Why we auscultate and percuss: Dr. Joseph Skoda (1805 – 1881)
Not all of thoracic surgery’s founding fathers were surgeons. In fact, one of the most important contributors to thoracic medicine, anatomy and physical examination, Dr. Joseph Skoda, was actually a dermatologist.
Walked to Vienna
The Czech born physician was also determined. Stricken with tuberculosis (consumption) as a child, yet determined to follow in the footsteps of his older brother, Franz, he defied his parents’ wishes that he enter the priesthood. While he initially studied theology, his affinity for mathematics, physics and natural sciences led him to pursue medicine. Of limited means, his education was financed by the beneficence of Madame Bischoff, the wife of a wealthy local industrialist.
Thus, instead of entering the church, in 1925, he spent six days traveling by foot; walking from his native Pilsen (Bohemia) to Vienna to attend medical school.
After obtaining his doctorate in medicine from the University of Vienna in 1831, Dr. Skoda spent a year in his native Bohemia studying Cholera before returning to the famed General Hospital of Vienna as an unpaid assistant physician. Over the next few years he worked in several different wards, including the Tuberculosis ward.
Multiple publications during the 1830’s*
During the early portion of his career, Dr. Skoda was a prolific author of medical publications such as “About percussion,” “About the Percussion of the Heart and the Sounds Originated by Heart Movements, and Its Application to the Investigation of Organs of the Abdomen”, “About the Diagnosis of Defects of Heart Valves” but it was his original research publication, “A treatise on auscultation and percussion” for which he is best known. He revived previously published but little known (or used) techniques of percussion and auscultation. He promoted the use of the stethoscope for physical examination and developed much of the terminology used for diagnosing and describing cardiopulmonary conditions.
However, these publications did little to earn the respect or admiration of his colleagues. Instead, he was demoted to ward physician for the insane ward as a punitive measure for disturbing patients with his methods of physical examination. But this animosity was not unilateral in nature.
Despite his enthusiasm for anatomy and physical examination – Dr. Skoda was not generally well-liked by his colleagues. In fact, he was appointed to several of his professional positions based on the recommendations of his close friend, Dr. Carl Freiherr von Rokitansky over the objections of his peers; including his appointment as a professor of the newly established “Modern” Medical School of Vienna. (This was a change in the traditional school of thought regarding medical education).
Some of their distaste may have stemmed from the fact that Dr. Skoda deviated from traditional dictates of the time and became the first professor to lecture in German instead of Latin. He more likely earned their enmity due to his failure to be duly impressed by their therapeutic marvels, medicinal treatments and patent medicines. Dr. Skoda was skeptical in regards to the actual therapeutic benefits to many of the medical treatments of the era, and frequently attributed the restoration of health to the fundamentals of healthy food, clean air and basic hygiene.
In an age where tinctures of mercury, laudanum and turpentine were popular remedies alongside bleeding, cupping and leeches, Dr. Skoda’s adage of “To do nothing is best in internal medicine” was probably more correct than his peers. This skepticism earned him the label of “therapeutic nihilist” who disdained modern medical interventions but this is far from the truth.
He was more like the fictional television physician, “Dr. House” of his generation.
First pericardial aspiration
Despite his mistrust of traditional medical and pharmaceutical quackery, Dr. Skoda ventured to experiment with specific medical interventions such as pleural aspiration, and pericardiocentesis as well as use of newer investigational medications such as salicylates (which later became modern-day aspirin). Dr. Skoda along with Dr. Franz Schul performed the first known pericardial aspiration in 1840.
Advancing physical examination and stethoscope use
Through the use of diagnostic tools like the stethoscope (which he promoted and refined after re-discovering and advancing the work of Viennese physician, Leopold Auenbrugger, as well as French physicians; Rene Laennec and Pierre Piorry), Dr. Skoda was instrumental in advancing physical examination as a tool for diagnosis.
Cardiac Murmurs and Adventitious Breath sounds
He first described and diagnosed the ‘drum-like’ sound of pneumonia, the Skodaic resonance of pleural effusions and supported the earlier work of Boullaud & Rouanet on cardiac sounds including the grades and distinguishing sounds of different murmurs. He gave us much of the terminology we use today, to describe rales, friction rubs, crepitus, bronchophony and voice conduction.
The next time you hear the tympanic sound during percussion [indicating a pleural effusion], remember this “Skodaic resonance” finding and Dr. Joseph Skoda.
* His major work in skin diseases and contributions to the specialty of dermatology begin in 1841. He continued to make various contributions to the field of medicine until his death at the age of 76 due to cardiac disease.
Davies MK, Hollman A. (1997). Joseph Skoda (1805-1881). Heart. 1997 Jun;77(6):492.
Sakula, A. (1981). Joseph Skoda 1805-81: a centenary tribute to a pioneer of thoracic medicine. Thorax. 1981 Jun;36(6):404-11
JAMA editiorial, “Joseph Skoda, Physican Diagnostician” October 19, 1964.
A Practical Guide to Clinical Examination: Lungs – University of California, San Diego.
Basics of lung percussion – Loyola University Medical Education Network
The Auscultation Assistant – UCLA site with examples of heart and lung sounds