Saturday, December 28, 2013

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,
such as asthma: Matthew Baillie and Rene Laennec.
He also earned fame for himself when he
re-introduced chest percussion to medicine.
Another pupil of his was Marie-Francois-
Xavier Bichat, the founder of biology. 
Joseph Auenbrugger introduced the medical community to chest percussion in 1761, although his idea was flat out rejected and rarely used.  Yet 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 his 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 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)
In 1788 he became elected as physician at Necker hospital. His predecessor was Desbois de Rochfort (1750-1786), (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.

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 other European physicians of his era.  By using these tools, Corvisart, and based on his studies of bodies, he 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.  
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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