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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)

Tuesday, 15 March 2016

Regency opera dresses

Opera dresses from The Mirror of the Graces (1811)
Here is the final post from The Mirror of the Graces depicting fashion at the beginning of the Regency. The other posts are: morning dresses, promenade dresses and evening dresses. This post looks at opera dresses.

Lady in pink
“The fourth plate represents two females in opera or full dress. First figure attired in a round robe, with a demi-train of pink imperial gauze, worn over a white satin slip, ornamented round the bosom, back, and shoulders, with fine Vandyke lace: white satin short sleeves, and appliqued stomacher of white satin, rising above the robe in front of the bust, so as decorously to shade the bosom: a Pomeranian bonnet of white satin, or silver frosted velvet: two white ostrich feathers drooping towards the left side: a diamond or pearl neck-chain, with Carmelite cross: a silver cestus and clasp: a Chinese scarf of white or fawn-colour silk, with variegated ends, and narrow corresponding border: white satin or kid slippers, trimmed with silver fringe: white gloves of French kid, and fan of spangled crape.” (1)
Vandyke lace

The lace is described as ‘Vandyke’, a term that was also used in the description of the morning gowns in The Mirror of the Graces which I looked at in a previous post. This means that the lace was edged in v-shaped points, the name coming from the Flemish painter, Sir Anthony Vandyke, who was known for his short pointed beard. 

Vandyke lace detail on a
dinner costume from  
La Belle Assemblée (1808)
Pomeranian bonnet

The bonnet is described as Pomeranian. Pomerania is an area in north east Europe bordering the Baltic Sea. As far as I can work out, in 1811, part was ruled by Prussia and part by Sweden. If anyone is an expert in European politics during the Regency, please feel free to correct me!

Carmelite fashion

The pendant worn by the first figure is described as a Carmelite cross. I wondered what the significance of Carmelite was and discovered the history of the Carmelite nuns. 

Carmelite derives its name from the Carmel mountain range in current day Israel. In the biblical story, it was on Mount Carmel that Elijah demonstrated that his God was the only true god and defeated the wicked prophets of Baal. This gave rise to various Carmelite Orders including the Discalced Carmelite nuns. Apparently discalced simply means that they went around with bare feet. 

The Discalced Carmelite nuns of Paris were guillotined in 1794, during the French Revolution, and became known as the Martyrs of Compiegne. I suspect that it was this tragic story that probably inspired the fashions based on the devotional clothes of the Carmelite nuns.

I have been unable to find out exactly what a Carmelite cross looked like, but have discovered a number of other references to Carmelite in the fashion descriptions of the period including several references to ‘Carmelite brown’, the colour of the Discalced Carmelites’ clothing. 
“Grey satin hats trimmed with rose colour, which forms a beautiful union, or of a Carmelite brown velvet, are reckoned most elegant;” (2)
“The dresses of the Ladies B was so singular in their construction and design, that they will be found worthy of delineation, were it only on the score of novelty; they were styled the Carmelite, or Convent vest, and were formed of a gossamer satin, the colour a nun's brown.” (3)
"…it will therefore only be necessary here to specify such articles as are most worthy of distinction in this and every other style of fashionable decoration. The Carmelite, or Convent cloak, of coloured sarsnet;” (4)
“The Carmelite cloak, though much in esteem, is rivalled by the Rugen mantle, or Swedish wrap, which owes its origin to the exquisite taste, and invention of my dashing cousin.” (4)
“Mary wore a single row of fine brilliants, by way of necklace, from the centre of which was suspended a Carmelite cross, her earrings and bracelets to correspond.” (4)
A silver cestus

The first time I Googled ‘cestus’ to find out what it was, I was told that it was an ancient battle glove a bit like a boxing glove! This didn’t sound right, so I looked again. Elsewhere in The Mirror of the Graces, it referred to “the cestus of Venus as the talisman of beauty”. By searching for ‘cestus of Venus’, I came up with a much more appropriate definition for cestus: a woman’s belt or girdle, particularly those worn by women of ancient Greece. 

Pale pink cestus or belt on an evening dress
from La Belle Assemblée (1812)
Lady in white
“The second figure in this plate appears in a Grecian robe of white gossamer satin or sarsnet, ornamented at the bottom with a deep silver border in the Egyptian style, and confined up the front, and across each side the bosom with small turquoise snaps, and clasps to correspond: the hair in full curls in front, formed in helmet crown behind, and ornamented with a wreath of white roses: a large pilgrim’s or Carmelite pelerine of spotted ermine, lined with blue silk: blue kid slippers, with silver clasps: gloves of French kid, and fan of carved ivory, with blue and silver crape mount.” (1)
More Carmelite fashion

A pelerine is a short or waist-length cloak or cape with long pointed ends hanging down in the front. Pictures of current-day Carmelite nuns show them wearing a shoulder cape or pelerine underneath their brown scapular or tabard-like garment. However, this picture of Mother Teresa of St Augustine (5) suggests that they may have worn them over their scapulars. We can be sure of one thing though – they certainly wouldn’t have been made of spotted ermine!

Mother Teresa of St Augustine, a Carmelite nun,
 from Life of the Venerable Mother Teresa
of St Augustine (1879)
Notes
(1) From The Mirror of the Graces; or the English lady's costume (1811) by a lady of distinction.
(2) From La Belle Assemblée (Dec 1814)
(3) From La Belle Assemblée (Aug 1807)
(4) From La Belle Assemblée (Sept 1807)
(5) Mother Teresa of St Augustine was the assumed name of Princess Louise of France (1737-1787), youngest child of Louis XV. She joined the Carmelite convent at Saint-Denis in 1770.

Sources used include:
A lady of distinction, The Mirror of the Graces; or the English lady's costume (1811)
Bell, John, La Belle Assemblée (1806-1837)
Life of the Venerable Mother Teresa of St Augustine: Louise of France, daughter of Louis XV, Carmelite nun of the convent of St Denis (1879) (in French)