A brief history of the Practice of Percussion.
By Erik Soiferman and Eric Rackow
In 1754, Leopold Auenbrugger
developed a new technique of physical
examination, which he called percussion. He tapped on the chest with the
fingertips with the hand drawn closed, and noted of the sounds that were
conveyed to identify a site of abnormality. He referred to these "percussed"
sounds as either high pitched, muted or dull. Auenbrugger attributed
his discovery to his boyhood experience watching his father tapping to define
the level of fluid in kegs. He published his new technique and findings in
a short monograph in 1761.
But percussion received little attention despite the fact that
physical examination was a recognized part of medical practice dating back
to the seventeenth century B.C. in ancient Egypt. Maximilian Stoll wrote
about the technique in 1770 and M. Rosiere translated Auenbrugger's treatise
into French in 1771. But percussion was not widely recognized until 1808, with
the publication of Jean Nicholas Corvisart's translation of the Auenbrugger
treatise. Corvisart annotated the text and turned a 49 page monograph into a 400
page book! Corvisart was a prominent physician, physician to Napoleon Bonaparte
and the teacher of Laennec. He was an adamant supporter of percussion and taught
it to his students. Corvisart publicly called for a text to be written on
the subject which he wanted called
"On the Causes of Diseases, Investigated by Diagnostic Signs and Confirmed by Autopsy."
One of his most famous students,
R.T.H. Laenenc, did just that with the publication of the treatise entitled
"A Treatise on Diseases of the Chest, and of Mediate Auscultation"
Laennec spoke poorly of his teacher. In an 1802 letter to his father,
Laennec said "I know only a M. Corvisart who is too lazy to write any book, although he is the coryphee of practical medicine; who does not want to see patients because it bothers him; who would hold it against me if I would speak to him of business; who would not open a letter or throw it on the fire, if one were to disturb him with such matters. His character pleases me so little that I have scarcely sought to know him better."
Percussion and auscultation took a while to become accepted
in medical practice. John Forbes, who translated Laennec's book from French
to English, did not believe in percussion or auscultation when he undertook this
work. Laennec's original work included several cases that documented the
importance auscultation and percussion played in arriving at the final
diagnosis. Forbes left these cases out of his first translation. It was not
until he finished his work that he became fascinated with the idea that
auscultation and percussion really did give great insight into the diseases of
the chest. He promised that he would revise his work should a second edition of
Laennec's book be published. It was, of course, and Forbes included in his new
translation full case histories from Auenbrugger, Corvisart, and Laennec, which
documented the use and benefit of auscultation and percussion.
As auscultation became
more widely practiced, and the stethoscope began to take on a more compact and
portable form. In fact, Adolph Piorry, who first improved Laennec's stethoscope,
invented a new instrument that he called a "pleximeter" in 1826. This was
designed to be placed against the chest and struck with the finger or other form
of "percussor." Piorry even devised a way to incorporate an ivory
pleximeter into the base of his stethoscope, which could be screwed on and off.
Piorry published his discovery and method in 1828 and wrote an
extensive book on the art of pleximetry in 1866.
|On the left is a typical pleximeter designed after the
Piorry model, which was about 2 inches long and 1 inch wide, circa
On the right is a Piorry Stethoscope incorporating ivory pleximeter (round solid
ivory disk on bottom second from left) and finger thimble ivory
percussor (on bottom right),
In Germany in 1854, Wintrich developed the
percussion hammer which was used to strike the pleximeter during percussion.
Some stethoscopes even came with a percussor, which was stored in the cone of
the stethoscope when not in use. Other models incorporated a rubber percussor
ring around the base of the ear piece so that the stethoscope could be
used as a percussion hammer as well as an instrument for auscultation. And
cased sets of a stethoscope, percussion hammer and pleximeter were also very
Burrow's stethoscope with original rubber ring
around the ear piece which enabled the stethoscope to also serve as a
percussion hammer, circa 1860.
||An auscultation and percussion set from Russia in a leather case with a stethoscope, percussion hammer and pleximeter, circa 1870.
The pleximeter was not just a simple flat piece of
material, either. Although the first ones were small pieces of wood, they soon
came to be made of ivory, glass, gutta-percha, as well as wood. They also came
in many different shapes and sizes. Many, if not most, of the pleximeters came
with small markings, or gradations. These were used to help the physician locate
sounds from within the chest. The pleximeter was placed against the chest, and
struck with the percussor. The physician used the gradations to note the exact
location of the sound, thereby allowing him to measure the size of the density
| Traube's pleximeter made of ivory, marked with a scale and with silver hinges that bend up to allow the physician to hold the pleximeter in place on the patient, circa 1850.
The percussor, as
mentioned above, is similar in appearance to today's reflex hammers. They are,
in fact, frequently interchanged. You will see that these also vary in size and
appearance, and some are even designed to fit over the finger, and are called
"percussion thimbles." Below are some examples of percussion
|On the left is Curschman's Percussor with Ivorine
||On the right is Seitz's Percussor with ebony handle.
percussion became the cornerstones of physical examination of the chest. In
1828, John D. Goodman was commenting on a textbook of physical diagnosis written
by Karl Gustavas Schmalz when he said:
"A part of his introduction is occupied with an excellent and perspicuous account of auscultation and percussion as a means of distinguishing diseases of the chest, and ears a very decided testimony in favor of their usefulness, no longer doubted, except by those who are too indolent to derive advantage from their ears."
This became the sentiment for much of the
nineteenth century. Auscultation and percussion were used widely. There were, of
course, those who did not wholeheartedly believe in the ability of auscultation
and percussion to predict disease. One of the most notable persons who spoke
against them was Edouard Seguin who, some half a century later in 1871,
classified certain instruments of physical diagnosis as
"modes of positive diagnosis."
These instruments included those that were numerically based, such
as the thermometer, the sphygmograph, the dynamometer, etc. He stated that
auscultation and percussion could not predict the early signs of disease when
used by themselves, but if the examiner used his positive modes of diagnosis
they could be useful.
As the practice of percussion grew more popular,
physicians sought to combine the pleximeter and percussor into a single
instrument for convenience. This exquisite example is Sibson's model from he
middle of the third quarter of the nineteenth century. There is an identical
instrument in the Wellcome Collection of the Science Museum, London.
| Sibson's percussor-pleximeter,|
An interesting sidebar to the practice of auscultation and
percussion was the combination of the two, termed "Auscultatory Percussion,"
which was first described by Drs. Cammann and Clark in the New York Journal of
Medicine and Surgery (July 1840). This practice was developed to determine the
size and density of organs, most notably the heart and the liver. It was
practiced with a solid stethoscope that was placed against the chest with one
hand. With the other hand, the examiner would strike the wall of the chest
and listen for the sound. Cammann and Clark discovered that bone was the best
conduction medium in the body, with cartilage slightly behind bone. They said
that muscle was a good conductor when tense, but not when lax, and that fat was
not good at all. This led them to document and classify the sounds they heard in
one of four ways, which they termed "Type Sounds:" The OSSEOUS sound was the
loudest and most energetic. The AQUEOUS was the least. Between the two were the
CARDIAC, which was acute, clear and had a muffled 'ring' quality, and the
HEPATIC, which was more continuous and less freely conducted. The technique
worked , and was embraced to a certain degree.
A number of physicians developed binaural stethoscopes for
auscltatory percussion. In 1887, Dr. Spier of Kings County, New York
developed an Echoscope which was a remodeled Cammann stethoscope with
a large "trumpet" bell and a rod with cushion attached to the yolk of the
tension mechanism holding the ear tubes together such that the chin could rest
on the cushioned rod to press the bell firmly against the chest wall during
auscultatory percussion. In 1890, Dr. T. O'Kelly of Chipping, Norton devised a
standard binaural stethoscope with Ford bell to have a 20cm rod that had a
cushioned end extend from the chest piece. The physician could rest his
forehead against the cushion rod in order to press the bell firmly on the chest
during auscultatory percussion. And Dr. Denison in 1892 announced his
elaborate improvement of the Cammann stethoscope which came with various sized
bells (please see the article and images on this web site). The largest bell was
used for auscultatory percussion by having the patient hold the bell in front of
his open mouth and then the physician percussed the chest. He claimed this
technique enabled the auscultator to identify "hollow" sounds of lung cavities
that connected to the bronchial tree and thus could be heard during auscultatory
No work on the diagnosis of the chest would be
complete without mention of the greatest American cardiologist,
Austin Flint, Sr.
Flint was a graduate of Harvard Medical
School, and practiced at Massachusetts General Hospital. He was also one of the
founders of the Bellevue Hospital in New York City. Flint is widely regarded as
the most influential teacher of auscultation and percussion in America and was,
therefore, called the "American Laennec." He is responsible for describing many
cardiac abnormalities and sounds (such as the Austin Flint murmur of aortic
regurgitation). Flint also developed a practical percussor and
pleximeter, pictured below. He first published his methods in the journal Transactions
of the American Medical Association in
1852 when he wrote an article entitled
"On variations of Pitch in Percussion and Respiratory Sounds, and Their Applications in Physical Diagnosis."
Flint's Pleximeter made of hard rubber on the left and Flint's Percussor
with rubber head and hard rubber handle on the right, circa 1880.
By the twentieth century, inspection, palpation,
percussion and auscultation had become the standard approach to the physical
examination of patients and remains so today.