Journal of the Royal Society of Medicine Volume 74 October 1981 759 Laennec's influence on some British physicians in the nineteenth century1

Alex Sakula MD FRCP Consultant Physician, Redhill General Hospital, Surrey

The news of Laennec's invention in 1816 of the monoaural stethoscope for use in mediate auscultation spread rapidly from Paris throughout Europe. After the first edition of 'De L'Auscultation M&diate' appeared in 1819, interest in the method grew further and physicians from the major European medical centres, including Great Britain, travelled to Paris to learn this new technique of clinical diagnosis from the master himself. By the time that Laennec had produced the second edition of his great treatise in 1826, nearly three hundred foreign students had attended his lectures and demonstrations at L'Hopital Necker, at the College de France or at La Charite, and they included many British physicians (Sakula 1981a). In the preface to the second edition of 'De L'Auscultation Mediate' (1826), Laennec (Figure 1) listed the names of a number of his foreign students. He was obviously impressed by his British students, since he included no less than fourteen of them: Thomas Hodgkin, Alex Urquhart, Will Bennet, Townsend, Henry Riley, Rob MacKinnel, Crawfort (probably a mis-spelling of Crawford), Jones, Edwin Harrison, Patrick Scott, Cullen, James Gregory and C J B Williams. He also referred to a visit by Sir James McGrigor (1771-1858), the pioneer Director-General of Medical Services in the British army, who promised Laennec that British army surgeons and physicians would be provided with stethoscopes and would be asked to report the results of their researches with the instrument. Sir William Burnett (1779-1861), the first Medical Director-General of the Royal Navy, did the same for his naval surgeons. Laennec also kept a list, in his own handwriting, of his foreign students, totalling around 180 names (Sakula 198 lb). Among these may be found a number of British doctors, including Thomas Hodgkin, on whose performance Laennec commented 'assez bien'; C J B Williams, against whose name he wrote 'tres bien'; and Charles Mitchell (1783-1856), who attended the Charite in 1824-1825, and of whom Laennec wrote: il etait chirurgien des etablissements de la marine anglaise a Sainte-HeHlne lors de la mort de Napoleon et a assiste a l'ouverture de son corps' (Huard & Grmek 1973). Mitchell had been, in fact, surgeon of HMS Vigo and was one of the five British doctors who signed the report of Napoleon Buonaparte's autopsy, which was performed by the Corsican Doctor Francesco Antommarchi in St Helena on 6 May 1821. Those British physicians who were most influenced by Laennec and whose writings helped to spread his teaching will now be considered. Augustus Bozzi Granville Laennec's first contact with a British physician was probably with Augustus Bozzi Granville (1783-1872) (Figure 2), who was born in Milan and qualified MD in Pavia in 1802; after serving as a surgeon in the Royal Navy, he settled in London. In 1816, he went to Paris to pursue his postgraduate studies in midwifery. In his book 'Sudden Death' (1854), Granville describes a ward round at l'Hopital Necker: 'One day (it was the 13th of September, 1816, for I took a note of it), Laennec seemed dissatisfied with the result of his percussion and direct auscultation, in an interesting butobscure case before him; when, 1 Accepted 23 June 1981. Paper based on lecture delivered in French at the Colloquium held at the Col}ege de France, Paris, on 19 February 1981, to celebrate the bicentenary of the birth of Rene Theophile Hyacinthe Laennec (17 February 1781-13 August 1826). A lecture entitled 'R T H Laennec: A bicentenary appreciation' was also delivered by Dr Sakula to the Section of the History of Medicine, Royal Society of Medicine, on 4 February 1981 0141-0768/81/100759-09/$O1.00/0 DC 1981 The Royal Society of Medicine 760 Journal of the Royal Society of Medicine Volwne 74 October 1981

Figure 1. Rene Theophile Hyacinthe Laennec. (By courtesy of the Wellcome Trustees) turning round to the circle of pupils around the bed, "Why", said he, "should we not avail ourselves of the help which acoustics yield to us, of making distant sounds more audible? The speaking-trumpet enables the dull of ear to hear the faintest whisper; the ascending tube in a warehouse conveys to the upper storeys, in audible sounds, the muttered directions of the master below; the ticking of a watch, placed at the end of a long beam, is heard loudly by the ear applied to the other extremity; a tube, therefore, applied over the lungs or to the chest over the heart, ought to instruct us more plainly through our ears, with the movements and sounds going on within"; and forthwith snatching the cahier des visites from the hands of the nearest eleve interne, and rolling it up lengthwise to the shape ofa cylinder, having a perforation through its axis, he applied it first to one side of the chest, then to the other, and again to the back, between and below the shoulder-blades, and declared (what we all know to be true)

Figure 2. A B Granville. Engraving which appears as frontispiece to his 'Autobiography' (1874). (By courtesy of the Royal College of Physicians of London) Journal of the Royal Society of Medicine Volume 74 October 1981 761 that he could make out with greater distinctness, than with the naked ear applied over the parts, their inward condition, from their respective sounds which he then described.' We may truly say that, as a student of obstetrics, Granville was present at the birth of the stethoscope! He returned to London in November 1817, armed with a cylinder, and settled down in practice in Savile Row. Granville was probably the first to use the instrument in London. When Laennec's 'De L'Auscultation Mediate' was published in 1819, Granville immediately wrote an appreciative four-part review of the great treatise in The London Medical and Physical Journal (1820), of which he was then editor.

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/_ Figure 3. Sir James Clark, Bart. (From Illustrated London News, 16 July 1810, p 61)

Sir James Clark, Bart Sir James Clark, Bart (1788-1870), a Scot, studied medicine in , and qualified MD in 1817 (Figure 3). After serving as a surgeon in the Royal Navy, he accompanied a phthisical English gentleman on a European tour; in 1818, while passing through Paris, he took the opportunity of visiting L'Hopital Necker. In his 'Medical Notes on Climate, Diseases, Hospitals and Medical Schools in France, Italy...'(1820), he describes how he missed Laennec on that occasion, but saw the stethoscope being demonstrated. He acquired one of these instruments and set up practice in l.ome, where most of his patients were aristocrats from Britain and elsewhere resorting in Italy for health reasons. Among his famous patients was the immortal English doctor-poet, John Keats (1795-182 1), who died ofphthisis in Rome at the age of 26. When Clark examined Keats in the autumn of 1820, he had not yet mastered the use of the stethoscope. Clark referred a number of his Rome patients to Laennec in Paris; in a letter from Rome, dated 12 May 1823, Clark wrote to Laennec: 'I have a stethoscope, and have endeavoured to make its utility generally known in Italy, as I was the first to do in England'. The latter claim was probably not strictly accurate. In 1826 Clark returned to England where his practice flourished and he later became physician to and Prince Albert. 762 Journal of the Royal Society of Medicine Volume 74 October 1981

Matthew Baillie Matthew Baillie (1761-1823), another Scot, was a nephew of the great Hunter brothers, John and William. He studied medicine and obtained a DM at in 1780. A successful career in practice culminated in his becoming Physician-Extraordinary to King George III. He is remembered chiefly for his important morbid anatomical studies, 'The Morbid Anatomy of the most Important Parts of the Human Body' (1793), of which Laennec must have been aware. When the first edition of 'De L'Auscultation Mediate' appeared in 1819, Laennec sent two copies to Matthew Baillie - one for Baillie himself and the other for the Prince Regent. Baillie wrote a letter of thanks to Laennec, and described the work as 'the fullest and most able account of the diseased appearances of the Heart and Lungs which has yet been published'.

In contrast to the somewhat lukewarm and even hostile reception given by the French medical press to Laennec's invention of the stethoscope, the early English reviews were enthusiastic (Bishop 1972). The review of 'De L'Auscultation Mediate' by James Johnson (1820) ended: 'To the enlightened author, of whom France may well be proud, the thanks of Europe are due'. By November 1819, one could buy a stethoscope in London from Mr Weiss in the Strand, and in the following year imported models from France were on sale at Trentell and Wurtz, booksellers in Soho Square (Paris price, two francs). When these supplies were exhausted, an English woodturner named Allnutt, of Piccadilly, made them and sold them for four shillings. Another early British stethoscope-maker was Grumbridge of Poland Street (Bishop 1980). Sir John Forbes The most important British contribution to the dissemination of Laennec's teaching were the writings of Sir John Forbes (1787-1861), another Scot, who studied medicine in Edinburgh, where he qualified MD in 1817 (Figure 4). He was a boyhood friend of Sir James Clark; like

Figure 4. Sir John Forbes. (By Courtesy of the Figure 5. Title page of 'Treatise of Diseases Wellcome Trustees) of the Chest' (1821) by Sir John Forbes Journal of the Royal Society of Medicine Volume 74 October 1981 763 him, he served for a time as surgeon in the Royal Navy. In 1817 he settled in , Cornwall, where he was in general medical practice and served as a physician to the local Dispensary. In 1822 he moved to , in Sussex. He settled in London in 1840 and there (with C J B Williams) was one of the founding consulting physicians of the Brompton Hospital in 1841. He also became Physician to Queen Victoria's household. Forbes' friend, James Clark, had brought back a stethoscope from L'Hopital Necker in 1818 and had introduced Forbes to its use. Forbes did not himself visit Paris, and did not meet Laennec, but they corresponded, with Laennec replying in Latin! Forbes was so impressed by the first edition of Laennec's 'De L'Auscultation Mediate' (1819) that he decided to produce an English translation, entitled 'A Treatise on the Diseases of the Chest. . . ' (1821), which was published two years after the French first edition and was dedicated to Matthew Baillie (Figure 5). Forbes has been criticized for taking liberties with Laennec's terminology of lung sounds (e.g. the use of rale and rhonchus), and for rearranging the text into two parts - Pathology and Diagnosis. Others, however, have praised Forbes' English version, even regarding it as an improvement on the original (Copland 1822). Forbes was considerably influenced by Laennec's teaching on the diagnosis of thoracic disease. In his preface, he wrote of Laennec: 'In short ... he may be said to have realised the wish of the ancient philosopher, and to have placed a window in the breast through which we can see the precise state of things within'. Forbes was, however, sceptical about the future general usefulness of the stethoscope and wrote: That it will even come into general use, notwithstanding its value, I am extremely doubtful ... It must be confessed that there is something even ludicrous in a grave physician formally listening through a long tube applied to the patient's thorax... Besides, there is in this method a sort of bold claim and pretension to certainty and precision of diagnosis, which cannot, at first sight, but be startling to a mind deeply versed in the knowledge and uncertainty of our art, and to the calm and cautious habits of philosophising to which the English physician is accustomed. Forbes also did not approve of some of Laennec's ideas on treatment, such as the use of seaweed in phthisis. In 1824, Forbes published his 'Original Cases.. .' which included English translations of the works of Leopold Auenbrugger (1722-1809) and Jean Nicolas Corvisart (1755-1821), in addition to those of Laennec. Because the first edition of his translation of 'De L'Auscultation Mediate' sold so well, Forbes later prepared three further editions: in 1827 the second edition (based on Laennec's French second edition of 1826); in 1829 the third edition; and in 1834 the fourth edition (based on Meriadec Laennec's French third edition of 1831). In a letter to Laennec in 1823, Forbes declared his intention to produce a complete translation (as opposed to an abridged version) of 'De L'Auscultation Mediate':

Chichester, 13th Decr. 1823 My Dear Sir, I had the honour of transmitting to you a copy of my Abridgement (I will not say translation) of your immortal work, I ought at the same time to have conveyed to you the expression of my profound respect for your great talents, and my apologies for the great liberties which I had taken with the matter and manner of your treatise. The only substantial excuse I can offer is the conviction I entertained at the time that a simple translation of so voluminous a work would not have met with any encouragement in this country, and, if attempted, would therefore have frustrated the great and important object of making your immortal labours and discoveries known to a great body of British practitioners... There can be no doubt that Forbes"translations of Laennec's treatise were of the greatest importance, since they introduced British physicians to Laennec's technique of mediate auscultation as well as his concepts of the clinicopathological approach to diseases of the chest, especially phthisis. Forbes' translations also sold successfully in the , so that Laennec's ideas had now spread to most of the English-speaking medical world. 764 Journal of the Royal Society of Medicine Volume 74 October 1981 Thomas Hodgkin Thomas Hodgkin (1798-1866), already mentioned earlier, is of course famous for his description in 1832 of the disease which bears his name. He studied medicine at Guy's Hospital and Edinburgh, where he qualified MD in 1823, but during his vacation while still a medical student he visited European medical centres, including Paris. In 1822 he was briefly a student of Laennec at L'Hopital Necker. He became proficient in mediate auscultation, and introduced the stethoscope to Guy's Hospital, where he read a paper on the instrument to the Guy's Physical Society. By 1837, Thomas Addison (1795-1860) of Guy's Hospital stressed the importance of the stethoscope in the diagnosis of pneumonia. Charles James Blasius Williams Another important British follower of Laennec was Charles James Blasius Williams (1805-1889) (Figure 6). He graduated MD at Edinburgh in 1824, and became a very successful London physician, specializing in tuberculosis and diseases of the chest. Like Forbes, he was a founding consulting physician of the Brompton Hospital in 1841. He was also Physician- Extraordinary to Queen Victoria. Shortly after qualifying in medicine, he proceeded to Paris where he spent fourteen months (1825-1826) attending Laennec's demonstrations at La Charite. In his autobiography, 'Memoirs of Life and Work' (1884), he described the medical scene in Paris at that time. Most of Laennec's students were foreigners, as many French students preferred to attend the courses of Laennec's rival, Francis Joseph Victor Broussais (1772-1838). There may also have been a political reason for this, as Laennec was a Royalist, and this did not earn popularity at that time. Williams considered that Laennec's lectures, given in Latin, were 'not first rate', and rather surprisingly, Laennec seemed to lay little emphasis on the pathological aspects of the cases described. However, Laennec's demonstration of auscultation was impressive, although he could not give a satisfactory explanation of chest sounds in terms of physics. Williams himself rectified this by making a study of the physical basis of chest sounds (in this respect, preceding Josef Skoda of Vienna), and published his findings in 'A Rational Exposition of the Physical Signs of Diseases of the Chest' (1828). In his great treatise, 'Pulmonary Consumption' (1871), he analysed 1000 personal cases of phthisis, but the discovery of the tubercle bacillus by Koch in 1882

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Figure 6. C J B Williams. Engraving which appears as frontispiece to his 'Memoirs of Life and Work' (1884) Journal of the Royal Society of Medicine Volume 74 October 1981 765 necessitated considerable revision of the text in the second edition in 1887. Williams must have been one of the very few of Laennec's pupils who lived to see the discovery of the tubercle bacillus. William Stokes The great Irish physician, William Stokes (1804-i878) (Figure 7) may be included in this account, as Ireland was then pirt of Great Britain. Stokes qualified MD at Edinburgh in 1825. He was not a student of Laennec in Paris, but when introduced to the stethoscope he immediately appreciated its importance. While still a final-year medical student, he published the first systematic treatise in English on auscultation: 'An Introduction to the use of the Stethoscope' (1825). He later published 'Two Lectures on the application of the Stethoscope...' (1828). His major work was the 'Treatise on Diagnosis and Treatment of Diseases of the Chest' (1837), which gave a masterly exposition ofthoracic disease. Stokes was Regius Professor of Medicine in the University of Dublin and became Physician to Queen Victoria in Ireland. He was associated with other great Irish physicians, including Robert James Graves (1796-1853), famed for his description ofexophthalmic goitre, and Sir Dominic Corrigan (1802-1880) whose name is associated with the diagnosis of aortic valvular disease (Corrigan 1829). Stokes himself is imortalized in the eponymous Stokes-Adams attack and Cheyne-Stokes breathing.

Figure 7. William Stokes. Engraving, by P W Burton, Figure 8. Sir Charles Scuddamore. (By courtesy which appears as frontispiece to his 'Treatise on of the Wellcome Trustees) Diagnosis and Treatment of Diseases of the Chest. Part I' (1837)

Sir Charles Scuddamore Another student of Laennec was the English physician, Sir Charles Scuddamore (1779-1849) (Figure 8), who studied medicine at Edinburgh but qualified MD at Glasgow in 1814. He was interested in spa treatment and consumption, and was one of the earliest British visitors to Laennec at La Charit&. In 1826 he published 'Observations on M. Laennec's Method...' and sent Laennec a copy of the book, accompanied by the following letter: 766 Journal of the Royal Society of Medicine Volwne 74 October 1981

London Wimpole Street May 2nd 1826 My dear Sir, I beg leave to take the earliest opportunity of requesting that you do me the honour to accept a copy of my little book on the Stethoscope, and on a few general points in medicine. I am fully aware with how much diffidence I should appear before you in this undertaking, although I do not profess much in my performance, but I know that you are a kind and gentle master. . . The book and the letter may still be seen in the Musee Laennec, Nantes.

Thomas Dodgson Thomas Dodgson (1795-1847) studied medicine at Guy's and St Thomas' Hospital, and qualified MD at Leeds in 1820. As a young doctor he visited L'Hopital Necker and met Laennec. On his return to England he brought with him a stethoscope which he used in country practice in Skipton, Yorkshire. He was intensely interested in the problem of tuberculosis, which he described as 'the giant malady of our land'. In 1827, Dodgson published 'Notes on Consumption', in which he wrote: 'I believe then that the stethoscope is destined to remove that dense veil with which chronic diseases of the thorax have hitherto been obscured, and that in many cases it may be considered as a clew eminently calculated to lead us out of the labyrinth of our doubts and perplexities, respecting the nature and identity of thoracic diseases'. However, he had some reservations: 'Although I consider the Stethoscope as a very valuable instrument I am far from being one of its idolatrous admirers; nor do I consider either Laennec's discovery or his work as without a macule. I believe that it will never be universally or even generally adopted in private practice; but in hospital practice, it must and will be generally used'. The last sentence is of interest, as in Thomas Dodgson's case we see the stethoscope being introduced into country practice away from the large hospitals in the great cities. William Edward Eugene Conwell Yet another student of Laennec was William Edward Eugene Conwell (1785-1836), who spent many years as a surgeon in the Far East, and in 1829 published 'Observations on Pulmonary Disease in India and an Essay on the use of the Stethoscope'. In the introduction, he asserts that, in reporting his work, 'I fulfil my promise to that effect made at the request of my excellent and learned master, the late M. Laennec, of Paris.' Thomas Davies Thomas Davies (1792-1839), a Welshman, began his medical studies at The London Hospital, but developed phthisis and was advised to move to a milder climate. He therefore continued his studies at Montpellier, and later spent two years in Paris as a student of Laennec, and graduated MD in Paris in 1821. On returning to London, he was one of the first physicians to use the stethoscope in that city. From 1825 he was on the staff of the Infirmary for Asthma, Consumption and other Diseases of the Chest. This was the first chest hospital in the world - its name was later changed to the Royal Chest Hospital. Davies' course of lectures was published as 'Lectures on Diseases of the Lungs and Heart' (1835). Francis Hopkins Ramadge The last physician to be considered is Francis Hopkins Ramadge (1793-1867), an Irishman, who studied medicine in Dublin and proceeded to DM at Oxford in 1821. Like Thomas Davies, he was physician at the old Royal Chest Hospital. In addition to his original writings on chest and heart disease, he is remembered for his translation in 1846 of Laennec's fourth French edition (1837), the one that Forbes never translated. It was put through the press by Theophilus Herbert, but there is no doubt that the translation was by Ramadge. Journal of the Royal Society of Medicine Volume 74 October 1981 767 Conclusion Laennec's invention ofthe stethoscope as a clinical tool for mediate auscultation ofthe thorax was undoubtedly one of the major steps forward in the history of medicine. It enabled Laennec to probe beneath the surface of the living patient and to correlate bedside clinical findings with the morbid anatomical condition of the underlying organs. This clinicopathological approach made it possible to refine diagnosis and to begin to understand the natural history of disease. Such an important advance in knowledge and technique was bound to be transmitted rapidly from its birthplace in Paris to the rest of the medical world. Britain and France had been at war but, after 1815, peace allowed physicians of both nations to turn towards more worthwhile pursuits. British physicians were eager to travel to Paris to learn at the feet of the great Laennec, whose teachings soon spread to Great Britain and were quickly absorbed into everyday medical thought and practice. The bicentenary of the birth of Rene Theophile Hyacinthe Laennec (1781-1826), being celebrated this year, provides an opportunity for British physicians to salute the memory of this great French master of medicine.

References

Bishop P J (1972) Catalogue of an exhibition of material relating to R T H Laennec held at the Brompton Hospital, 1972 Bishop P J (1980) Journal of the Royal Society of Medicine 73, 448-456 Clark J (1820) Medical notes on climate, diseases, hospitals and medical schools in France, Italy... .London Conwell W E E (1829) Observations chiefly on Pulmonary Diseases in India and an Essay on the use of the Stethoscope. Mission Press, Malacca Copland J (1822) London Medical Repository 17, 209-218 Corrigan D J (1829) Lancet i, 586-590 Davies T (1835) Lectures on the Diseases of the Lungs and Heart. London Dodgson T (1827) Notes on Consumption, Part I. Leeds Forbes J (1821) A treatise on the diseases of the chest, in which they are described according to their anatomical characters, and their diagnosis established on a new principle by means of accoustick instruments. London (Translation of Laennec's (1819) 1st edn; 2nd edn 1827, 3rd edn 1829, 4th edn 1834) Forbes J (1823) Autograph letter to Laennec, 13 December. Musee Laennec, Nantes Forbes J (1824) Original cases with dissections and observations illustrating the use of the stethoscope and percussion in the diagnosis of diseases of the chest; and also commentaries on the same subjects selected and translated from Auenbrugger, Corvisart, Laennec and others. London Granville A B (1820) The London Medical and Physical Journal 43, 164-170, 241-249, 337-342, 421-428 Granvifle A B (1854) Sudden Death. Churchill, London; p20 Hoard P & Grmek M (1973) Revue D'Histoire des Sciences 26, 316-337 Johnson J (1820) Medico-Chirurgical Review 2, 461-494 Ramadge F H (1846) A treatise on mediate auscultation, and on diseases of the lungs and heart ... translated from the latest edition by a Member of the College of Physicians. Edited by Theophilus Herbert, M.D. With practical notes condensed from the lectures of F. H. Ramadge. London Sakula A (1981a) Thorax 36, 81-90 Sakula A (1981b) Journal of the Royal College of Physicians of London 15, 55-57 Scuddamore C (1826) Observations on M. Laennec's method of forming a diagnosis of diseases of the chest by means of the stethoscope and percussion. London Scuddamore C (1826) Autograph letter to Laennec. Musee Laennec, Nantes Stokes W (1825) An introduction to the use of the stethoscope. Edinburgh Stokes W (1828) Two lectures on the application of the stethoscope to the diagnosis and treatment of thoracic disease. Dublin Stokes W (1837) A Treatise on Diagnosis and Treatment of Diseases of the Chest. Part I: Diseases of the lung and windpipe... Dublin Williams C J B (1828) Rational exposition of the Physical Signs of Diseases of the Chest. London Williams C J B (1871) Pulmonary consumption: Its Natural Varieties, and Treatment, with an Analysis of One Thousand Cases to Exemplify its Duration. London Williams C J B (1884) Memoirs of Life and Work. London