Austin Flint and Auscultation in America DALE C. SMITH
1. W. H. Welch, 'Address ofWm. H. Welch, M.D., Baltimore, Md.,' in 'Addresses delivered at the memorial meeting of the New York County Medical Association in honor of the late Austin Flint,' GanianTs med.J., 1886, 42, 585-389, p. 589. 3. W. Osier, 'Remarks to the dass in clinical medicine. University of Pennsylvania,' Canada med. surg.J., 1886,14, 571-574. P- 572. 3. S. W. Gross and A. H. Gross, eds., Autobiography of Samuel D. Gross, MD., with sketches of Ms contemporaries, 2 vols. (Philadelphia, 1887), n, 161. Since completing this paper I have read the interesting study of Flint by Dr. Oliver P. Jones, 'A student's impression of Austin Flint (""The American Laennec"), 1848-49,' Coll. Phys. Phila. Tr. Stud., 1977,43,13-17. In areviewof lecture notes taken by J. D. Mil, one of Flint's Buffalo students, Dr. Jones suggests that Flint probably had some deficiencies as a teacher, at least in the early years. However, even Hill was impressed by Flint's knowledgeable and clear instruction in physical diagnosis (p. 14). 4. C. Singer and E. A. Underwood, A short history of medicine (New York, 1062), p. 172.
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j M O N G American physicians in the nineteenth century Austin Flint seemed to his contemporaries to have played a particularly significant role in the development of auscultation in America. At the time of Flint's death in 1886, William Welch said that Austin Flint 'did more by his writings and his teachings than anyone else in [America] to render popular the methods of exploration by physical signs.'1 William Osier told his students at the University of Pennsylvania that 'Not one of you who takes a stethoscope into his hand but is a debtor to Dr. Flint for simplifying much that was complicated in the auscultation of heart and of lungs,'2 while the Philadelphia surgeon Samuel Gross, who had been Flint's colleague at Louisville, Kentucky, thirty years before, described Flint as 'the American Laennec.'3 From ancient times physicians had realized that information they obtained by physical examination of the patient was more accurate and reliable than the patient's description of his own symptoms. The practice of listening to the sounds of breathing and the movements of fluid in the chest is very ancient, but the listening to the chest which occurred before the mid-eighteenth century was very superficial because little was known of the pathology involved. In 1761 a great stride forward was made by Leopold Auenbrugger when he introduced the technique of percussion.4
130
Journal of the History of Medicine : April
militate.1
The Paris medical community of the 1820s rapidly recognized the value of Laennec's work and foreign students who studied at Paris took stethoscopes home with them to Great Britain, Russia, the Germanic states, and to America. During the 1820s, although American physicians were becoming increasingly aware of the French medical literature, diey were slow to take up physical diagnosis. The first notice of mediate auscultation in the American medical literature seems to have appeared in January 1820, when the Journal of Foreign Medical Science and Literature ran a notice from the London Medical Re-
pository of the previous August announcing the new method of investigation and predicting the early availability of Laennec's publication. In 1821 the same journal reprinted a lengthy review of Laennec's L'auscultation mediate from the Quarterly Journal of Foreign Medicine and Surgery from
1819-20.8 Laennec's monograph was translated into English by John Forbes in 1821 and published at London; in 1823 Forbes's translation of Laennec was published in Philadelphia. Americans recognized both the promise and the difficulties of physical diagnosis. In a review of Laennec's book in the New EnglandJournal of Medicine and Surgery, the reviewer, who
may have been Dr. James Jackson, professor of medicine at Harvard, ex5. E. H. Ackerknecht, Medicine at the Paris Hospital, 1794-1SS4 (Baltimore, 1967), pp. 53-57, 83-85. 6. P.J.B., 'Amciiltation before Laennec,' Tubercle, 1956,37, 213-215. 7. Ackerknecht, Paris Hospital (n. 5), pp. 88-99. 8. 'Laennec's new syitem of rliagnoiii.'J. Foreign med. sd. Lit, 1821,1, 360-379.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
At Paris around 1800 Jean Nicolas Corvisart learned of Auenbrugger's earlier work and reintroduced the largely ignored diagnostic technique of percussion, demonstrating its value by correlating the clinical histories •with the post-mortem appearances of patients suffering from heart diseases.5 In 1817 Francois J. Double, a student of Corvisart, devoted several pages in his Simiiologie Ghihale to auscultatory signs.6 But already in 1816 Rene" T. H. Laennec, also a student of Corvisart, faced with the delicate problem of listening to the chest of a female patient, rolled paper into a tight cylinder to improvise an instrument to permit indirect listening. In doing so he developed the principle of the stethoscope and the possibility of mediate, as opposed to immediate, auscultation. Laennec then made a more durable wooden stethoscope and used it to make clinical observations. He correlated such clinical observations with pathological changes observed at post-mortem examination, after the fashion of his teacher Corvisart, and in 1819 published the results of his study in L'auscultation
Smith : Austin Flint and Auscultation
131
9. 'Review De I'auscultation mediate,' New Engl.J. Mti. & Stag., 1821, 10, 132-156, 265-293. 10. J. Bel], 'Some general remark] on the uie of the jtethojeope, as an aid in forming a correct diagnosu of diieajes of the lungj . . . ,' N.Y. med. phys.J., 1824,3, 269-281, p. 271. 11. Ibid., p. 273.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
pressed a common concern about the new instrument: 'The author [Laennec] allows that it is only by experience one can learn to make all the distinctions he has pointed out; and in private practice it must take a long while to acquire this experience.'9 American physicians, trained largely by apprenticeship, seldom had the opportunity to see large numbers of patients in hospitals. In Boston, for example, the Massachusetts General Hospital was only opened in 1821, the year of this review. Among the earliest Americans to write on the use of the stethoscope was John Bell, a physician to the New York City Dispensary. In 1824 Bell published an article from which one may infer that he had observed Laennec use the stethoscope in hospital practice at Paris. He noted that few physicians in the United States had yet begun to use percussion and that 'the great mass of the profession [remained] . . . ignorant or indifferent with regard to it. . . .' 10 Bell recognized that it was even more difficult to learn to use the stethoscope because the sounds could not easily be described by words alone in such a way that the student might later recognize the individual sounds described by Laennec. For this reason Bell said that the 'use of the stethoscope . . . can be learned only in hospitals, or where it can be applied to a large number of patients. . . .' Another requirement for learning to use the new instrument effectively was that the student be allowed to check his clinical observations by post-mortem examination so as to learn the physical nature of the anatomical changes that occur in diseases of the chest.11 In addition to the great difficulties involved in learning auscultation, Dr. Bell saw little advantage for the general practitioner who learned the technique because he thought it had no application to therapy. Although Bell realized that the cure of disease must be related to pathological knowledge, in the five years since the publication of Laennec's book the accepted therapy in thoracic disease had not changed. Regardless of the precision of the diagnosis most diseases of the lungs were thought to involve inflammation, and inflammatory diseases were treated by such antiphlogistic measures as bleeding. Disappointment with the stethoscope was probably a frequent occurrence in nineteenth century America. Most physicians in the United States
132
Journal of the History of Medicine : April 1978
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practiced alone, often in small towns or villages. Without training, with no one to guide them in the use of the stethoscope, and without access to groups of patients in hospitals, American physicians found the new technique very difficult, if not impossible to learn. Some thought that the value of the stethoscope had been vastly overrated by the French.12 A negative attitude was by no means universal. Young American physicians who had studied in France began to bring to the United States a practical knowledge of physical diagnosis with the aid of the stethoscope. But for auscultation to become common in America, the technique of using the stethoscope had to attract the attention of influential physicians, especially teachers of medicine. In only two cities did auscultation become common in the first half of the nineteenth century, namely, at Philadelphia and at Boston. In both cities by the mid-i82os leading physicians were beginning to appreciate the potential value of the stethoscope for diagnosis. In the 1820s Philadelphia was the chief medical center of the United States. It had a long tradition of medical excellence and a well-established program of clinical teaching which utilized the Pennsylvania Hospital and the Almshouse infirmary. Philadelphia physicians became interested in the new developments of French medicine and in the wards of the Pennsylvania Hospital and Almshouse infirmary acquired some measure of skill in the use of the stethoscope. This interest and skill they passed on to their students so that before mid-century auscultation was a fairly common procedure in Philadelphia.13 Similarly at Boston, another important medical center, the need for clinical training was appreciated. In 1810 the Harvard medical school moved from Cambridge to Boston so that its students might gain more clinical experience in the wards of the Marine Hospital of the Port of Boston. At Boston as at Philadelphia, influential physicians recognized the importance of the new developments in French medicine. In particular
12. In Louijville, Kentucky, then part of the wertern frontier, Dr. John P. Harrisonreadof the new instrument developed by T.aentire and decided to try it He ordered a stethoscope, but without training, with no one to guide him, and without a large hospital, Harrijon found the imtrument more difficult to use than he had expected. He announced that it had been vastly overrated by the French. Harrison later advocated the use of the stethoscope, when he taught in Ohio in the 1840s, but there is no evidence that he had mastered the instrument J. P. Harrison, 'On the faculty and habit of clinical observation,' West Lancet, 1849, a, 1-14. C£ J. Ware, 'Condition and prospects of the medical profession,' in Discourses on medical education and the medical profession (Boston, 1847), pp. 3-49, p. 33. 13. E. Strudwidc, 'Remarks on the stethoscope in relation to phthisis pulmonalis,' Phila.J. med. phys. Sri., 1824, 8, 33-54. C£ N. F. Cooke, 'Advantage* of physical diagnosis to the homeopathic physician,' Phila.]. Homeopathy, 1854,3, 1-5, p. 4.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
M.
Figure l. Austin Flint, M.D. (1812-86). From Thomas Harrington, The Harvard Medical School, 3 vols. (New York and Chicago, 1905), 11, opposite p. 802.
Figure 2. The Buffalo Hospital of the Sisters of Charity. From Byron H. Daggett, Historical Sketch of the Buffalo Hospital of the Sisters of Charity (Buffalo, 1899), p. 11.
HI H- \ l
1. W. H. Welch, 'Address ofWm. H. Welch, M.D., Baltimore, Md.,' in 'Addresses delivered at the memorial meeting of the New York County Medical Association in honor of the late Austin Flint,' GanianTs med.J., 1886, 42, 585-389, p. 589. 3. W. Osier, 'Remarks to the dass in clinical medicine. University of Pennsylvania,' Canada med. surg.J., 1886,14, 571-574. P- 572. 3. S. W. Gross and A. H. Gross, eds., Autobiography of Samuel D. Gross, MD., with sketches of Ms contemporaries, 2 vols. (Philadelphia, 1887), n, 161. Since completing this paper I have read the interesting study of Flint by Dr. Oliver P. Jones, 'A student's impression of Austin Flint (""The American Laennec"), 1848-49,' Coll. Phys. Phila. Tr. Stud., 1977,43,13-17. In areviewof lecture notes taken by J. D. Mil, one of Flint's Buffalo students, Dr. Jones suggests that Flint probably had some deficiencies as a teacher, at least in the early years. However, even Hill was impressed by Flint's knowledgeable and clear instruction in physical diagnosis (p. 14). 4. C. Singer and E. A. Underwood, A short history of medicine (New York, 1062), p. 172.
[ 129 ]
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
j M O N G American physicians in the nineteenth century Austin Flint seemed to his contemporaries to have played a particularly significant role in the development of auscultation in America. At the time of Flint's death in 1886, William Welch said that Austin Flint 'did more by his writings and his teachings than anyone else in [America] to render popular the methods of exploration by physical signs.'1 William Osier told his students at the University of Pennsylvania that 'Not one of you who takes a stethoscope into his hand but is a debtor to Dr. Flint for simplifying much that was complicated in the auscultation of heart and of lungs,'2 while the Philadelphia surgeon Samuel Gross, who had been Flint's colleague at Louisville, Kentucky, thirty years before, described Flint as 'the American Laennec.'3 From ancient times physicians had realized that information they obtained by physical examination of the patient was more accurate and reliable than the patient's description of his own symptoms. The practice of listening to the sounds of breathing and the movements of fluid in the chest is very ancient, but the listening to the chest which occurred before the mid-eighteenth century was very superficial because little was known of the pathology involved. In 1761 a great stride forward was made by Leopold Auenbrugger when he introduced the technique of percussion.4
130
Journal of the History of Medicine : April
militate.1
The Paris medical community of the 1820s rapidly recognized the value of Laennec's work and foreign students who studied at Paris took stethoscopes home with them to Great Britain, Russia, the Germanic states, and to America. During the 1820s, although American physicians were becoming increasingly aware of the French medical literature, diey were slow to take up physical diagnosis. The first notice of mediate auscultation in the American medical literature seems to have appeared in January 1820, when the Journal of Foreign Medical Science and Literature ran a notice from the London Medical Re-
pository of the previous August announcing the new method of investigation and predicting the early availability of Laennec's publication. In 1821 the same journal reprinted a lengthy review of Laennec's L'auscultation mediate from the Quarterly Journal of Foreign Medicine and Surgery from
1819-20.8 Laennec's monograph was translated into English by John Forbes in 1821 and published at London; in 1823 Forbes's translation of Laennec was published in Philadelphia. Americans recognized both the promise and the difficulties of physical diagnosis. In a review of Laennec's book in the New EnglandJournal of Medicine and Surgery, the reviewer, who
may have been Dr. James Jackson, professor of medicine at Harvard, ex5. E. H. Ackerknecht, Medicine at the Paris Hospital, 1794-1SS4 (Baltimore, 1967), pp. 53-57, 83-85. 6. P.J.B., 'Amciiltation before Laennec,' Tubercle, 1956,37, 213-215. 7. Ackerknecht, Paris Hospital (n. 5), pp. 88-99. 8. 'Laennec's new syitem of rliagnoiii.'J. Foreign med. sd. Lit, 1821,1, 360-379.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
At Paris around 1800 Jean Nicolas Corvisart learned of Auenbrugger's earlier work and reintroduced the largely ignored diagnostic technique of percussion, demonstrating its value by correlating the clinical histories •with the post-mortem appearances of patients suffering from heart diseases.5 In 1817 Francois J. Double, a student of Corvisart, devoted several pages in his Simiiologie Ghihale to auscultatory signs.6 But already in 1816 Rene" T. H. Laennec, also a student of Corvisart, faced with the delicate problem of listening to the chest of a female patient, rolled paper into a tight cylinder to improvise an instrument to permit indirect listening. In doing so he developed the principle of the stethoscope and the possibility of mediate, as opposed to immediate, auscultation. Laennec then made a more durable wooden stethoscope and used it to make clinical observations. He correlated such clinical observations with pathological changes observed at post-mortem examination, after the fashion of his teacher Corvisart, and in 1819 published the results of his study in L'auscultation
Smith : Austin Flint and Auscultation
131
9. 'Review De I'auscultation mediate,' New Engl.J. Mti. & Stag., 1821, 10, 132-156, 265-293. 10. J. Bel], 'Some general remark] on the uie of the jtethojeope, as an aid in forming a correct diagnosu of diieajes of the lungj . . . ,' N.Y. med. phys.J., 1824,3, 269-281, p. 271. 11. Ibid., p. 273.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
pressed a common concern about the new instrument: 'The author [Laennec] allows that it is only by experience one can learn to make all the distinctions he has pointed out; and in private practice it must take a long while to acquire this experience.'9 American physicians, trained largely by apprenticeship, seldom had the opportunity to see large numbers of patients in hospitals. In Boston, for example, the Massachusetts General Hospital was only opened in 1821, the year of this review. Among the earliest Americans to write on the use of the stethoscope was John Bell, a physician to the New York City Dispensary. In 1824 Bell published an article from which one may infer that he had observed Laennec use the stethoscope in hospital practice at Paris. He noted that few physicians in the United States had yet begun to use percussion and that 'the great mass of the profession [remained] . . . ignorant or indifferent with regard to it. . . .' 10 Bell recognized that it was even more difficult to learn to use the stethoscope because the sounds could not easily be described by words alone in such a way that the student might later recognize the individual sounds described by Laennec. For this reason Bell said that the 'use of the stethoscope . . . can be learned only in hospitals, or where it can be applied to a large number of patients. . . .' Another requirement for learning to use the new instrument effectively was that the student be allowed to check his clinical observations by post-mortem examination so as to learn the physical nature of the anatomical changes that occur in diseases of the chest.11 In addition to the great difficulties involved in learning auscultation, Dr. Bell saw little advantage for the general practitioner who learned the technique because he thought it had no application to therapy. Although Bell realized that the cure of disease must be related to pathological knowledge, in the five years since the publication of Laennec's book the accepted therapy in thoracic disease had not changed. Regardless of the precision of the diagnosis most diseases of the lungs were thought to involve inflammation, and inflammatory diseases were treated by such antiphlogistic measures as bleeding. Disappointment with the stethoscope was probably a frequent occurrence in nineteenth century America. Most physicians in the United States
132
Journal of the History of Medicine : April 1978
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
practiced alone, often in small towns or villages. Without training, with no one to guide them in the use of the stethoscope, and without access to groups of patients in hospitals, American physicians found the new technique very difficult, if not impossible to learn. Some thought that the value of the stethoscope had been vastly overrated by the French.12 A negative attitude was by no means universal. Young American physicians who had studied in France began to bring to the United States a practical knowledge of physical diagnosis with the aid of the stethoscope. But for auscultation to become common in America, the technique of using the stethoscope had to attract the attention of influential physicians, especially teachers of medicine. In only two cities did auscultation become common in the first half of the nineteenth century, namely, at Philadelphia and at Boston. In both cities by the mid-i82os leading physicians were beginning to appreciate the potential value of the stethoscope for diagnosis. In the 1820s Philadelphia was the chief medical center of the United States. It had a long tradition of medical excellence and a well-established program of clinical teaching which utilized the Pennsylvania Hospital and the Almshouse infirmary. Philadelphia physicians became interested in the new developments of French medicine and in the wards of the Pennsylvania Hospital and Almshouse infirmary acquired some measure of skill in the use of the stethoscope. This interest and skill they passed on to their students so that before mid-century auscultation was a fairly common procedure in Philadelphia.13 Similarly at Boston, another important medical center, the need for clinical training was appreciated. In 1810 the Harvard medical school moved from Cambridge to Boston so that its students might gain more clinical experience in the wards of the Marine Hospital of the Port of Boston. At Boston as at Philadelphia, influential physicians recognized the importance of the new developments in French medicine. In particular
12. In Louijville, Kentucky, then part of the wertern frontier, Dr. John P. Harrisonreadof the new instrument developed by T.aentire and decided to try it He ordered a stethoscope, but without training, with no one to guide him, and without a large hospital, Harrijon found the imtrument more difficult to use than he had expected. He announced that it had been vastly overrated by the French. Harrison later advocated the use of the stethoscope, when he taught in Ohio in the 1840s, but there is no evidence that he had mastered the instrument J. P. Harrison, 'On the faculty and habit of clinical observation,' West Lancet, 1849, a, 1-14. C£ J. Ware, 'Condition and prospects of the medical profession,' in Discourses on medical education and the medical profession (Boston, 1847), pp. 3-49, p. 33. 13. E. Strudwidc, 'Remarks on the stethoscope in relation to phthisis pulmonalis,' Phila.J. med. phys. Sri., 1824, 8, 33-54. C£ N. F. Cooke, 'Advantage* of physical diagnosis to the homeopathic physician,' Phila.]. Homeopathy, 1854,3, 1-5, p. 4.
Downloaded from http://jhmas.oxfordjournals.org/ at University of Birmingham on July 2, 2015
M.
Figure l. Austin Flint, M.D. (1812-86). From Thomas Harrington, The Harvard Medical School, 3 vols. (New York and Chicago, 1905), 11, opposite p. 802.
Figure 2. The Buffalo Hospital of the Sisters of Charity. From Byron H. Daggett, Historical Sketch of the Buffalo Hospital of the Sisters of Charity (Buffalo, 1899), p. 11.
HI H- \ l
