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Laennec’s Prescience

By Roy Smythe, MD

Paris, December 1816

The young physician strode quickly and purposefully across the narrow cobblestone thoroughfare that would soon widen and pass in front of the Palace d’ Louvre.  “Always I rush”, he thought to himself, shaking his head.  He looked down as he moved forward, and his frustration slowly changed to amusement.  It seemed the dark grey rectangular stones were amazingly uniform in both structure and alignment, and he wondered how the workmen who had laid these stones, perhaps fifty years earlier, had been so precise.  He also mused, as he was apt to do, based on his love for “pathologie anatomique”  the surface resembled a cirrhotic patient’s diseased liver specimen he had recently studied at the Hôpital Neckar.

It was too early for most to be engaged in their daily activities, especially on this back street – a short cut he did not usually take en route to the arrondissement that was his destination.  Each brisk step echoed a sharp report as the hard leather soles of his single buckle black shoes struck the stone – “click-click-click”, between the edifices on either side of him.

When he exited the narrow thoroughfare, and came upon the edge of a more spacious area surrounding the palace grounds, he noticed two young urchins playing with a piece of lumber.  It looked as if it may have been an old fencepost – one had at some point been trimmed into roughly cylindrical shape.  He guessed it was about six feet in length, and perhaps four or so inches in width.  The boys were laughing loudly, taking turns – one hefting it up on his shoulder and placing the end of the wooden length to the ear of one, the other scratching his end of the post with a large, rusty nail.

He slowed, then stopped and watched.

“I can hear it… I can hear it!” the boy on the listening end exclaimed, laughing…

Laennec stood by patiently waiting while they did this in turn a few times, and then walked over and asked, “may I try, juenes amis?”.  The boys gladly complied, and he placed his ear on the listening end of the post.  When one of the boys ran the point of the nail over the other end, ever so gently, Laennec laughed out loud as well, “Viola!  Now I understand… indeed!”

He then took several turns with the two boys – either listening or manning the nail at the opposite end of the post…  Eventually, he remembered his patient, and bade the boys farewell, pitching a coin from his frockcoat pocket to the smaller of the two.  He picked up his daybook and bag, and hurried along.

“Once again,” he mumbled to himself, “I rush…”

His morning had started in the usual way.  He awoke early, before sunrise, had a small bowl of porridge and dressed, excepting his frockcoat.  He then spent some time playing his flute – his sheet music placed on a small wooden stand in front of a window overlooking the street from his second story window, and he on a high wooden stool facing it…  He started with the scales, and then began working on a new Shubert piece he was attempting to learn.

He had been struggling with a particular passage for several days, but he was no stranger to the concept of “le problem.”  Even though he was but 35 years old, he had already contributed a great deal to medicine as a pathologist and clinician interested in diseases of the chest – solving problems was of particular interest to him.  A figure came and quickly departed from his window view – running down the lane in front of his home and diverted Laennec’s gaze briefly over the top of his sheet music.  A few moments later there was a loud knock at his front door.

“Monsieur,” the boy, whom Laennec judged to be no more than twelve or thirteen years of age, blurted out his speech pressured and hurried, “I have been asked to summon you, if you are available, to see a woman living in my mother’s boarding house.”  “What is the problem,” Laennec asked, “that requires me… young man?”  He quickly examined the boy more closely.  He clothing was clean, but worn, and his hair long and relatively unkempt beneath a dark brown felt hat.  He noted there were perspiration stains about the area where a headband would normally be.

“She complains of difficulty getting her breath, and is having pain… pain… in her… busom”

“What part of her busom?” Laennec inquired, “in the front, or on one side…  or both sides?”

“I’m not sure monsieur… In the front… I believe… yes, in the front area…” the young man replied, pointing to the middle of his own chest, his finger trembling from the exertion of having just run several blocks, and his social discomfort.

“Give me your address, and please return and tell your mother, and the woman of whom you speak, that I am shortly en route.”

After leaving the boys and their listening game behind, Laennec finally arrived at the address he had hastily scrawled on a piece of paper earlier. He stood before a two-story boarding house – its stucco surface covered in flaking yellow paint, with several grey wooden shutters – all missing slats or parts of their frames, some hanging askance at the margins of the clouded glass windows they had originally bracketed.  The young messenger again appeared at one of the two doors at the front of the structure, and let Laennec in, after which they climbed a flight of dusty, wooden steps to the building’s second story.  The doctor noted the mixed odors of urine and cooked cabbage as he ascended.

The boy rapped gently on a door at the top of the steps, and then pushed it open without waiting for a reply.  An older woman was waiting in the two-room dwelling, just a few feet behind the door – the front room in which they now stood was a combination of sitting area and kitchen – furnished with a few crude apparently hand-made pieces of furniture. There was a large iron pot on the wooden stove, with liquid bubbling over the edges of the rim and steam rising up and dissipating as it approached the low ceiling.

Ah,” Laennec thought to himself, “the source of the one of the two odors.”

The old woman was still dressed in off-grey nightgowns, and cap.  She walked up to Laennec and grabbed him by the upper arm, without speaking, and pointed to the door of the other room.  Laennec noticed her face was wet with tears.

“Yes, madam,” he whispered, “the patient?”  She nodded her head.

Laennec walked into the second room.  In the center of the space, there was a small bed, low to the ground, containing what appeared to be a very obese person, amidst a large disorganized pile of white cotton and tan burlap bedding.

“Madam?”

The woman lifted her hand off of the bed a few inches, with no obvious intentionality, then let it fall.

Laennec walked up to her side, leaned over and gently moved the blankets down from around the woman’s neck.  Her round face was pale and drenched in sweat, and her eyes half-closed.  Her unwashed hair was matted up in a great wad on the top of her head, and she had obviously not bathed in some time – based on the strong odor.  She was breathing fast, he noted, and he ascertained, silently… “mild distress, but no imminent danger”.

“May I examine you, Madam?”

She opened her eyes a bit more, focused on Laennec, and nodded, almost imperceptibly.

He leaned over, and touched the back of his hand to her forehead.  He then lifted her eyelids, and took a look at the mucous membranes around her eyes, examining the color, and moisture.

No signs of having lost blood, or fluid”, he thought to himself, “and there is no fever.

He reached down and untied the strings holding her gown together at the neck, and pulled it down slightly.  To his dismay, he immediately noted that her breasts were enormous – there was absolutely no space between her cleavage and her almost equally ample double chin.  He stood up, looked over at a corner in the room, rubbed the palms of his hands on his breaches, and sighed.

From behind him came the nervous and now stuttering voice of the young messenger, “Why… why… do you stop, monsieur?  What… did you see?”

Laennec did not know the boy had followed him into the patient’s home, and was startled, “Oh!.. oh… yes…  He then turned his back to the woman, leaned over to him and replied in a low voice, “this woman is younger than I expected, and her… um… habitus… makes direct auscultation impossible.  I am at a loss, in the moment, regarding my next maneuver.”  As he looked in the boy’s direction, he found his eyes were drawn to a small vanity in the corner behind him, covered in a jumbled stack of writing paper, and a dry inkwell lying on its side.

He walked over the table, pushing the boy aside absentmindedly.  He gathered up a large number of sheets and rolled them tight, into a “solid” tube of paper.  He then walked back over to the woman’s bedside, placed one end of the rolled paper between her breasts, onto the firm surface of her breastbone, and placed his ear to the other end.

The young boy watched him, nervously.   He had no idea what the word “auscultation” meant, and feared, due to his strong aversion to the sight of blood it might be some sort of surgical procedure.  He had no longer recovered from that consideration, when he then feared Laennec might strike him, or the woman, with the paper “weapon” he had created.  Momentarily relieved once again, he then wondered, as Laennec placed it into the woman’s cleavage, whether or not the doctor might have taken leave of his senses.

Laennac stayed in that position for several seconds with his eyes tightly shut, his ear to the paper tube, listening intently.

He smiled.

Later that night, he dined with his friend and confidante, François Louis Becquey.

“How was your day, good doctor?” Becquey asked, as they were sitting down.  His voice gravelly from years of giving speeches in the Legislative Assembly and his cheeks ruddy from years of heavily imbibing in drink – both frequently in efforts to change the minds of his argumentative colleagues.

Laennec replied, “my day… was, in fact… remarkable.”

“Pray tell?” Becquey implored casually, reaching for his glass of wine.

Laennec stared blankly at Becquey’s face, then down at the off-white canvas tablecloth, “I believe I have discovered a contrivance, one that may extend the physician’s ability to do many things, and know many things… things previously undiscerned.”  Becquey took a sip, pursed his lips in feigned interest, and nodded.  He was a politician after all, and somewhat inured to his brilliant young colleague’s frequent musings about advances in medicine.  Laennec waited until Becquey sat his wine glass back down, looked up, and continued, “It is my sense more and more contrivances will be created, my good friend – many we could not conceive of in our wildest imagination, and likely changing for all time the nature of how the physician approaches the patient… and his disease…”

Laennec then fell silent, and turned his head, staring off into a dark corner of the dimly lit tavern.

After a long moment, he whispered to himself a quote from Copernicus – one he had learned as a young schoolboy…

“Pouring forth its seas everywhere, then, the ocean envelops the earth and fills its deeper chasms.”

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Roy Smythe, MD is a former academic surgeon, biomedical investigator, medical school endowed chair and healthcare administrator currently working as a value-based care consultant.  He has written prolifically in the medical academic research literature, and has also published narratives, fiction and opinion pieces in the lay scientific and humanities press.  He is a monthly contributor to the Forbes Business / Healthcare and Pharma panel.  Dr. Smythe is a native Texan who works and lives in the Chicago area, and struggles to survive each winter.

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