Skoda J

SKODA & BLACAS

"Profiles in Cardiology - Joseph Skoda (1805-1881)" - by Zdenek Fejfar,

M.D., and Ludmila Hlavácková, Ph.D. (Institute for the History of Medicine,

First Medical Faculty, Charles University Prague), in 'Clinical Cardiology'

(August 1997) 20 (8): 740-741. (Reproduced by permission of the Institute

for the History of Medicine, University of Vienna, Vienna, Austria).

Joseph Skoda was born in Plzen, Czechoslovakia, on May 12, 1805. The third

son of a poor locksmith, he had to give private lessons as a teenager in

order to graduate from the gymnasium (high school) in Plzen. There was no

money for candles or lamp oil, and the adolescent Skoda spent evenings

studying by the light from the kitchen stove flames. In 1825, after

graduation and studies in philosophy, he went to Vienna to study medicine.

In addition to medicine he studied higher mathematics and physics and he

passed the examination so successfully that his teacher, Prof. Baumgartner,

urged him to devote his life to mathematics.

The degree of doctor of medicine was conferred on Skoda on July 18, 1831.

Because of the cholera epidemic at that time he was obliged, as were other

doctors, to work in the so-called cholera districts. Young Skoda, with a

fresh medical degree, performed this duty for a year, leaving it in November

1833. On his return, he obtained a job at Vienna General Hospital as a

houseman without pay. This started his amazing career as the founding father

of modern physical diagnostics. His famous courses on diseases of the chest

began in 1834 and soon attracted young colleagues from the Austrian monarchy

as well as from other European countries.(1)

Objective observation based on physical diagnosis confirmed or corrected by

pathology revolutionized medicine at that time ­ the generation before Skoda

and his friend Rokitansky had attempted to explain diseases by changes in

the environment (temperature, barometric pressure, humidity, etc.).

Percussion of the chest, introduced by the Austrian L. Auenbrugger in his

book, published in 1771 in Latin, remained unnoticed in his country. It was

promoted, on the other hand, by J.N. Corvisart (1755­1821) in Paris, and

together with auscultation, introduced by R.T.H. Laennec (1748­1822), the

French clinicians moved ahead of the old Austrian school. Their diagnostic

conclusions, however, were reached intuitively, and percussion or

auscultation phenomena were ascribed as typical for specified organ disease

(liver, lung tuberculosis, etc.).

Skoda reimported Auenbrugger's use of percussion. His approach ‹ in contrast

to that of the French colleagues ‹ was based solely on the objective

description of physical signs. To him, the acoustic phenomena produced by

percussion were not specific for a given organ, but for the amount of air or

fluid; hollow, empty, tympanic, high, deep, clear, dull. Based on acoustic

phenomena, Skoda tried to explain the physical changes in an organ and then,

from the anatomical and pathologic possibilities, he reached a clinical

diagnostic conclusion. In a similar way, Skoda developed a system of

physical diagnosis of the diseases of the heart and pericardium. His

classical monograph Abhandlung über Percussion und Auscultation was first

published in 1839.(2)

Although he was famous abroad and well-known in European intellectual

circles, he was not accepted - was even rejected - by older Austrian doctors

who could not understand his new diagnostic procedures. Before instituting a

new procedure at the Vienna General Hospital, it was necessary to obtain the

approval of the director and the chief physician of the hospital. In their

absence and thus without their consent, Skoda performed a tracheotomy with

his colleague, surgeon Schuh. The procedure was performed correctly;

nevertheless, Skoda was in danger of losing his medical license.

Fortunately, thanks to his fame, which was recognized in Austria by, among

others, the Court Councellor baronet Türckheim, officer in charge of the

Court Committee for Studies, Skoda was disciplined only by having to work in

an asylum for three months.

Skoda's chief in the medical department allowed him, however, to continue

his diagnostic investigations. Nevertheless, Skoda declined to prolong his

contract with the Vienna General Hospital that year and, in October 1839,

started work as doctor of the poor in St. Ulrich, a suburb of Vienna. The

temporary assignment did not stop his increasing fame.

The case of the Duc de Blacas, a resident of Vienna, is an example of

Skoda's expertise. Three top Austrian experts diagnosed the severe state of

health of the patient as liver disease. The duke's French personal physician

was not in agreement with them and asked for a consultation with Dr. Skoda.

The latter, using his technique of percussion and auscultation, found a

large abdominal aneurysm and predicted an early death of the patient. At

autopsy, Skoda, using percussion, again proved that he had outlined the

dimensions of the aneurysm correctly.

One of the consultants was Dr. Türckheim, who realized the importance of the

new diagnostic approach and followed all of Skoda's activities (e.g.,

pericardial paracentesis, performed again with Dr. Schuh 1840). He also

appreciated the fact that an increasing number of foreign doctors came to

Vienna to learn Skoda's diagnostic methods. In 1840, he established the

department for diseases of the chest, with Skoda in charge. A year later,

Skoda was appointed chief physician and the department was expanded to

include two wards, for internal and skin diseases. Skoda selected young Dr.

F. Hebra from Moravia (1816­1880) to care for patients with skin diseases.

The choice was excellent; in a few years, Hebra became another leading

physician of Czech origin at the Vienna University and is considered the

founding father of classical dermatology.

In September 1846, Skoda was at last given the chair of Professor of Special

Pathology and Therapy at the Vienna University and became Ordinarius at the

Department of Internal Medicine. Two years later, he became a full member of

the Royal Academy of Sciences in Vienna. For reasons of health (he suffered

from severe gout for years) Prof. Skoda resigned from all his functions in

1871. The students honored him with a famous torch parade. He died in Vienna

10 years later and was buried in the same cemetery as Hebra and Rokitansky.

The three stars of the Vienna second medical school remain together for

eternity.(3)

The most famous publication by Skoda was Percussion and Auscultation (1st

edition 1839), in which the young house physician described the fundamentals

of physical diagnostics that are still valid today. In the same year,

jointly with the pathologist J. Kolletschka (1803­1847), he published an

important paper on the relation between the pathology and in-life diagnosis

of pericarditis. The authors presented precise observations in patients and

compared them with autopsy results in a way never done before. Diagnosis of

the pericardial concrescence in life is the subject of another important

paper that utilizes the physiologic approach to describe the influence of

the atria and of lung ventilation on function of the heart and on

circulation.(4, 5)

Skoda critically evaluated various therapeutic approaches using statistical

methods and tried to eliminate those that were ineffective, futile, or

harmful (e.g., ungrounded venesection). On the other hand, he treated

patients with digitalis, quinine and scilla (squill), started to use

chloralhydrate, salicylates, and syringe of Pravaz. The label of

"therapeutic nihilist" conferred on him by some of his pupils was

unjustified and unjust. Moreover, he insisted on prophylactic hygienic

measures (for example, of the drainage and water supply in Vienna) in view

of the epidemics of cholera and typhoid, and supported the effort of I.F.

Semmelweiss.(1)

Dr. Joseph Skoda died June 13, 1881. He ended his life as a famous and

wealthy physician but used the greater part of his possessions for charity

and also for financial support of his cousin in Plzen, the founder of the

Skoda automobile factory.

References

1. Lesky E: Wiener medizinische Schule im 19. Jahrhundert, p. 1­660. Graz,

Cologne, Vienna: Herrmann Böhlauf, 1865

2. Skoda J: Abhandlung über Perkussion und Auskultation, p. 1­271. Vienna:

J.G.Ritter von Mösle Witwe & Braumüller, 1839

3. von Schrötter L: Josef Skoda. Wiener klin Wschrft 1805;18(50): 1­26

4. Skoda J: Erscheinungen, aus denen sich die Verwachsung des Herzens mit

dem Herzbeutel am lebenden Menschen erkennen lässt. Reprint of the Royal

Academy of Sciences (mathematics-natural history class) session, November

1851

5. Skoda J: Über die Funktion der Vorkammern des Herzens und über den

Einfluss der Contractionskraft der Lunge und der Respirationsbewegungen auf

die Blutzirkulation. Reprint of the Royal Academy of Sciences

(mathematics-natural history class) session, November 1852

©1997-2002 Foundation for Advances in Medicine and Science

JOSEF SKODA & IGNAZ SEMMELWEIS

Semmelweis became a pupil of Josef Skoda when he entered the Vienna Medical

School in 1840. Skoda had recently become head of new department of Diseases

of the Chest there; was clinician in his late 30s, and from his Semmelweis

learned mysteries of physical diagnosis, though not generally of treatment -

as old theories and treatments were being discarded, for time v. little

taking their place and this why Skoda got reputation as a nihilist:

Semmelweis would later remember how he would shrug off suggestions for

treatment with cryptic phrase, "Ach! Das ist ja alles eins". Was utterly

dedicated to developing methods of diagnostics, however, using Laennec's

stethoscope: Semmelweis greatly impressed by Skoda's cool bearing and his

carelessness of etiquette and dress, which reflected his attitude towards

medicine - his calm rejection of authority, his firm insistence on the

importance of observation and statistics, and inexorably logic with which he

summed up the facts relating to a difficult diagnostic problems. Always

refused to go beyond positive facts towards conjecture or hypothesis -

amazingly intellectually rigorous for time.

Semmelweis profited much from Skoda's teaching, which - like that of

Rokitansky - was to contribute greatly to his future career, for in

establishing his doctrine on the etiology of puerperal fever his principal

proof was massive assembly of facts and statistics. However, Semmelweis

unable to subscribe to Skoda's therapeutical nihilism however.

Oddly enough, was Skoda who played part in keeping Semmelweis in obstetrics

• in late 1845, Semm. applied for the post of assistant to Skoda, who had

just been appointed successor to Lippich in the professorship of Internal

Medicine, to begin in 1846. However, although Skoda had shown much interest

in Semmelweis, he did not give him the desired appointment, but gave it

instead to Dr. Löbel, who had assisted Skoda in the Dept. of Chest Diseases.

Disappointed, Semmelweis then returned to study of obstetrics.

From time Semmelweis introduced his new regime into Vienna Hospital in 1847,

Skoda was one of his two first proponents (other was his friend Hebra, the

dermatologist), in face of rigorous opposition from Johann Klein, Director

of the Lying-in Hospital. Skoda also proved vital to communication of

Semmelweis's ideas, as by 1849 he was still stubbornly refusing to publish

the remarkable results of his method and growing mass of proof for his

doctrine - Skoda one of several of his friends who took various measures to

further his cause. In Jan 1849, Skoda presented the case of the Semmelweis

doctrine before the Board of Studies of the Vienna Medical School, stating

that - since the former director of medical studies had wholly ignored

Semm.'s achievements, it was the duty of the Vienna medical faculty to

undertake an investigation of this important innovation, evolved within its

own institution, and advocated the appointment of a faculty commission to

undertake various tasks. These included constructing a statistical table

showing the correlation between puerperal-fever mortality in the past and

the extent to which students and assistants had occupied themselves in

dissection; alleged low mortality among cases of street-birth should be

investigated; facts should be ascertained whether the puerperal-fever

mortality was always low in institutions where possibility of cadaveric

infection was excluded; and should test the new theory by experiments on

animals. Skoda's proposals exploded like bomb-shell in the faculty meeting:

Klein was furious and opposed investigation fundamentally - was certain that

proposed statistical report on conditions in the Lying-in Hospital could

contribute nothing whatever to the explanation of puerperal fever, for

steadfastly believed that increase and decrease of extent of the disease was

dependent on vagaries of uncontrollable epidemic influences - plus took the

very suggestion of investigation as a personal insult and huge interference

in administration of his clinic. Others sprang to Klein's defence,

describing Skoda's proposal as a slander on Klein, but fortunately Skoda had

many backers in faculty group, and hsi recommendations were adopted by a

strong majority, with only Klein, ophthamologist Rosas and Reimann voting

against.

Although news at first good, Klein at once addressed protest to the Ministry

of Education against the resolution, and Skoda now victim of vicious

counter-attack by clerical and medical groups concerning his "materialistic

opinions". Decision made in Feb 1849, when right of medical faculty to force

an investigation upon Klein was denied - he himself was to conduct such

investigations on peurperal fever as he saw fit. However, despite this and

many other setbacks, Skoda remained absolutely determined to support

Semmelweis - even in face of Semm's own reluctance to speak about or

publicize his work. As Rokitansky said of him, Skoda was a beacon for the

learned, a model for the aspiring, and rock for the disheartened - plus

never forgot his own conflict with forces of convention, when he was

entirely dependent for his career on powerful friends. Result was that he

now used his power without stint to help Semm. - for 2 yrs he, with others,

had tried vainly to persuade Semm. to publish his theory and its proofs in

complete and authoritative form, but he had not done so, so Skoda decided to

do this himself. In autumn 1849, he therefore borrowed from Semm. all his

notes and records, and from these prepared an article which he then read at

a meeting of the Imperial Academy of Sciences on 18 October 1849 - then

published in 'Transactions' of Academy of Sciences and by Hebra in journal

of the Society of Physicians. This address won for Semm. immediate election

to membership in the Academy of Sciences, and on Skoda's motion the Academy

offered Semm. and Brücke, Prof. of Physiology, funds to enable them to

continue animal experimentation on puerperal fever.

In his paper on Semm.'s work, Skoda surveyed the facts upon which Semm. had

based his discovery and showed how those facts annihilated the epidemic

theory of the fever. After remarkably clear exposition of the pathology of

the disease, Skoda then discussed the use of the chlorine prophylaxis and

gave statistics proving the value of this preventive measure. He briefly

described previous attempts to publicize the discovery, and finally reviewed

the animal exps carried on by Semm. and Lautner and recommended further

research in this direction.

Unfortunately, Skoda made 2 important errors in his paper, which did not

help Semm's case. First, an error of omission, was that he emphasized the

cadaver as source of infection, but made no reference to the possibility of

infection from the discharge of living organisms. Result of this was that

Semm. now believed to be saying that peurperal fever caused on by cadaveric

infection, when many hospital doctors were well aware that, while the

cadaver might be one of the sources of infecton in peurperal fever, it was

certainly not the only source - meant that many physicians sympathetic to

Semm's ideas now felt he had been proved wrong. Skoda's second mistake was

an error in tact - a reference to the Prague obstetrical clinic, in which he

alluded to a letter he had written to the clinicians there in 1847 urging

chlorine-washings be introduced in Prague, but announced in the lecture that

poor results from Prague suggested that either the believers in the epidemic

theory had obtained the upper hand, or else the chlorine-washings had been

conducted with reprehensible carelessness - either way, he managed greatly

to offend and outrage the Prague obstetricians, in particular Scanzoni, who

at once defended themselves against Skoda's "slander" by systematic

refutation of Semm's ideas. Thus, Skoda's help - despite his best intentions

• by no means all positive, but was not helped at all by Semmelweis himself.

Tragedy of Semmelweis's life was to large degree of his own making: he

delayed too long in publicizing his discovery, and found too late the method

by which his theories could be spread: in 1848, Skoda, Rokitansky, and Hebra

pleaded with him to write the volume which appeared as 'Die AEtiology', but

even when it finally did appear, while one of the most remarkable scientific

documents ever published, it was so long and wordy, countlessly reiterating

the truth he was seeking to establish, that many sincere men were unable to

assimilate that truth and gave up. In Vienna, he would have had the benefit

of active editorial assistance which he might then have taken - later, he

was so irascible and already emotionally unstable, that he was unable to

accept any such aid.

Josef Skoda (Schkoda) - From Catholic Encyclopedia

Josef Skoda (Schkoda)

Celebrated clinical lecturer and diagnostician and, with Rokitansky, founder

of the modern medical school of Vienna, Skoda was born at Pilsen in Bohemia

on 10 December, 1805, the son of an impoverished locksmith. He attended the

gymnasium at Pilsen, entered the University of Vienna in 1825 (had to walk

whole way there, as no money for transport), and received the degree of

Doctor of Medicine on 10 July 1831. He first served in Bohemia as physician

during the outbreak of cholera, and was assistant physician in the general

hospital of Vienna, 1832-38, but in 1839 was demoted to the position of

physician to the city almshouse in Vienna. (Had been accused of injuring and

alarming patients by his incessant tapping and listening).

However, on 13 February, 1840, on the recommendation of Dr. Ludwig, Freiherr

von Türkheim, chairman of the imperial committee of education, was appointed

to the unpaid position of chief physician of the new department for

consumptives (ie chest diseases) just opened at the Vienna General Hospital.

(This through also influence of powerful friends in the Prague medical

school, and in spite of big opposition of the Vienna men von Hildenbrand,

prof of Internal Medicine, and Schiffner, Director of the General Hospital,

who had together secured his demotion the year before).

Skoda's great merit lies in his development of the methods of physical

investigation. The discovery of the method of percussion diagnosis made in

1761 by the Viennese physician, Leopold Auenbrugger (1722-1809), had been

forgotten, and the knowledge of it was first revived in 1808 by Corvisart

(1755-1821), court-physician to Napoleon I. Laennec (1787-1826) and his

pupils Piorry and Bouillaud added auscultation to this method. Skoda began

his clinical studies in close connexion with pathological anatomy while

assistant physician of the hospital, but his superiors failed to understand

his course, and in 1837, by way of punishment, transferred him to the ward

for the insane, as it was claimed that the patients were annoyed by his

investigations, especially by the method of percussion.

His first publication, "Über die Perkussion" in the "Medizinische Jahrbücher

des K.K. österreichen Kaiserstaates", IX (1836), attracted little attention.

This paper was followed by: "Über den Herzstoss und die durch die

Herzbewegungen verursachten Töne und über die Anwendung der Perkussion bei

Untersuchung der Organe des Unterleibes", in the same periodical, vols XIII,

XIV (1837); "Über Abdominaltyphus und dessen Behandlung mit Alumen crudum",

also in the same periodical, vol. XV (1838); "Untersuchungsmethode zur

Bestimmung des Zustandes des Herzens", vol. XVIII (1839); "Über Pericarditis

in pathologisch-anatomischer und diagnostischer Beziehung", XIX (1839);

"Über Piorrys Semiotik und Diagnostik", vol. XVIII (1839); "Über die

Diagnose der Herzklappenfehler", vol. XXI (1840). His small but up to now

unsurpassed chief work, "Abhandlung über die Perkussion und Auskultation"

(Vienna, 1839), has been repeatedly published and translated into foreign

languages, and established his universal renown as a diagnostician. In 1841,

after a journey for research to Paris, he made a separate division in his

department for skin diseases and thus gave the first impulse towards the

reorganization of dermatology by Ferdinand Hebra.

In 1846, thanks to the energetic measures of Karl Rokitansky, professor of

pathological anatomy, he was appointed professor of the medical clinic

against the wishes of the rest of the medical faculty. In 1848 he began to

lecture in German instead of Latin, being the first professor to adopt this

course. In 1848 at the request of the ministry of education he drew up a

memorial on the reorganization of the study of medicine, and encouraged

later by his advice the founding of the present higher administration of the

medical school of Vienna. On 17 July, 1848, he was elected an active member

of the mathematico-physical section of the Academy of Sciences.

Skoda's intense sense of duty as a teacher, the large amount of work he

performed as a physician, and the early appearance of organic heart-trouble

are probably the reasons that from 1848 he published less and less. The few

papers which he wrote from 1850 are to be found in the transactions of the

Academy of Sciences and the periodical of the Society of Physicians of

Vienna of which he was the honorary president. Early in 1871 he retired from

his professorship, and the occasion was celebrated by the students and the

population of Vienna by a great torchlight procession in his honour.

Rokitansky calls him "a light for those who study, a model for those who

strive, and a rock for those who despair". He died at Vienna on 13 June

1881: his benevolent disposition is best shown by the fact that,

notwithstanding his large income and known simplicity of life, he left a

comparatively small fortune, and in his will bequeathed legacies to a number

of benevolent institutions.

Skoda now popularly remembered as perhaps most extreme example of the

"nihilism" of the Vienna Medical School. He refined Laennec's ausculatory

and percussive techniques to explain the physical bases for the various

sounds produced by pathological lesions in the chest, showing that it was

not the disease itself but the alterations in the physical condition of the

organ which produced the properties of pitch and timbre. An objective

evaluator of treatment, he saw little use for medications or active

interference in sickness, even giving placebos to patients with pneumonia to

demonstrate that the illness ran its course unaffected by any therapy.

Moreover, his therapeutics were exceedingly simple in contrast to the great

variety of remedial agents used at that time, which he regarded as useless,

as in his experience many ailments were cured without medicines but merely

by suitable medical supervision and proper diet. Arguably, at this time, his

"nihilism" was therefore probably more beneficial than the bleedings,

emetics, and purgings that were still central to much medical treatment.

Plus, nihilistic tag not entirely justified anyway - as DSB points out,

Skoda's critical approach to therapy led him to replace obsolete,

inefficient methods with rational new methods, plus he also introduced

effective medicines, such as chloral hydrate and salicylic acid.