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Thursday, 31 March 2016

Regency medicine - the invention of the stethoscope

Left: Laennec's original stethoscope © Science Museum, London
Right: A modern Littmann stethoscope © Medisave UK Ltd
This year, 2016, is the 200th anniversary of the invention of the stethoscope. As with so many innovations, the stethoscope was not immediately welcomed by many Regency physicians. But then, so much of the medical knowledge we now take for granted was a mystery to doctors in the early nineteenth century.

The Georgian killer disease: consumption

Consumption, or tuberculosis as we now know it, killed more people in Georgian England than any other disease. Spread by contact with an infected person, tuberculosis thrived in the crowded streets and homes of rapidly growing cities. 

By 1800 it may have taken the lives of up to one in four Londoners each year. There was no cure and doctors were at a loss how to prevent infection. One of the biggest unknowns was how people contracted the disease.

Across the Channel, in Paris, a 35 year old French doctor was making the study of tuberculosis his life work. In 1816, René Laennec had just been appointed chief physician at Hôpital Necker, where he regularly encountered patients exhibiting symptoms of consumption.

René Laennec (1781-1826)
from Laennec, sa vie et son oevre by H Saintignon (1904)
Physicians had long understood that listening to the body could help them understand a patient’s condition - a technique known as auscultation. Putting an ear to the chest was common practice. An alternative method involved percussion, which meant tapping or striking the body and using the sound to assess what was going on within. Laennec had been schooled to use percussion.

The fat young lady inspires an idea

Soon after taking up his post at Hôpital Necker, Laennec encountered a tricky situation.
“In 1816,” he wrote later, “I was consulted by a young woman labouring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness.” (1)
The only other option was to put his ear to her chest, which he felt was “rendered inadmissable by the age and sex of the patient” (1). At that moment he remembered a simple acoustic principle and, grabbing a piece of paper and rolling it into a tube, he placed one end on the patient’s chest and put his ear to the other. Laennec had created the first stethoscope.

Amazed by the quality of the sound, Laennec dedicated himself to perfecting the instrument. What became of the young lady is not recorded, but within months, Laennec had decided on the ideal form for his new device. It was a hollow wooden tube about 30cm long, funnel-shaped on the inside. He also gave it the name it’s been known by ever since.

Laennec’s original stethoscope (the wooden version, not the paper tube!) is on display in the Science Museum, London.

Laennec's original stethoscope © Science Museum, London
The stethoscope comes to Georgian England

Laennec announced his creation of the stethoscope in front of an audience of medical and scientific specialists at the Academy of Sciences in Paris in 1818. Perhaps unsurprisingly, not everyone thought it was a good idea - hadn’t putting the ear to the chest worked well for hundreds of years?

In 1819, Laennec published a book about his work on chest diseases, including the designs for the stethoscope. In 1821 he returned to Paris and his work at Hôpital Necker. From then until his death in 1826, he regularly entertained medical visitors wanting to see him and learn about his invention.

Plate showing Laennec's design for the stethoscope as shown
in the first edition of his work, A treatise on the diseases of the 
chest and on mediate auscultation (1819)
In 1826, the authors of The Medico-chirurgical Review and Journal of Medical Science claimed to be “the first in this country to introduce the subject of auscultation, (January, 1820) through the medium of an extensive review of Laennec’s work.” (2)

They noted that in 1826 only a small number of practitioners studied auscultation and percussion, and very few of those were aged over 45. On these “we cannot expect to make much impression. Their habits are confirmed - their routine established - their opinions almost irrevocably fixed” (2). This reluctance to change they refer to as “the stigma of indolence (to give it the mildest term)” which gives rise to “the taunts of the prejudiced and the ignorant” (2)

One of those under 45 was Sir John Forbes, who was aged 34 when he published his first edition of Laennec’s work translated into English in 1821, following it with further editions into the 1830s.

In the preface to the second edition, published in 1827, he is presumably addressing sceptics when he makes a plea to physicians to learn how to use the stethoscope properly.
“When, therefore, we hear, as we sometimes do, that certain persons have tried the stethoscope, and abandoned it upon finding it useless or deceptive; and when we learn, on enquiry, that the trial has extended merely to the hurried examination of a few cases, within the period of a few days or weeks; we can only regret that such students should have been so misdirected, or should have so misunderstood the fundamental principles of the method.” (1)
He also writes that following another work he had published about the stethoscope in 1824, he had received a letter from the Director General of the medical department of the British army. In this letter he was told that general directions had been given to the medical officers of the army to make trial of the new methods, and to report the result. The Navy was also experimenting with the stethoscope.

The stethoscope as a symbol of forward thinking

In a preface to a translation of another work on the stethoscope, published in 1825, W N Ryland wrote that some objected to the device because it “has too much the appearance of quackery” (3) and offered no real benefits. 

He went on to say:
“As to what has been advanced in favour of bringing the ear in immediate contact with a female’s breast, in preference to the use of an instrument which enables to hear with ten times the accuracy, at a respectful distance, and seldom requires the part to be naked, it would be ridiculous to waste an argument upon it: let both plans be tried upon half a dozen patients, and the one which merits preference will soon be decided upon.” (3)
Just as some resist innovation and change, others are keen to experiment with new ideas. Records of a clinical examination in Edinburgh, in November 1821, make reference to the use of a stethoscope.

In her novel Middlemarch, published in 1871 but set in the 1830s, George Eliot put a stethoscope into the hands of a doctor and explained that using a stethoscope “had not become a matter of course in practice at that time”. (4)

Throughout the late Georgian period, the stethoscope remained a single wooden tube. Variations in design included some that were bell-shaped, and smaller models intended for use with children. Doctors began experimenting with flexible tubes in the late 1830s, but the binaural stethoscope (with two earpieces) didn’t arrive until around 1850.

A modern Littmann stethoscope © Medisave UK Ltd
 Laennec’s achievement

René Laennec, inventor of the stethoscope, is remembered as one of France’s greatest doctors. He knew that his discovery was a significant step forward for medicine, allowing a better understanding of the body while the patient still lived.

Sadly, his work in close proximity to tuberculosis sufferers meant that he too became a victim of the disease and he died in 1826, ten years after inventing the stethoscope. For the next sixty years, doctors would continue to be mystified as to how tuberculosis spread. It wasn’t until a hundred years after Laennec’s death that effective vaccinations were made available.

Notes
(1) From A treatise on the diseases of the chest and on mediate auscultation by René Laennec, translated by Sir John Forbes (1838)
(2) From The Medico-chirurgical Review and Journal of Medical Science, Volume 8 (1819)
(3) From A treatise on the different methods of investigating the diseases of the chest particularly percussion and the use of the stethoscope, translated from the French of M Collin with preface by W N Ryland MD (1825)
(4) From Middlemarch by George Eliot (1871)

Sources:
Collin, M, A treatise on the different methods of investigating the diseases of the chest particularly percussion and the use of the stethoscope, translated from the French with preface by WN Ryland MD (1825)
Laennec, René Théophile Hyacinthe, translated by Sir John Forbes, A treatise on the diseases of the chest and on mediate auscultation (1838)
Nicholson, Malcolm, Medicine and the five senses, The introduction of percussion and stethoscopy into early nineteenth-century Edinburgh (1821)
Saintignon, Henri, Laennec, sa vie et son oeuvre (1904)
The Medico-chirurgical Review and Journal of Medical Science, Volume 8 (1819)

3 comments:

  1. Fascinating article as always, Rachel, many thanks for the wonderful read!

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  2. Fascinating! curiously enough my current WIP has a major character in it who is dying of tuberculosis, also known as phthisis, so I had come across Laennec for his investigations into it, without discovering how he had also invented the stethoscope.

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  3. Some wonderful information in there. Thank you.

    ReplyDelete