well as in
medicine. Accordingly, when he suggested the invitation of De Haen,
who had also been a pupil of Boerhaave, the suggestion was promptly
accepted, and the Leyden colleagues became the founders of the Old
Vienna School of Medicine, as it is called. They established the
tradition of bedside teaching, of actual practical experience in the
treatment of patients, and of the collection of detailed information
of every feature of cases that could possibly be helpful for
diagnosis. They also established the custom of demonstrations on
pathological material with confrontation of the diagnostic conclusions
during life and the findings of the postmortem examination in fatal
cases, which, down to our own day, makes Vienna an ideal place for
serious post-graduate work in clinical medicine.
It was not long after the establishment of the clinic on these broad
lines at Vienna before the first important fruit of the new teaching
method was to be gathered. Curiously enough, however, this initial
advance in practical medicine did not come from one of the
distinguished heads of the clinic, but from a comparatively young man
of no previous reputation. The greatest discovery ever made at Vienna
is due to Auenbrugger, an unassuming practitioner of medicine, who
came from the Austrian province of Styria, or, as it is called in
German, the Steiermark, about the middle of the eighteenth century. He
was the son of a small hotel keeper of Gratz, and, after making his
medical studies in Vienna, he remained at the capital for some years,
doing hospital work.
While thus engaged, the young Styrian, who attracted very little
attention except for his affability, and who made no pretension to
special knowledge or genius in observation, {59} laid the first stone
in the structure of modern exact diagnosis of pulmonary disease, and
cleared up many of the obscurities in which all affections of the
chest had been shrouded before his time. Having accomplished this
noteworthy achievement before he was forty years of age, Auenbrugger
then quietly settled down to be an ordinary medical practitioner in
the Austrian capital, with a special reputation for his knowledge of
chest diseases, and for kindly ways that gave him as much interest in
his poor patients as in those that could afford to pay handsomely for
his services.
Leopold Auenbrugger, afterward Edler von Auenbrug--a term about
equivalent to the English "Knight of Auenbrug"--who thus stands at the
head of modern medical diagnosis, was born on the 19th of November,
1722, at Gratz, in Lower Austria. His early education was received at
Gratz, and it seems to have been of rather a comprehensive character,
for Auenbrugger, later in life, was a member of the elegant literary
circles in Vienna and a welcome friend at the tables of cultured and
distinguished fellow-townsmen. It will be recalled, by those who
remember German literature, that at this time Vienna was the centre of
culture in Germany, attracting many literary men--as, for instance,
the two Schlegels--from other parts of Germany.
Auenbrugger's father was of the lower middle class, the proprietor of
the Gasthaus Zum Schwarzen Mohren, in one of the suburbs of the city
of Gratz, but also the owner of another hotel in the city itself, so
that he was able, by making some sacrifices, to afford his son a
university and medical education in Vienna. The family were not in
very affluent circumstances, however, and in this Auenbrugger was in
the same condition as many other of the distinguished medical men who
have made important original discoveries. Volta, Laennec, Johann
Mueller, Helmholtz, Pasteur and {60} Virchow were all the sons of
comparatively poor parents, and had to eke out their university
education by doing teaching work as soon as they were considered
capable.
Auenbrugger's studies in medicine were pursued under the well-known
Baron Van Swieten. Van Swieten was, as has been said, one of the most
distinguished of Boerhaave's pupils, and devoted most of his life to
writing a set of commentaries on Boerhaave's aphorisms and editing his
master's work. Van Swieten's greatest ambition was to make the
Austrian capital the home of the great clinical school of medicine and
a pilgrimage at least as attractive for physicians seeking to study
practical medicine at the bedside as had been his own alma mater at
Leyden. He was of so great administrative ability that Maria Theresa
made him one of her state counsellors.
With all the influence of the government behind him, then, it is not
surprising that Van Swieten succeeded in his very laudable project of
establishing a great medical school at Vienna.
It was fortunate that Auenbrugger made his medical studies under such
good auspices. We have no details of his student life nor of his
success in his examinations. Even as a student his engagement of
marriage to Marianna von Priesterberg was announced. The formal
marriage ceremony took place in 1754, when Auenbrugger was about
thirty-two years of age. His wife seems to have had a dowry, and this
enabled Auenbrugger to begin his medical career in Vienna. Some years
before this, as a young graduate physician, he had accepted the
position of resident medical attendant at the Spanish military
hospital of the Holy Trinity in Vienna. This hospital was large and
important and provided manifold opportunities for clinical study. Its
wards were frequently drawn on by the {61} clinical department of the
University of Vienna for cases to be demonstrated before the students.
This fact was sufficient to make Auenbrugger's position of great
educative value for him. Mistakes in diagnosis would be apt to be
discovered, since the interesting cases were reviewed by some of the
best physicians of the time in Europe. His position carried with it no
salary beyond his maintenance, but proved well worth the time he gave
it, since it developed in him habits of careful investigation. Just
ten years after he began his work at this hospital he published the
little book called "Inventum Novum," or new discovery, on which his
reputation depends. It was written in Latin, and its full title ran:
"A New Discovery that Enables the Physician, from the Percussion of
the Human Thorax, to Detect the Diseases Hidden within the Chest."
Altogether his little manual probably does not contain much more than
ten thousand words. It is perhaps two or three times as long as
thousands of medical articles published every year in our modern
medical journals. It contains, however, one of the most important
discoveries in the whole history of medicine. One of the best
diagnosticians of the nineteenth century, Skoda, the distinguished
head of the Vienna school of sixty years ago, calls the discovery that
Auenbrugger outlined so unpretentiously "the beginning of modern
diagnosis," and hailed Auenbrugger himself as the founder of the new
science of diagnosis that was to prove so fruitful of good in the
prevention of human suffering.
It is interesting to compare Auenbrugger's little book with Van
Swieten's commentaries on Boerhaave's works, which were published in
some eight huge volumes. Van Swieten's successor, De Haen, an equally
illustrious contemporary of Auenbrugger, published about the same time
some eighteen volumes on the science of medicine. Neither {62} of
these works is ever consulted now, except by some enthusiastic student
of the history of medicine, who wishes to clear up a point in medical
historical development; but Auenbrugger's unpretending monograph is,
and will ever remain, a classic. Practically nothing has been needed
to complete the clinical usefulness of his discovery. Like Laennec,
whose work was done just half a century later, he had the genius to
realize what the possibilities and the limitations of his discovery
are, and he completed it in all its details before giving it to the
public.
Auenbrugger's discovery consisted in recognizing that diseases of the
chest can be distinguished from one another and their varying
character differentiated by the sounds elicited when the chest is
tapped with the finger. To this tapping he gave the technical name,
since become classic in medicine, of percussion. Wherever there is air
in the chest, that is all over the healthy lungs, the sound elicited
by percussion resembles that given out by a drum over which a thick
woolen cloth has been placed. Over the heart, where there is no air,
the sound given out, when the chest is percussed, corresponds very
nearly to the sound produced when the thigh is tapped. The sound
elicited by percussion of the thigh Auenbrugger took as the standard
of dulness and applied to it the term Schenkel-ton, or thigh sound.
When the lungs become consolidated because of an inflammatory process
such as pneumonia or tuberculosis, then the percussion note over the
consolidated area resembles the sound over the leg or that found over
the heart. As a rule the heart is somewhat covered by the lungs, and
the sound produced by percussion over it is not quite as dull as that
over the solid muscular structures of the legs. Whenever fluid finds
its way into the thorax, as in pleurisy, then the sound produced on
percussion is very dull.
{63}
Auenbrugger further showed that by means of the sound thus obtained he
could demonstrate the size of the heart under varying conditions, and
so determine whether it is larger than normal or not. This gave the
first inkling as to the discernment of hypertrophy and dilatation of
the heart, and was the first step in the modern differential diagnosis
of heart diseases. He showed, moreover, that he could, by percussion,
outline very exactly the extent to which a consolidation of the lung
has taken place, or the height to which an effusion into the pleural
cavity reaches. These conclusions and demonstrations require not only
the greatest care but the most deliberate confirmation of every detail
by comparison of the diagnosis during life with the condition found
after death in fatal cases.
Auenbrugger seems to have spared neither time nor labor in this work
of confirmation. He made a number of experiments upon dead bodies,
injecting fluid into the pleural cavity and then demonstrating by
percussion the line of demarcation that indicated the level of the
fluid within the chest, as well as the pulmonary conditions that
developed because of its presence. In the study of pneumonia and
tuberculosis particularly, Auenbrugger spent many hours of patient
investigation during his ten years of hospital service. He succeeded
not only in demonstrating the presence of consolidation, but also the
existence of cavities in the lungs and their size and general
character.
Vienna was an ideal place for the development of Auenbrugger's ideas
of confirmation. At this time, it must have been one of the most
unhealthy places in Europe as regards pulmonary diseases. The city was
surrounded by walls that occupied the ground now taken up by the
magnificent Ring Strasse and the inhabitants were packed into
extremely narrow quarters, The modern municipal sanitary {64}
conscience is lax enough in our own day, but at that time it had not
been awakened to the slightest sense of duty toward the citizens.
Narrow, wandering streets lined by high buildings that made an attache
of the British Legation of Vienna speak of the houses of the city,
scarcely more than fifty years ago, as "well-like," were the universal
rule.
It must be remembered that the present magnificent Austrian capital,
containing, perhaps, the handsomest single street and some of the
finest buildings in the world, is entirely a creation of the last
half-century. The old city had every cause to be unsanitary. Situated
in the valley of the Danube, liable in the spring-time to serious
floodings from the capricious, mighty river, which has been brought
under control only in recent years at great expense; in an exposed
situation, which makes it a veritable temple of the winds during the
autumn and winter; it is not surprising that tuberculosis should have
been very frequent. Even with all its improvements in recent years,
sanitary, hygienic, municipal and domiciliary, Vienna has at the
present time one of the highest death rates from tuberculosis in
Europe. In Auenbrugger's time there must have been practically
unlimited opportunity for the study of pulmonary diseases of all
kinds.
How well the brilliant young medical observer took advantage of the
opportunities thus afforded him can be judged very well from the
passages of his book that refer to chronic pulmonary diseases. He
divides the chronic diseases of the thorax in which abnormal
percussion sounds are heard into two classes. In the first place, he
places those in which the thoracic organs are rendered less capable of
resisting disease and become actually affected, because of insidious
influences, such as hereditary conditions, depressing circumstances,
poverty and poor nutrition. Without really calling it tuberculosis, it
is evident that in this group pulmonary {65} consumption is included.
The second class consists of affections in which the thoracic organs
become diseased from definite, easily recognizable causes. Such are
disturbances of the general health in pulmonary affections that follow
thoracic disease not completely recovered from. By these diseases
Auenbrugger evidently intends cases of pneumonia or other affections
of the lungs, or trauma and the like, which are followed by
tuberculous processes.
With regard to cavities in the lungs, Auenbrugger was able not only to
demonstrate their presence and to show by autopsy records that his
localization and determination of their approximate form and size were
correct, but he also understood the method of their formation and
explains the reasons for certain varieties of cavities that occur. He
speaks of two classes of cavity formations. From one kind there is an
ichorous discharge; from the other variety the evacuations are
purulent. Cavities with non-purulent secretions are situated only in
the lung. Abscesses of various kinds--that is, cavities with purulent
secretions--may occur in any part, or in any of the organs of the
thorax. The lung cavities are usually due to the breaking down of what
he calls crude tubercles. Both kinds of cavities may either be closed
or have an opening into the bronchi.
Auenbrugger showed very well how to distinguish, by percussion,
cavities of various kinds, and set it down as a principle, that before
the evacuation of the contents of the cavity percussion over it gave a
distinctly dull note, resembling that obtained when the thigh is
percussed, while after evacuation, as by copious expectoration, a
distinctly resonant note occurred. It is clear from his discussion of
the symptoms noted in cavities (at least in the opinion of Dr.
Merbach, who wrote a sketch of Auenbrugger's life for the
Jahresbericht der Gesellschaft fuer Natur und Heilkunde in Dresden,
{66} in 1861), that Auenbrugger was very near the discovery of
auscultation in his study of pulmonary cavities. Auenbrugger says that
when a cavity has been located by means of percussion, if the hand be
laid over the place beneath which it lies and the patient is asked to
cough, the fremitus produced by the pus in the cavity can be felt as
it moves under the coughing impulse. This is what we now know as
palpation. If instead of using his hand Auenbrugger had applied his
ear to the chest, auscultation would have been discovered nearly half
a century before Laennec began his work upon the subject. Perhaps
Merbach, who was himself a native of Styria and a professor at the
University of Gratz, was for patriotic motives more ready than others
might be to give Auenbrugger credit for practically discovering
auscultation.
Auenbrugger's and Laennec's observations were made on exactly the same
sort of clinical material. They were both studying advanced cases of
tuberculosis in the hospitals of a great city. Laennec's work was
actually not anticipated in the slightest degree however. How
Auenbrugger could have made the careful examinations of the chest that
he did in thoracic diseases without acquiring some knowledge of the
value of the further application of the sense of hearing, which
Laennec was to employ so fruitfully in the diagnosis of affections of
the lungs and heart, seems to us almost impossible to understand.
Discoveries once made, however, always seem so obvious that the wonder
is they were not made long before. It takes genius to cross the line
into the realm of the hitherto unknown, and the contemporary
generation usually occupies itself mainly with making little of the
new discovery. Even genius very rarely makes more than one original
observation in a lifetime, and it would be too much to expect more
from Auenbrugger.
{67}
The preface to Auenbrugger's little book is a model of concise
directness typical of the man and his ways. As the modest introduction
to a work that will ever be a classic in medicine it seems to deserve
a place here:
"I present to you, kind reader, a new sign for the detection of
diseases of the chest, which I have discovered. It consists in the
percussion of the human thorax and the determination of the internal
condition of this cavity by the varying resonance of the sounds thus
produced. My discoveries in this subject are not committed to paper
because of an itch for writing, nor an inordinate desire for
theorizing. Seven years of observation have put the subject in order
and have clarified it for myself and now I feel that it should be
published.
"I foresee very well that I shall encounter no little opposition to
my views and I put my invention before the public with that
anticipation. I realize, however, that envy and blame and even
hatred and calumny have never failed to come to men who have
illuminated art or science by discoveries or have added to their
perfection. I expect to have to submit to this danger myself, but I
think that no one will be able to call any of my observations to
account. I have written only what I have myself learned by personal
observation over and over again, and what my senses have taught me
during long hours of toil. I have never permitted myself to add or
subtract anything from my observations because of the seductions of
preconceived theory.
"I would not wish, however, that any one should think that this
method of diagnosis, which I suggest, has been developed to its
utmost perfection. I confess with all candor that there are defects
in the system which conscientious observation will, I hope, amend
with time. It is possible that there are even other important truths
for the recognition {68} of disease still hidden from this method of
diagnosis. Some of these may prove of great usefulness for the
differentiation, prognosis and cure of diseases of the chest.
"This was the reason why in my personal experience, after I had
succeeded in finding the signs in the chest and proceeded further to
the investigation of their causes so far as my own observation could
help me, I have always afterward had recourse to the commentaries of
the illustrious Baron Van Swieten, since I have considered that
whatever can be desired by an observant man is sure to be found in
his work. I have thus been able to spare you a long disquisition. I
have found in his work a sure basis of knowledge on which my slight
superstructure may be raised up to view.
"I do not doubt, however, that I have accomplished a work which will
earn the gratitude of all true devotees of the art of medicine,
since I have succeeded in making clear certain things which shed not
a little light on our knowledge of the obscure diseases of the
chest, a subject hitherto very imperfectly understood.
"I have omitted many things that seem doubtful because they are as
yet not sufficiently elaborated. I shall endeavor, however,
faithfully to devote myself to [literally to sweat over] the further
development of these points. Finally, it has not been my effort to
write in any elegant diction. I have chosen a style in which I may
be thoroughly understood.
_Vale;_
"December 31, 1760."
Auenbrugger's own realization of the importance of his work and of its
significant value for medicine kept him faithfully investigating his
chosen subject, though he seems to have met with very little
encouragement from members of {69} the medical profession near him. It
is extremely difficult to understand how his practical observations
and thoroughly conservative claim failed to attract more attention
than they did from really great physicians who were deeply interested
in the progress of medicine. At least two distinguished writers on
medicine, Van Swieten and De Haen, compiled treatises on medical
subjects that included the consideration of diseases of the chest
within a few years after Auenbrugger's _Inventum Novum_ appeared, and
yet neither of them devotes any space to the question of percussion
nor hints at its possible value.
Van Swieten's work consisted of commentaries upon the aphorisms of
Boerhaave. The Vienna professor did not, however, limit himself to the
consideration of the aphorisms alone, but made his work also a
compendium of his own clinical experiences with acute and chronic
diseases. As a matter of fact his commentaries on the aphorisms are
each a monograph on some special disease. The two last volumes of this
commentary appear after the publication of Auenbrugger's book on
percussion, one volume being published in 1772, the other in 1774.
The first of these articles contains a long article on pulmonary
consumption, and the other an almost equally long chapter on pleurisy
with effusion. In neither of the volumes, however, is there any
mention of percussion, or of Auenbrugger's work, though if Van Swieten
had given any serious attention to the subject, he must have become
convinced how valuable Auenbrugger's invention was in the diagnosis of
these conditions.
This omission is all the more surprising as Auenbrugger was a pupil of
Van Swieten's and practically dedicated his _Inventum Novum_ to his
master. He mentions Van Swieten's work several times in his little
book. Auenbrugger's {70} investigations were not unknown to Van
Swieten then, and the only conclusion to be drawn from his neglect to
mention Auenbrugger's methods is that he deliberately omitted
reference to them because of his failure to recognize the value of the
discovery. This constitutes one of the most serious blots on Van
Swieten's medical career. He was succeeded as the head of the clinic
in Vienna by De Haen, who also came from Leyden and brought with him
the methods of Boerhaave's clinical school. As the time during which
Auenbrugger was making his valuable observations at the Spanish
military hospital coincides with the years when De Haen was professor
of clinical medicine, and when he was frequently indebted to his
colleague of the Spanish hospital for his cases for demonstration, it
is impossible to conceive that Auenbrugger or his work should have
remained unknown to the distinguished head of the clinic.
There is not a single mention, however, to be found anywhere in De
Haen's voluminous writings of Auenbrugger or his work. De Haen's
principal work is his _Ratio Medendi_ (_System of Medicine_),
published at Vienna during the years from 1757 to 1779. It consists of
eighteen volumes, in which all the important forms of disease as well
as the rarer types of affections that came to the clinic are
thoroughly discussed. De Haen treated of pneumonia, of consumption, of
pleurisy with effusion, which he calls dropsy of the chest, but never
suggests the use of percussion. On the contrary, he complains in a
number of places how very obscure and difficult of diagnosis are
thoracic diseases and especially dropsy of the chest, pleuritic and
pericardial exudates, and insists on the ease with which errors of
diagnosis may be made in these subjects. He failed completely to
recognize how much light had just been thrown on this subject by
Auenbrugger's work, and how much easier the differential {71}
diagnoses of these conditions were to be as the result of systematic
percussion.
Some of the commentaries on Auenbrugger's work are not entirely
depreciative, however. In Ludwig's _Commentaria de Rebus in Scientia
Naturali et Medicina Gestis_ for the year 1762, published at Leipzig,
there is an excellent notice of Auenbrugger's work within a year after
its appearance. It is not known who the reviewer was, but he calls
Auenbrugger's discovery "a torch that was designed to illumine the
darkness in which diseases of the thorax had up to this time lain
concealed." A brilliant future was prophesied for the new method of
examination. It is evident that the writer not only thoroughly
comprehended Auenbrugger's work, but had himself applied the
percussion method for purposes of diagnosis.
This is almost the only favorable and reasonably intelligent review of
Auenbrugger's work to be found in the medical journals of the time. In
the new Medical Library, issued by Rudolph Vogel, Professor of
Medicine in Goettingen, published in six volumes in 1766, there is a
short mention of Auenbrugger's book and his new discovery. This
reference is, however, an extremely curious affair. The good professor
completely failed to understand in what the new discovery really
consists. It is clear that he had never read Auenbrugger's book. He
seems to have heard of the subject from some medical friend, and to
have obtained an entirely wrong notion. He talks of Auenbrugger's new
diagnostic method as if it were an imitation of Hippocrates's
succussion method of recognizing the presence of fluid in the chest by
shaking the patient till the liquid gave the characteristic splash.
Other medical writers of the time perhaps, as the result of reading
Professor Vogel's book, made the same mistake {72} in their
appreciation of Auenbrugger's work. Vogel himself insisted that
Auenbrugger did wrong to claim any originality for his invention,
since it had been used so long before by Hippocrates. He adds that
what is original with Auenbrugger is of very little value, the older
ideas being the only ones worth while considering with regard to the
application of this so-called new method of diagnosis. Vogel was an
authority in medicine at the time and other commentators took the key
note from him in this matter, and in many parts of Germany it was
generally accepted that Auenbrugger's method of percussion was only an
elaborated method of the so-called succussion of Hippocrates.
Under these circumstances it is perhaps not surprising that
Auenbrugger's work attracted very little attention in the
German-speaking countries. In Vienna itself, as we have already said,
Van Swieten and De Haen failed utterly to recognize its value. Outside
of Vienna their example was naturally followed, for the Vienna school
was considered authoritative, and surely, if any one, the professors
of the University of Vienna might be expected to know whether
Auenbrugger's new discovery was really of any value or not.
It is interesting to compare Auenbrugger's state of mind, with regard
to the neglect of his discovery, with Laennec's remark in the preface
of his book. Laennec said: "For our generation is not inquisitive as
to what is being accomplished by its own sons. Claims of new
discoveries made by contemporaries are apt for the most part to be met
by smiles and mocking remarks. It is always easier to condemn than to
test by actual experience." Auenbrugger seems to have suffered from
more than the neglect of which Laennec complains. When he speaks of
envy and calumny in no uncertain terms, the only conclusion possible
is that his representations as to his discoveries must have been set
{73} down as pretensions that his contemporaries considered
unjustified by what they knew of his work.
It is interesting also to note that both men found their prospects of
reward, not in the good will of their contemporaries, nor even the
prospect of fame, but in the hope that their work would be useful in
lessening the sum of human suffering. Laennec said: "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 snatched
from untimely death."
Laennec's words are almost an echo fifty years afterward of
Auenbrugger's expressions, just quoted: "I console myself," he said,
"with the thought that I have accomplished a work which will earn the
gratitude of all true devotees of the art of medicine, since I have
succeeded in making clear many things which shed not a little light on
the chapter of the obscure diseases of the chest, in which our
knowledge has hitherto been so very incomplete."
As a rule it may be said that medical observers whose genius leads
them to step across the narrow line that separates the known from the
unknown are likely to lack the appreciation of their own generation.
Long before Auenbrugger or Laennec, Harvey, the discoverer of the
circulation of the blood, said to friends that he did not expect any
one of his generation to accept the new doctrine, and it is well known
that the great medical men of the time did not accept it. Harvey is
not an isolated example, and even in our own time real medical
progress sometimes waits for years for recognition, while
well-advertised pretended advances are occupying the centre of the
stage. Auenbrugger's discovery made its impress, however, and was
never entirely lost to sight. Even {74} before his death there was the
consoling prospect of its meeting with adequate attention.
De Haen's successor in Vienna, Maximilian Stoll, treated Auenbrugger's
work very differently from his predecessors, and was the first to
introduce it practically into clinical medical training. Stoll did not
hesitate in his clinic, on the strength of what was discovered by
means of percussion, to attempt the evacuation of fluid from the
pleural cavity on a number of occasions. It can be easily understood
that with their lack of knowledge of the necessity for thorough
cleanliness in the surgical sense, such an operation might readily be
followed by discouragingly fatal results. This actually happened in
Stoll's own experience. He does not, however, seem to have abandoned
his practice of tapping the chest because of this. He insisted to his
students that Auenbrugger more than anyone else had experience in
removing fluid, and especially purulent collections, from the chest,
and he recommended the practice to them. He added that medicine owed
as much to Auenbrugger for his rational method of treating effusions
into the pleural cavity, whether of pus or serum, as for his
diagnostic sign by which the presence of the fluid could surely be
recognized.
Some of Stoll's pupils took up the work of commending Auenbrugger's
method, and a little book written by one of them, Eyerel, came into
the hands of the distinguished French physician, Corvisart. Eyerel did
not hesitate to say, in his treatise on empyema, that the practice of
percussion of the thorax, a diagnostic method introduced by the very
distinguished Vienna physician, Auenbrugger, had been of great help to
them in the study of this disease.
Once the great French professor of medicine, Corvisart, took it up,
the new method of diagnosis was destined to have an immediate and
world-wide vogue. Corvisart was not {75} only a power in medicine
because of his faculty of observation and his thorough appreciation of
the work of others, but he was the court physician of the first
Napoleon, and this gave any ideas that he favored many adventitious
chances for publicity. Napoleon's well-known faculty for selecting men
for special positions whose genius was calculated to be of service to
him was never less at fault than when he violated most of the court
medical traditions in Paris and chose Corvisart for the imperial
physician. Corvisart's selection was the result of Napoleon's
appreciation of his new method of diagnosis, namely, that of
percussion, in chest diseases.
The Emperor himself was suffering from a persistent cold and was told
that Corvisart, instead of following the traditional method of feeling
the pulse, looking very wisely at the tongue and then gazing learnedly
into space, conducted an actual examination of the chest and sounded
it carefully all over, in order to determine where abnormal conditions
might exist. This struck Napoleon as a very practical and possibly
valuable feature of diagnosis. Accordingly Corvisart was summoned to
give his professional opinion. After the consultation he was made the
Emperor's private physician. When Corvisart took up the subject of
percussion of the chest, it was practically unknown in Europe outside
of Vienna. Even in the city of its origin, as we have seen, it was not
well appreciated. Auenbrugger's little book had fallen into oblivion.
Corvisart obtained his hint as to the possible value of percussion
from Stoll's and Eyerel's appreciative remarks with regard to it. The
Frenchman used the method to some extent and, realizing its value,
resolved to call the attention of his countrymen and the medical world
to this very helpful aid in diagnosis. It was at this time that he
came upon Auenbrugger's original monograph. Instead then of writing
himself on the subject, he translated {76} Auenbrugger's little book
into French and made a commentary on it.
Corvisart was Laennec's patron in medicine, his favorite teacher, and
the man to whom the great French physician owed much of his early
inspiration. It is no little merit in Corvisart's career thus to have
been the connecting link between the men who did most for the
practical science of medicine, and especially for the important but
obscure chapter of diseases of the chest. He did not attempt at all to
claim for himself any of the merit that he felt should rightfully go
to Auenbrugger, and while his own observations and writings
established percussion upon a firm basis and extended its knowledge,
he shares the immortality of his discoverer, and comes down to us in
medical history as an example of the reward of having rendered
faithfully what was due, where it was due. It has been the custom to
praise Corvisart for his justice toward Auenbrugger. Mere justice
seems scarcely a worthy reason for praise of a great man, yet the
history of medicine is so full of failures on the part of subsequent
observers to acknowledge priority of discovery, that perhaps the
praise does not seem quite as futile as it otherwise would.
It is not surprising then that Corvisart's pupil Laennec should have
appreciated very thoroughly the value of Auenbrugger's discovery. In
the preface of his book on Mediate Auscultation, Laennec bewails the
fact that men are generally neglectful of discoveries made in their
own time, and fail to give them the attention they deserve. He
attributes this neglect rather to the well-known carelessness of men
than to any deliberate failure to recognize the merit of contemporary
work. He says:
"Lack of attention is an extremely common failing of all men. What
it takes years and hard labor to acquire, is not {77} infrequently
passed over without notice. Auenbrugger's method, published some
fifty years ago, though capable of being learned in a few days, and
without difficulty, and of being put into practice without the use
of any instruments, although snatched from oblivion by my
illustrious preceptor, Professor Corvisart, and made clearer than it
had been left even by the author himself, is not as yet in ordinary
use among physicians. Even the wonderful invention of the
illustrious Jenner, though received with so much praise, and with
regard to whose efficaciousness numberless confirmatory observations
have been made, is already somewhat less prominent in the minds of
men than it should be, or at least it would be, only for the fact
that the governments of many countries, provinces and cities, the
foresight of the clergy, of the authorities of all kinds, and the
advice of the best physicians have exerted all their influence to
keep it at public expense constantly in practice."
After about ten years of service at the Spanish military hospital,
Auenbrugger resigned his position there and took up private practice.
In this he was eminently successful, being, as might be expected,
especially in demand for cases involving affections of the thorax. His
practice appears to have been to a great extent among the better class
of people, but he seems never to have neglected the poorer patients
whom he had come to know during his hospital experience. There are
traditions in Vienna of his unfailing willingness to assist the poor
and even to put himself to considerable inconvenience in order to be
of service to them.
Tradition tells that he was very conscientious in the pursuit of his
vocation as a physician, and among the family relics there is
preserved a small lantern which he kept always by his bedside, to
light him on his visits to the sick when called out at night. It must
not be forgotten that city streets {78} were not regularly lighted at
the end of the eighteenth century, and night calls even in city work
must have been a source of great annoyance and discomfort. There is a
family tradition, too, that the night bell at his house was connected
directly with Auenbrugger's room, so that the others of the household
might not be disturbed when night callers came for him. Every
tradition points to him as a man among men in his unselfish readiness
to save others trouble, and do all the good in his power.
Auenbrugger was, according to well-grounded traditions, especially
admirable in his relations toward other members of the medical
profession. This may not seem a very significant sign of amiability to
those outside the profession, but it is well recognized that even
great physicians have not always been known to get on well with
brother practitioners. Auenbrugger has, besides, the pleasant
reputation of having been of great material assistance to a number of
needy medical students during the time of their university careers,
and to have frequently lent a helping hand to young practitioners in
the city, who probably found it quite as discouraging, beginning
practice in those days, as any of their young confreres of this
generation find it at the present time.
To physicians and medical students when ill, Auenbrugger was almost
unceasing in attention. Two or three physicians of the generation
immediately after his attributed to his unselfish care and devotion to
them their recovery from what would otherwise have been mortal
illnesses. In this way Auenbrugger seems to have been a man whom
everyone who came to know him, even slightly, learned to love and
respect. His relations to his family and relatives were always of the
most happy, kind character, and family traditions show that his
fatherly care was befittingly returned to him in his old age. The
number of his friends was very great, {79} and he counted among them
some of the most distinguished inhabitants of the Austrian capital.
Notwithstanding his devotion to his practice, Auenbrugger did not
cease to make observations that occasionally he considered worthy of
being committed to paper. He was especially careful in the study of
his cases, and left fully written records of over 400 important cases
that he had studied very faithfully. His attention seems to have been
attracted particularly to certain mental diseases. This work was done
half a century before even the first beginnings of the modern
classifications of mental diseases were attempted. He wrote a short
article with regard to mania and its treatment, and a longer article
on melancholia. How well he recognized the essential feature of this
latter affection and the main symptom that must be guarded against,
can be gathered very well from the title of his paper, which he called
"The Still Madness, or the Impulse to Self-Murder."
It is about the time that he was engaged in the study of melancholia,
perhaps as a contrast to sadder things, that he wrote a comic opera,
of which we shall have more to say presently. His description of the
conditions that he saw during an epidemic of dysentery that occurred
in Vienna show how exact and careful a clinical observer he could be,
and that the demands of his practice did not absorb all his attention
to the detriment of his faculty for observation. He seems himself to
have suffered from a severe attack of typhus fever which raged
epidemically in Vienna in 1798.
Auenbrugger had a wide circle of interests beyond the subject of
medicine. There is a family tradition that he had a magnificent
library. He seems with true Viennese spirit to have been a great
devotee of the opera, and to have had an especial liking for music. He
wrote the text, {80} score, and libretto of a comic opera with the
title, "The Chimney Sweep." This operetta evidently enjoyed more than
a _succes d'estime_, and further writing in this line was confidently
expected from him by his friends. There is even a story to the effect
that the Empress Maria Theresa, of whom he was an intimate friend, and
who made use, it is said, of his counsel in political matters more
than once, asked him why he did not follow up his first success in
operatic writing. His blunt reply shows how intimate must have been
his relations with the great empress. He said he had things much
better with which to occupy himself than the writing of comic operas.
Seeing that he was so favored at court, it is not surprising to find
the family tradition that Auenbrugger was associated with many of the
most prominent persons in the Austrian capital during his lifetime. He
was a special friend of and spent a great deal of time with the famous
philosopher, Werner. As he grew older he delighted especially in
music, and spent many hours at the house of Baron Zois, where many of
the distinguished European musicians were to be found and where famous
matinee concerts were given every Sunday from twelve to two. The day
and the time may seem strange to foreigners, but Vienna still has
concerts at this time on Sunday, and after the Viennese have gone to
Mass in the morning they think that they could not occupy themselves
better than with listening to good music in the middle of the day.
Toward the end of his life, Auenbrugger lived during the summer time
in the suburb of Rossau and cultivated a little garden, taking the
greatest pleasure in spending his time at this simple occupation. It
is a source of satisfaction to find that though Auenbrugger's medical
work failed during his life to attract the attention it deserved, he
had his reward, {81} for his patient investigations in earlier life,
in a peaceful and contented ending to a career that had been so worthy
of what was best in the man. He lived to celebrate his golden wedding
in 1804 and was especially happy in the almost constant companionship
of the good wife who had proved so faithful a helpmate during her long
life. After her death, which took place the year following the
celebration of their jubilee, his vitality and his contentment with
life seemed to abandon him. He was a changed man and kept himself for
the most part to his room. He went to bed very early and did not care
to see anyone but his near relatives. His last illness was the result
of a cold, and his advanced age, eighty-seven, left him little
resistive vitality. He retained his consciousness until the very end,
and said the day before his death that the next day would be his last.
Shortly before noon of the day of his death he looked at the clock in
his room and said that when the hands would point to two o'clock he
would be no more. His prophecy came true.
Vienna has never had the reputation of honoring its great geniuses
during their lifetime, unless they happened to belong to the higher
nobility. The exclusiveness of court society at the capital made
itself felt in all circles, and the consequence was that genius sprung
from the lower orders was almost sure not to receive its due share of
attention. The comparative neglect of Auenbrugger does not seem so bad
when we recall the case of Mozart. Music has always been one of the
special fads of the Austrian and the Viennese pride themselves on
their appreciation of it. Mozart, however, perhaps the greatest
musical genius that ever lived, received some attention during his
life, but passed away almost unnoticed at the early age of
thirty-five, was buried in a common trench with the poor people of the
city, and now Vienna cannot {82} find his resting place. There is a
magnificent monument to him, but his bones lie with his own people
forever.
Outside the circle of his personal friends Auenbrugger did not receive
much attention, so that even the year of his death was until recently
more or less uncertain and the resting place of his remains continues
to be unknown. The present generation of medical men has done more to
afford the due meed of praise to Auenbrugger than any preceding
generation. The interest in tuberculosis particularly has led medical
men to appreciate all the significance of Auenbrugger's work, and the
practical importance of his discovery for the early recognition and
consequently for the cure of the disease. The appreciation of
Auenbrugger in our time has been so flattering as quite to make up for
previous neglect. His name has been linked with that of Laennec as the
great discoverers of physical diagnosis in chest diseases.
At the opening of his address as President of the American
Climatological Association, some five years ago, Dr. Edward O. Otis,
of Boston, said:
"It is quite improbable, I think, that we should be here to-day, or,
indeed, have an existence as a society largely devoted to the
consideration of diseases of the chest, were it not for the methods
of thoracic examination which Auenbrugger and Laennec have given us
in their discoveries of percussion and auscultation. Without these
two precious methods of investigation we could scarcely have arrived
at any degree of precision or certainty in thoracic pathology and
might have been not unlike the old physicians and surgeons, 'who
would swear,' as Morgagni says, 'that there was fluid in the chest
when in reality there was not a single drachm, or perform
paracentesis of the thorax upon a duke for an empyema which did not
exist.'"
His tribute is only an echo of many others not less {83} appreciative
of Auenbrugger's important original work than have been expressed by
modern medical men of all nations. The simple old German practitioner,
who had the annoyance of seeing his discovery neglected by his
contemporaries for so many years, has at last come into his own. There
is scarcely an important medical meeting held anywhere in the world in
which diseases of the chest are discussed without a mention of
Auenbrugger's name. This is not surprising in Germany, but is quite as
true of France, and England, and America. As Dr. Otis said, in closing
the address from which we have just quoted:
"Although we possess but meagre and fragmentary records of
Auenbrugger's life, there is yet enough to enable us to fill in the
lines and gain a distinct idea of his personality and character.
With some persons one does not need to be acquainted with much of
the detail of their lives in order to know what manner of men they
are; a few characteristic illustrations here and there in their
career redeem the spirit and motives of their lives, and show the
kind of men just as they are, quite as well and clearly as an
extended and continuous biographical narrative. Always
enthusiastically devoted to the study of disease, Auenbrugger
escaped the not infrequent misfortune of the student, a loss of
sympathy with one's kind. His love for his fellow-men, for suffering
humanity, for struggling students in his own profession, kept pace
with his love for medical study. He never sacrificed the man for the
scientist, nor did he lose his interest for other things in life, as
happens sometimes with men intensely devoted to one pursuit. A man
of original powers, as some one has truly remarked, can never be
confined within the limits of a single field of activity.
"He was interested in music, philosophy and the drama, and well
illustrates what Dr. Da Costa has so happily styled {84} 'the
scholar in medicine.' With dignity, sympathy, enthusiasm in his
profession, even to the last; ever seeking to improve and add to his
art; modest, like most great men; never refusing to give what is
best to suffering humanity, he richly lived out his long life. As we
teach our students percussion, as a matter of just recognition and
due honor let us tell them something of the life of the discoverer,
and at least his name, which I fear but few, who avail themselves of
the result of his long and arduous labors, know."
Auenbrugger's German biographer, Professor Clar, of Gratz, says of his
early life that from his parents he received an excellent early
training, especially edifying because of the exemplary Christian
family life he saw about him, the piety of his father and mother, and
of the other members of the family. The baptismal register of the
parish church at Gratz is one of the important documents in his life
history, for there is some dispute as to the exact date of his birth,
as there is also with regard to his death. In 1798 he suffered from a
severe attack of typhus fever, which at the time was epidemic in
Vienna, and some of his biographers report his death in this year as a
consequence of it. His descendants, however, have shown, by the burial
register of the parish church in Vienna, that his death did not take
place until May 17, 1807; from this church, of which he had been for
half a century a faithful member, he was buried.
Few of the lives of the great discoverers in medicine have in them
more of encouragement for the busy practitioner of medicine than that
of Auenbrugger. He began his medical career by a series of practical
observations that stamped him for all time as one of the great
geniuses. When his discoveries failed to meet with the acceptance they
deserved, he was not disturbed, and, above all, he did not insist on
acrid controversy. He took up the practice of medicine and {85}
demonstrated how much his discovery could help in the diagnosis of the
obscure chapter of the diseases of the chest. In the mean time he went
on his way placidly doing the good that he found to do, taking care of
his poor patients and faithfully tending brother-physicians who
happened to be ill. He found an avocation to fill the moments spent
apart from his vocation, and added to the pleasure of humanity by his
work in music. All the time he remained a simple, faithful believer in
the relation of Providence to man, and considered that somehow the
inexplicable things of this life would find an explanation in the
hereafter. He was probably the best-liked member of the profession in
Vienna during his lifetime, and the profession of his native town are
very proud to recall the example that he sets physicians generally in
all the ethical qualities that make a physician's life not only
successful in the material sense, but also in inspiration for those
around him to do their duty rather than seek the fulfilment of merely
selfish aims.
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