Stop Listening Immediately! by asafwewe


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									                   Stop Listening Immediately!
                                   Dr Rod. Taylor
           Consultant Respiratory Physician, Calderdale Royal Hospital

1. This lecture tells the story of Rene Laennec, his invention of the stethoscope, and
how it came to be developed and used in clinical practice.

2. We can't be exactly sure what Rene looked like. This slide shows three
impressions: the first is an idealised version, the second possibly a self-portrait, and
the third is thought to be a fairly accurate portrait.

3. Rene was born at Quimper in Brittany, on 17th February 1781.

4. The house where he was born, shown in the middle of the picture, was demolished
in the 20th century.

5. Rene must have had a difficult time as a youngster. He was only 5'3" tall, he had
asthma, and his name was Hyacinth – I just hope the poor lad didn't have ginger hair
as well….

6. Rene's father, Theophile, was a complete washout, both as a parent and in his
chosen occupations of both lawyer and poet.

7. To make things even worse, Rene's mother died when he was only five years old.
Rene was then sent to live with an uncle at Nantes, and this move turned out to have
a huge effect on his career.

8. The reason for this is that Uncle Guillaume was Professor of Medicine at the
University of Nantes.

9. These events all occurred as the French Revolution was having its effects. Several
people were executed by guillotine in the square right outside where Rene lived.

10. In 1795, Rene went to the Hotel-Dieu de Nantes, which, despite its name, was a

11. There, at the age of 14, he became a Surgeon Third Class in the Revolutionary
Army – a bit like an orthopaedic SHO. Uncle Guillaume was on the staff. In 1801,
Rene moved on, to the Charity Hospital in Paris.

12. There, he came under the influence of Corvisart, who was Physician to Napoleon,
and a keen advocate of percussion of the chest as a means of examination.

13. In 1804, Rene produced a thesis, 'Propositions on the doctrine of Hippocrates,
relative to medical practice'. Interestingly, this bore the date from the Revolutionary
calendar: the 22nd Prairial, Year 12, which was actually the 11th of June 1804.

14. The only way of listening to a patient's lungs in those days was for the physician to
place his ear directly on the chest. This was known as 'immediate' auscultation,
because nothing mediated between the listener and the listened to. Rene thought
this was inconvenient for both parties, and, in the sort of people he came across in
hospital, also pretty disgusting!

15. This slide shows a physician performing immediate auscultation. You can imagine
the thoughts going through the minds of the two parties.

16. In 1816, Rene found himself in a quandary. He needed to examine a young
woman, because of concerns about her heart. Percussion would be unhelpful,
because she was a big girl, and immediate auscultation would be indelicate and

17. In a moment of inspiration, Rene remembered how distinctly sound could be
transmitted by scratching a piece of wood. Some versions of this have it that, on the
very day he set off to examine his young female patient, he saw children sending
messages to each other by tapping a long piece of wood.

18. He rolled up a notebook, placed one end on the girl's chest, and the other to his
ear. To his amazement, he could hear the heart better than he'd ever heard it before.

19. This exquisitely artistic interpretation captures the very essence of this magical

20. In February 1818, Rene presented his experiences with the stethoscope to the
Academy of Sciences: 'Memoire on auscultation, with the aid of diverse acoustic
instruments employed as a means of examination in diseases of the thoracic viscera,
and particularly in pulmonary phthisis'.

21. The following year, Rene published his now famous treatise 'On mediate
auscultation, or treatise on the diagnosis of diseases of the lungs and heart, founded
principally on the new means of examination'.

22. Rene decided to call his new listening instrument 'The Cylinder'. He was a skilled
woodworker, and made it himself. It was about a foot long, and an inch and a half
wide, with a small central channel, and a shaped end, into which a shaped wooden
funnel could be inserted.

23. The word 'stethoscope' comes from two Greek words, 'stethos' meaning 'chest',
and 'skopein' meaning 'to examine'.

24. The original Laennec stethoscope allowed the listener to put the funnel in to listen
for heart sounds, and take it out to listen to lung sounds.

25. This scene shows our hero, Rene, holding a stethoscope in his hand, but
performing immediate auscultation at the Necker Hospital in Paris. It also shows the
ward sister (who's used to his little ways), the SHO, earnestly recording every detail,
the SpR (who's seen it all before), not forgetting the 'disgusting person'.

26. Here is Rene performing mediate auscultation on a patient who doesn't appear to
be quite so disgusting.

27. Rene quoted his colleague, Buisson, who felt there was a difference between
simply hearing sounds, and actively listening to them, or auscultation.

28. Rene was convinced that his new instrument could detect new signs of respiratory
disease, which revealed as much information as a surgeon could find by direct
examination with a finger.

29. He described and named several new auscultatory signs, many of which we still
use today: vesicular and bronchial, both normal sounds; added sounds or rales, but
these came to be associated with the death rattle, so Rene used the Latin word
'rhonchus' instead; and pectoriloquy, in which the voice seemed to come from the
chest (rather in the way we use 'ventriloquy now).

30. He also described a sound which he called 'aegophony', because it sounded like
the bleating of a goat…

31. …and another which sounded like the creaking of new leather, which he
associated with pleurisy.

32. Rene may have been highly enthusiastic about his stethoscope, but his passion
was not shared by others. Distinguished physician Sir John Forbes was confident that
it would never catch on – but he did later come round, and translate Rene's work.

33. Rene's own countryman, Pierre Louis, felt that the unaided ear was just as good.

34. Henry Clutterbuck acknowledged that the stethoscope might reveal new findings,
but felt there would be no advantage in this, as the disease would already be too far

35. However, support was forthcoming from the Times, of December 1824. There
was a wonderful, new instrument, it gushed, which was all the rage in Paris.

36. Furthermore, Rene was not alone in his estimation of how useful the stethoscope
could be. Pierre Piorry felt that physicians couldn't manage without it.

37. In the late 1820s, Piorry produced his own, more elaborate versions of the basic
stethoscope. The Piorry scope came in several parts, which could be fitted together
as the circumstances required.

38. Piorry also invented the plexor and pleximeter, for percussing the chest. The
pleximeter was usually made of ivory, and was calibrated for accurate measurement.

39. Dr James Hope, who did postgraduate training in Paris, was a keen user of the
stethoscope, and awarded one as a prize to his best student.

40. The best known of these prizes is the British Thoracic Society's stethoscope,
which was presented by Dr Hope in 1837, and features on the BTS's symbol.

41. Mrs Hope was herself a convert to the stethoscope cause. She said her husband
regularly used his on the ward, and like all good respiratory physicians, he always got
the diagnosis right. She felt that any sensible man couldn't fail to see what a terrific
thing the stethoscope was.

42. Stethoscopes were made of different materials, and many could be taken apart,
so they were easier to carry round. Here are some examples, mostly from my own
collection. This scope is made of wood, and the shaft unscrews from the earpiece.

43. This shaft of this wooden scope plugs into the base. I have come across some
people who think the scope could actually be used in this manner, to get access to
difficult areas!

44. Some stethoscopes were made so that the end swivelled to lie flat.

45. This scope comes completely to pieces, and fits into a small bag.

46. This stethoscope is made from Bakelite, which was invented by Dr Baekeland in
the early 20th century.

47. Brass or ceramic scopes were cold on the ears. The ceramic one shown here
was made in Germany, and bears the name of an anti-TB drug.

48. If you wanted to impress your colleagues and your patients, you could have a
luxury stethoscope, made of ivory or silver-plated.

49. The Fergusson model was designed by distinguished surgeon Sir William, and
was used well into the 20th century. This one is stamped 'Allen and Hanburys".

50. This stethoscope has a cupped earpiece, to help exclude extraneous sounds. It
proves that there are still bargains to be had; I bought it on ebay for only 99p!

51. Dr Charles Williams modified the stethoscope by adding a removable piece,
which could be fitted into either end, to alter the size.

52. This slide shows the various ways the parts could be fitted together.

53. In those days, the chest was often percussed with an instrument, rather than the
bare fingers. This stethoscope had a rubber ring round the earpiece, so it doubled up
as a percussor.

54. The flexible stethoscope is often mistaken for a Victorian speaking tube, but the
latter is much longer, and generally has an end shaped to fit snugly into the ear.

55. Shorter stethoscopes, used for assessing pregnancy, came into use quite early

56. This stethoscope is designed for teaching: the student applied his ear to the side-
branch. It must have been a pretty cosy threesome!

57. Dr William Leonard introduced a long instrument, known as a pauper stethoscope.
This was because the extra length meant that the physician could keep further away
from the disgusting person whose chest he was listening to.

58. Many of the developments in the design of stethoscopes depended on advances
in the technology of the materials from which they were made. Rubberised fabric was
introduced by Mackintosh in 1820.

59. I used to think that vulcanisation was an out-of this-world experience, but this isn't
the case; it is instead a special way of treating rubber, which was later used for tyres.

60. Some physicians used different types of stethoscopes for different purposes; here,
a flexible one for the lungs, and a rigid one for the heart.

61. This photograph shows a physician with stethoscope at hand. Some physicians
have a clip inside their top hats, to hold a stethoscope.

62. When Dr George Camman was not doing orang-outan impressions, he was busy
inventing the first practical binaural stethoscope.

63. A binaural scope, made of lead, had been made as early as 1829, but it was not
of any practical use, because of its weight.

64. The Camman scope had flexible woven tubes and an ebony chestpiece.

65. The tension was supplied by what looks like knicker elastic, and the instrument
came apart and fitted into a small case.

66. One of the developments that promoted the switch to the binaural stethoscope
was the introduction of blood pressure measurement, which was more or less
impossible to do with a monaural scope. This chart shows the fraction of patients in
Massachusetts General Hospital who had their BP measured. In the first few years of
the 20th century, only about 1 in 20 did, but soon after Korotkoff described his method
for measuring BP, 9 out of 10 patients had it done.

67. The Alison differential stethoscope was an attempt to improve diagnostic
accuracy, by using two chest pieces to help identify and locate sounds. We should
seriously reconsider introducing this model, as junior doctors could then examine two
patients at once, and so help to meet the European working time directive as well as
the 4-hour wait target.

68. The Knight and Boston scope came with a range of features, but still closely
resembled the Camman instrument.

69. The first diaphragm chestpiece was introduced by Bowles in 1894. The
diaphragm was on a short extension tube, which plugged into the aperture of the bell.

70. The combined chestpiece was introduced by Sprague in 1926, and is still used

71. Dr David Littmann introduced the stainless steel and tygon model in 1961. This
portrait shows him with one on his desk.

72. But now back to our hero, Rene. In 1824, he received the French equivalent of a

73. Later that year, he married Jacquemine Argou, a distant relative who kept house
for him.

74. Not long after this, Rene began to develop worsening chest symptoms. His
cousin, Ambroise, listened to his chest, and heard the very sounds of cavitating
tuberculosis that Rene had himself described. Bravely, Rene withdrew from company,
as he didn't want to be a burden on anyone.

75. This sketch, thought to be a self-portrait, shows the hermit of Kerlouarnec, as
Rene was then known.

76. This is the house in which Rene died at Kerlouarnec, in August 1826.

77. Rene was buried in Ploare cemetery.

78. It wasn't until 42 years after Rene died that his home town erected this statute in
his memory.

79. Rene made his stamp on the French people, and they made a stamp out of him.

80. There is a plaque in Rene's memory outside the Necker Hospital in Paris.

81. It simply says "In this hospital, Laennec discovered auscultation"

82. Thank you for listening!

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