THE JAMES HOPE
By Eric Rackow and Erik Soiferman
the invention of the stethoscope by R.T.H.Laennec in 1816 in France and
publication of his classic text on mediate auscultation (Laennec 1819)
James Hope was born on
After completion of his studies in
Hope returned to
At this time the prejudice against auscultation was still very strong in England. In her memoir of Dr. Hope, Mrs. Hope writes that "Dr. Hope determined to remove these prejudicies, and he adopted a most judicious course. He never spoke nor argued in favor of auscultation, but allowed facts to speak for themselves. He was always to be seen, stethoscope and journal in hand, at the bedside of every chest case; he took the most minute notes of all, wrote the diagnosis in as great detail as possible, and, before proceeding to a post mortem examination, publicly placed his book on the table in order that it might be read by all; his diagnosis was invariably correct. Attention was soon drawn to him; his diagnosis was generally asked for, and read aloud; its accuracy silenced every objection, and all intelligent and candid men became convinced of the utility of the stethoscope" (Mrs. Hope 1842).
Hope’s major research was devoted to the auscultatory findings of aortic regurgitation. Hope disagreed with Laennec’s ideas that the first heart sound was due to the contraction of the ventricles and the second sound due to that of the atria. Following the lead of his fellow physicians Thomas Hodgkin and Sir Domenic Corrigan, Hope conducted experiments on a donkey and, after stunning it, exposed the heart and was able to correlate the sounds heard through auscultation with the motions of the beating heart. He enlisted the help of another very prominent physician, Charles J. B. Williams. They took a dissecting hook and passed it into the pulmonary artery and then into the aorta, thus blocking the aortic valve from closing. They found by doing this they were able to eradicate the second heart sound, and that the sound returned when the hooks were removed. They thus concluded that the sound made was that of the valve closing.
Hope presented a paper discussing these experiments and
aortic regurgitation, making certain to note that auscultation of an early
diastolic murmur was essential for the diagnosis of the disease
Hope realized that physicians were slow to accept the use of the stethoscope, at least in part because they were afraid to learn a new technique. He thus decided to host a public demonstration of the use of the stethoscope in July 1838. He had one of his students describe the event in a letter to the London Medical Gazette so that those unable to attend would know the results. "The following experiment, made by four students at St. George’s Hospital, affords demonstrative proof that the diagnosis in question, usually supposed to require years of experience, may be efficiently taught in the brief space of ten minutes; and I communicate it to you in the hope that, through the medium of your valuable journal, it may by encouraging the diffident proof subservient to the progress of medical science.Dr. Hope took four students, all novices in auscultation, and as several of them did not know the sound of valvular murmur, he introduced a single patient to afford them the opportunity of hearing it. He then ascertained by examination, that they were acquainted with the anatomy of the heart, and with its situation and relation to the exterior. This being done, he occupied ten minutes in giving and explanation, elucidated by a chalk diagram, of the mode of discriminating between the various valvular diseases and in catechizing to ascertain that it was understood. Six patients presenting five distinct varieties if valvular disease, some complicated and some obscure, were now introduced and each pupil examined as many of them as the leisure of the patients would permit, writing his notes and diagnosis on the slips of paper which I forward to you. Out of sixteen diagnoses which were made, one alone was partially defective" (Pocock 1838).
This experiment, designed to alleviate the stress and fear of learning mediate auscultation was quite a success. However, R.J. Graves and William Stokes, voiced some continuing concerns. "Dr. Hope, of whom we wish to speak with the respect which his labours have earned him, has authorized the publication of a series of diagnoses, made by his pupils after a ten minute lecture on the most difficult part of medicine, namely the valvular diseases of the heart. That the pupils, after having been instructed in Dr. Hope’s views of the causes and situations of valvular murmurs, should have come to the conclusions such as he would have done, is not wonderful; but that these conclusions were correct we have only Dr. Hope’s word. We object to the whole proceeding" (Graves and Stokes 1839). They were in no way opposed to the use of the stethoscope, but only to the idea that it was simple to learn to use.
Hope answered that if others did not agree with his findings that they should come and take the test themselves. One eminent physician, announced that he would come to St. George’s to meet Hope and accept the challenge. "One of the opponents of auscultation offered to come down to St. George’s and choose six cases, write the diagnosis, and defy auscultation to throw more light on the cases than he had done. He came, but got no further than his first case, which he said was hydrothorax, he omitted to write his diagnosis down, but Hope accepted the challenge, examined the case and wrote as follows: 'Hypertrophy and dilation of the heart. Hydropericardium. Lungs enlarged emphysematous, lack of any hydrothorax.' At a subsequent post mortem both were present. Hope read his diagnosis and his opponent stuck to his original opinion. No fluid was found in the pleural cavities, while Hope’s diagnosis was found to be correct in every point" (James 1911).
Hope used other methods to enhance the acceptance of the stethoscope. At the time, it was customary for professors to award prizes to students in their lectures who had exceptional performance. Hope extended this practice to his teaching mediate auscultation. In the biography written by Mrs. Hope, she states "Besides the two prizes which are generally given by every lecturer on the Practice of Physic, Dr. Hope gave a third, for the proficiency in auscultation, which, as coming from him, was peculiarly valued, and was contended for with greater eagerness that any of the others. It was a stethoscope, ornamented with a band of silver, on which was engraved the name of him who gained, and of him who gave it, together with the date and all usual particulars. Three of these were given at
Only three of the four of these prizes are known to have survived. One is in the possession of the British Thoracic Society and was the first of these auscultation prizes awarded in 1836 to Mr. Bampton, the most promising student of the year at Aldersgate. It carries the inscription "Prize for Auscultation awarded by Dr. Hope to G.L.Bampton, 1836-7". In the spring of 1837, Mr. Bampton gave a speech commending Dr. Hope for his first year of teaching at Aldersgate. Mr. Bampton passed his examinations of the Society of Apothecaries in July, 1837 and received his diploma from the College of Surgeons in May, 1838 (Coope 1952). The last was awarded to Mr. T.W. Pocock at St. George's in 1840. Mr Pocock was the student of Dr. Hope who wrote to the London Gazette about Hope's public demonstration of the use of the stethoscope in July 1838.
The third one was awarded at Aldersgate in 1839 to Mr. Freeman, another exceptional student. It is engraved "Prize for auscultation awarded to C.J. Freeman by Dr. Hope, 1839." The stethoscope is part of the collection shown on this web site. This presentation stethoscope was obtained from a physician who was given it as a gesture of gratitude after treating a direct descendant of Freeman.
In his book, Treatise on Diseases of the Heart,
Dr. Hope presents cases that illustrate diseases of the heart and the
importance of mediate auscultation in order to make accurate diagnoses. The last
case presented in the text is from St. Bartholomew's Hospital, dated May 4,1839.
Dr. Hope writes that "the following case is a curiosity, as it presents a
greater number of different murmurs (namely ,six, including that rare one- the
direct mitral) than I have heard in any other instance: yet it will be seen that
they were unraveled with the greatest clearness by a student! This gentleman was
James Freeman, a pupil of my class on the practice of medicine, who brilliantly
won my prize for auscultation for the year. I give this case in his own words,
the accuracy of which I have verified by a personal examination of the patient."
Unfortunately, the patient died on
Charles James Freeman was born on
Dr. Hope's work on auscultation and heart diseases was quite extensive. Although he was not the only one advocating the use of the stethoscope at the time, his devotion to mediate auscultation was instrumental in allowing the practice to become accepted and widely used throughout England. A wonderful piece of medical history, the Dr. Hope Presentation Stethoscope allows us to see how important it was to Hope that this practice be recognized for its value in diagnosing diseases of the chest and most especially of the heart.
A special note of thanks is given to The Worshipful Society of Apothecaries for their help in obtaining information about C. J. Freeman. This information was vital in tracing this wonderful piece of medical history.
Bluth, Edward I., James Hope and the Acceptance of Auscultation. Journal of the History of Medicine, April, 1970, 202-210.
Coope, R. The Tale of an Old Stethoscope. The Lancet, September, 1952, 577-580.
Clutterbuck, H. Lectures on Blood Letting. Philadelphia: Haswell, Barrington and Haswell, 1839, 88.
Elliotson, J. The Various Diseases of the Heart. Lumleyan Lectures, 1829. London: Longman, Rees, Brown and Green, 1830, 7.
Graves , R.J. and Stokes, W. Dr. Hope on Auscultation. Dublin Journal of Medical Science, 1839, 178-180.
Hope, J. Reply to Drs. Graves' and Stokes' Remark on Dr. Hope. London Medical Gazette, 1, 1838, 127.
Hope, J. A Treatise on the Diseases of the Heart. London; John Churchill,
Hope, Mrs. J. Memoir of the Late James Hope.
James, R.R. James Hope, M.D., F.R.S.
Laennec, R.T.H. De L'Auscultation Mediate ou traite du diagnostic des maladies des poumons et du coeur. Paris: J.-A. Brosson et J.-S. Chaude, 1819.
Laennec, R.T.H. A Treatise on Diseases of the Chest, translated by J. Forbes. London: T. and G. Underwood, 1821, 19.
Laennec, R.T.H. A Treatise on Diseases of the Chest and on Mediate Auscultation, translated by J. Forbes. London: T. and G. Underwood, 1827, 11.
Louis, P. Lectures on the auscultation of the chest. London Medical Gazette, 20, 1837, 712.
Pocock, T.W. Letter to the Editor.