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" in 1819.

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.

Ivory Pleximeter Piorry Stethoscope
On the left is a typical pleximeter designed after the Piorry model, which was about 2 inches long and 1 inch wide, circa 1826. 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), circa 1828.

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 popular.

Burrow's stethoscope Cased Russian set
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 being percussed.

Traube's pleximeter
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 hammers:

Curschman's percussor Seitz's percussor
On the left is Curschman's Percussor with Ivorine On the right is Seitz's Percussor with ebony handle.

Auscultation and 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 instrument
Sibson's percussor-pleximeter,
circa 1860.

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 percussion.

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 Flint's Percussor
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.

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