THE MONAURAL STETHOSCOPE

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Assessing the sounds of the human body was reported in the ancient medical literature. Amongst the earliest known medical manuscripts are the medical papyruses of ancient Egypt dating to the seventeenth century B.C., which referred to audible signs of disease within the body. Hippocrates, the Father of Medicine, advocated for the search of philosophical and practical instruments to improve medicine in 350 B.C. He discussed a procedure for shaking a patient by the shoulders (succussion) and listening for sounds evoked by the chest. Hippocrates also used the method of applying the ear directly to the chest and found it useful in order to detect the accumulation of fluid within the chest. In the sixteenth century, the renown surgeon Ambroise Pare noted that "if there is matter or other humors in the thorax, one can hear a noise like that of a half filled gurgling bottle." The distinguished scientist William Harvey, in his 1616 lecture on the structure and function of the heart, described the heart's motion as "two clacks of a water-bellows to rayse water" and noted that "with each movement of the heart, when there is delivery of a quantity of blood from the veins or arteries, a pulse takes place and can be heard within the chest." The French physician Jean-Nicolas Corvisart, who is considered the founder of French clinical medicine, was accustomed to placing his ear over the cardiac region of the chest to listen to the heart. Bayle and Double, who like Laennec were students of Corvisart, used the unaided ear to listen to the heart of their patients. Double suggested the regular use of this technique in his treatise on Semiologie.
Nevertheless, the evolution from listening with the unaided ear ( immediate auscultation ) to the aided ear ( mediate auscultation) awaited Laennec's invention of the stethoscope in 1816.



An engraving of a physician examining a patient by "immediate" ausculatation, in which the doctor placed his ear on the chest of the patient to hear the sounds made by the lungs during breathing.The print shows a group of phiscians, medical students and nurses observing the physician performing his exam. This print is entitled "A Visit to the Hospital" by the artist Luis Jimenez Aranda was copyrighted in 1894, and originally displayed at the Chicago World's Fair in 1893.


The stethoscope was invented in 1816 when a young French physician named Rene Theophile Hyacinthe Laennec was examining a young female patient. Laennec was embarrassed to place his ear to her chest ( Immediate Auscultation ), which was the method of auscultation used by physicians at that time. He remembered a trick he learned as a child that sound travels through solids and thus he rolled up 24 sheets of paper, placed one end to his ear and the other end to the woman's chest. He was delighted to discover that the sounds were not only conveyed through the paper cone, but they were also loud and clear. The first recorded manuscript documenting auscultation using the stethoscope ( Mediate Auscultation ) was  in March 8, 1817, when Laennec noted examining a Marie-Melanie Basset, who was 40 years old.


                                            

Four portraits of Rene Theophile Hyacinthe Laennec, circa 1820s.
           (  Photos courtesy of the National Library of Medicine )               

                           
                                                      
Laennec preferred to have his instrument simply called "Le Cylindre," as he thought naming such a fundamental instrument was unnecessary. He became remorse at the names it was being given by his colleagues and decided that if it should be called anything, it should be "Stethoscope," which is derived from the Greek words for 'I see' and 'the chest.' Laennec was a skileed wood turner and set up a small shop in his home with a wood-turning lathe and stocked different types of wood.. He created a stethoscopef rom a turned piece of wood with hollow bore in the center. It was made of two pieces. One end had a hole to place against the ear and the other end was hollowed out into a funnel shapped cone. There was a plug that fit into this cone which had a hollow brass tube placed inside it. This plug was put in the funnel shapped end ot the stethoscope to listen to the heart, and removed to examine the lungs. Laennec published his classic treatise on mediate auscultation in 1819 in which he discussed mediate auscultation and illustrated the design of the stethoscope. A second edition was published in 1826, just after Laennec died from the very diseases he spent long hours studying with the aid of his stethoscope, Tuberculosis. The stethoscope was described as being 12 inches long and 1.5 inches in diameter with a 3/8 inch central bore hole throughout its length. His stethoscope could be bought for 2 francs along with the purchase of the Treatise on Mediate Auscualtation. 


                               

Original version of the Laennec stethoscope made of a turned dense, finely grained, light colored wood, circa 1819. This cylindical stethoscope is made with three parts fitting together by wood screw thread and brass tube fitting with an overall length of 12.6 inches and a diameter of 1.5 inches. Both ends are slightly concave. This first version is illustrated in Laennec's first edition text on auscultation which described the stethoscope as having an overall length of 12 inches and a diameter of 1.5 inches. Laennec turned the first stethoscopes himself and these were somewhat longer than described in his text. The stethoscope shown above has the same features as a surviving stethoscope that is tracable to Laennec himself. On the left the stethoscope is assembled with the chest plug protruding from the funnel shaped chest end of the stethoscope. On the right the stethoscope is taken apart revealing the wood screw thread that attaches the two parts of the body of the stethoscope and the chest plug with brass tube fitting that holds the chest plug in place in the funnel shaped chest end.

Also shown is the title page from Laennec's 1819 text on mediate ausculatation with the plate illustrating his stethoscope.    
                                                            
                                                

                                                               
                         

Laennec examining a tuberculous patient by "immediate" ausculatation with the unaided ear in the Necker Hospital, Paris. In his left hand is the stethoscope that he used for "mediate" auscultation. Picture after the fresco by Theobold Chartan in the Sorbonne commemorating the invention of the stethoscope in 1816. The Necker Hospital was established in 1778 by Madame Necker, wife of Jacques Necker, Minister of Finance in the court of Louis XVI. Madame Necker was appalled at the conditions of Paris hospitals caring for the poor and secured funding from the king to open a 100 bed hospital under her direction as a model of  efficiency and hygiene for hospitals of Paris. Shown on the left is an illustration of the hospital in 1778 from the book "A Popular History of France form the Earliest Times" by F.P.G. Guizot. Also shown on the right is the facade and floor plan of the Necker Hospital in 1809, as line engraving by J.E. Thierry after H. Bessat, which represents the hospital where Laennec studied ausculatation and invented the stethoscope.
 



                

A second version Laennec stethoscope made of a turned finely grained, light wood, circa 1826. The cylindical stethoscpe has three parts fitting together by rounded wood pressure fitting and brass tube fitting and horn rings at the juncture of the three parts. It has an overall length of 12 inches and a diameter of 1.5 inches. This second version is illustrated in Laennec's second edition text on auscultation published in 1826, which described the stethoscope as having an overall length of 12 inches and a diameter of 1.5 inches. On the left the stethoscope is assembled for auscultation. On the right the stethoscope is taken apart showing the rounded wood pressure fitting which holds the two parts of the body together and the brass tube fitting which holds the chest plug in place in the funnel shaped end of the stethoscope.

This stethoscope is the so-called third version of the Laennec stethoscope, most likely developed in England. It is marked Weiss, London, under a Crown and GR, which stands for George Rex (King George IV) who reigned from 1820-1830, thus clearly dating this stethoscope to that period. The only other known example with this mark is in the Wellcome Medical Museum, London. On the left the stethoscope is shown assembled for auscultation and in the middle taken apart. Note that a brass tube is no longer used to hold the chest plug in place and that the parts of the stethoscope are attached by a funnel shaped, wood pressure fitting. A close up of the maker's mark in shown on the right.

                       

Unique second version Laennec stethoscope made of cedar wood with an extension piece made of cedar, ivory and horn, circa 1826.
On the left is the main body of the stethoscope taken apart.
In the middle the extension piece is taken apart. 
 On the right the main body of the stethoscope is assembled and the extension piece screwed into the chest plug. The extension piece was based on the design of Nauche to allow fetal auscultation via the vaginal portion of the uterus.

                

These one piece stethoscopes are probably as far as the Laennec design of the stethoscope was developed, circa 1830.
On the right is the model for adults and on the left is an early obstetrical or pediatric model.

  

                     Stethoscopes were often carried in a medical bag when the doctor was making a house call on a patient. But such medical  bags called attention to the physician and the possibility that he may be carrying drugs, most especially opiates that were commonly used as medication in the 19th century. Medical canes were a method for carrying drugs in a form that would not reveal the identity of the physician. American medical canes are very scarce, and the example shown below is the only known medical cane that incorporates a stethoscope in the body of the cane.


                      

Exceedingly rare and unique medical cane made of hard rubber with removable metal assembly that holds all the original fourteen cork-stopped medicine vials. The vials have their original label and medicine content. By removing the lower tube of the cane and attaching a bell and earpiece from the handle, a seventeen inch stethoscope is assembled. The brass presentation ring just below the handle is inscribed: From Dr. Parsons to Dr. Hallock Aug. 1882. Dr. Robert Parsons is listed in the 1880 census of Salida, Colorado. Dr. Richard Sanford Hallock, also in the 1880 Salida census, was born in Orange County, New York, in 1829 and died in Salida on March 25, 1891. Dr. Hallock moved from Oakfield, Iowa, to Colorado in 1879. He served late in the Civil War as an Assistant Surgeon with the 67th U.S. Infantry of Colored Troops. The cane was clearly used by Dr. Hallock, as the brass tip is worn from walking. In the middle photo the cane is assembled for walking, with the brass tip at the top of the photo and the hard rubber handle with inscribed brass ring at the bottom. In the left photo the cane is taken apart, showing the all original medication vials it still contains. The lower tube with the brass tip is on the bottom and the middle tube and handle taken apart is at the top of the photo.In the right photo the middle tube and the earpiece and bell components of the handle are screwed together to form a monaural stethoscope.  

Laennec was the first to describe the auscultatory signs we still use in medicine today, such as 'bruit,'
'rales,' bronchophony,' and 'egophony.' He was also well known for his work on cirrhosis, which is
still referred to as "Laennec's cirrhosis." The stethoscope allowed him to extensively study chest diseases and especially tuberculosis. He died in 1826 from this disease just following the publication of the second edition of his book.              

In his book, Laennec tells of how he went through several experiments to get from the rolled up
paper to the hollow wooden cylinder. He also gives the reader strict guidelines on how a proper
stethoscope is to be constructed, as well as used.
 
This new instrument was not embraced immediately, but it eventually became recognized by physicains as a valuable instrument for physical diagnosis. There were several improvements to Laennec's stethoscope over the years, the most notable was that of Pierre Adolphe Piorry in 1828. Piorry also incorporated another diagnostic instrument, known as a "pleximeter" into his stethoscope



                     

Three portraits of Pierre Aldophe Piorry, circa 1830s.
( Photos courtesy of the National Library of Medicine)



                   

Original Piorry stethoscope made of wood and ivory, circa 1828. This is the stethoscope illustrated in Piorry's text on percussion published in 1828.
Shown in the middle is the stethoscope assembled with the extension piece. The stethoscope could be used with or without the extension piece attached.
On the left it is shown taken apart to display the main stem, extension piece, chest plug that fits in the chest funnel end, pleximeter that screws on to cover the chest end, ear piece that screws on the the stem end, and finger thimble used as a plexor. On the right the same stethoscope is shown put together for carrying (the extension piece fits inside the main stem for carrying).

The Piorry stehoscope evolved to have a thinner stem without an extension piece and was about half the size of Laennec's. It was trumpet shaped, made of wood, and had a removable wood plug, ivory earpiece and chest piece. The ivory chest piece also served as a pleximeter. Most stethoscopes made after 1830 were modeled after the Piorry design. And the Piorry stethoscope was the inspiration for Sir Oliver Wendell Holmes to write his "STETHOSCOPE SONG." 




          

Typical Piorry Stethoscope made from cedar. On the left the stethoscope is taken apart showing the main stem, plug that inserts into the funnel shaped chest end, ivory chest piece also used as a pleximeter and ivory ear piece that screws onto the stem as the ear plate, circa 1830. On the right it is assembled for auscultation.

            

Cased Piorry Stethoscope made of cedar and ivory with Percussion Hammer, circa 1835.
On the right the assembled stethoscope and hand carved ebony percussion hammer with cork tip are shown taken out of the case.



Later model Piorry stethoscope made from ebony. The stethoscope is taken apart showing the ivory pleximeter with finger grasps and a smaller ivory ear plate, circa 1840.

            

Charles James Blasius Williams developed another approach to the design of the stethoscope. He introduced a two-piece monaural stethoscope in 1843 with a trumpet shaped chest end that fit more comfortably and snuggly against the chest wall. His stethoscope had a removable ear piece.  
            
           
           

On the left is a photograph of Charles James Blasius Williams, circa 1840. On the right is a photograph of him, circa 1880.
( Photo courtesy of  the National Library of Medicine )

                         
             
Williams Stethoscope, circa 1845.
On the right the stethoscope has the ear-piece removed.
In the middle the ear-piece is inserted in the smaller end, leaving a trumpet shaped end for examination of the chest.
On the left the ear-piece inserted in the trumpet shaped end, leaving the smaller end for listening to the heart.



Flexible monaural stethoscopes were introduced around 1832. These were tubes of coiled spring covered with woven silk, usually 14 to 18 inches long, with a chest piece at one end and usually a very short, straight earpiece at the other. Flexible stethoscopes are often confused withconversation tubes, which looked the same, but were much longer than stethoscopes.

                    

Three examples of flexible stethoscopes.
On the left is an early model made with pewter ear piece and chest piece, circa 1832.
Golding Bird's model with wooden ear piece and chest piece is shown in the middle, circa 1875.
Arnold's model also made with a wood ear piece and chest piece is on the right. circa 1885.



                      

A unique Piorry Flexible stethoscope made of wood, ivory and horn, circa 1835. Note that the typical Piorry ear plate and chest piece are attached to the flexible tube shown in the middle photo. On the left the stethoscope is shown assembled for carrying. On the right the pieces are taken apart.

READ AN ARTICLE ON THE DIFFERENCES BETWEEN FLEXIBLE MONAURAL STETHOSCOPES AND CONVERSATION TUBES

               

                                
Sir William Fergusson's model of the monaural stethoscope was designed in England and became the most popular model used in the later half of 19th century medical practice. It was made of straight grained, less dense woods with a small bore central hole such that sounds were readily transmitted. It measured approximately 7 inches in  length with a slender stem that had a rounded chest-end bell about 1 inch in diameter that rested comfortably on the patient. The ear plate was approximately 2.5 inches in diameter and fit snuggly over the ear in order to prevent disperson of the transmitted sounds. The Fergusson stethoscopes often had a maker's mark, physician's name or initials, or other identifying characteristic engraved on the ear plate.



                                       

Portraits of Sir William Fregusson 1847 to 1874.
(Photos courtesy of the National Library of medicine)
                 
                                         

The stethoscope on the left is a typical unmarked, wood Fergusson monaural, circa 1890. 
              In the middle is a Fergusson stethoscope with the name T. M. Pickthall hand engraved on the top of the ear plate, circa 1880 (click on the image to see the engraving).
          The Fergusson shown just to the right is made by Coxeter & Son with a hand engraving of a mascot carrying a flag and the initials F.C.H.S. circa 1870 (click on the image to see the engravings).
The Fergusson stethoscope to the far right is made S. Maw& Son, circa 1870 (click on image to see mark).

    
In 1729, the four bed Edinburgh Infirmary was established with funds from the Royal College of Physicians of Edinburgh at the head of  Robertson's Close in the heart of city. At first, it was also known as the Hospital for the Sick Poor, Physicians' Hospital or Little House. It was the first volunatry hospital in Scotland. Granted a Royal Charter in 1736, the Royal Infrimary of Edinburgh moved to new premises on what is now known as Infirmary Street in a 228 bed facility designed by William Adam in 1741. It was in this Royal Infirmary that Dr. James Hope first used the stethoscope and learned the art of auscultation at the bedside of patients, when he served as a House Physician and Surgeon in 1824-1825. In 1872, David Bryce was commissioned to design a new hospital, and in 1879 the Royal Infirmary moved to a "clean air" site at Lauriston Place. The main building of the Royal Infirmary at Lauriston conformed to the Florence Nightingale's pavilion design of medical and surgical wards. The Infirmary set apart a portion of the beds for clinical instruction by Professors of the University of Edinburgh and its Medical Department gave special instruction in Physical Diagnosis. Postmortem examinations were conducted by the patholgist in the Anatomical Theatre. Separate Wards were devoted to certain types of illness. Wards 32 (men) and 33 (women) were designated for General Medicine and ultimately in the 1963 for Medicine of the Ederly (MOE).  In 2002, the Royal Infirmary of Edinburgh moved to its current home at Little France in the southern suburbs of Edinburgh. The MOE service still exists today in wards 201 and 202 in the new Royal Infirmary. The University of Edinbuirgh School of Medicine required that a medical student attend at least two years of medical and surgical practice at a General Hospital. Continuing the long standing relationship since 1750 of the Royal Infirmary and Medical School, the University of Edinburgh also moved the Medical School to Little France and located its new home, The Chancellor Building,  adjacent to the Infirmary.    


                                        
 
A Fergusson wood stethoscope, circa 1880, with hand engraved initials R.E.I. / W.H. Hill. Wards 32. 33.
(click on image to see the detail of the engraving) 
The stethoscope belonged to William Henry Hill, MB. Mast. Surg. who used it at the Royal Edinburgh Infirmary on General Medicine wards 32 & 33 while he was a medical student at the University of Edinburgh. Dr. Hill graduated from the University of Edinburgh School of Medicine in 1886 with a degree in medicine (Bachelor in Medicine) and surgery (Master in Surgery). He did his medical and surgical clinical clerkships at the Royal Infirmary for at least two years as noted in the Student Register of Tickets. These tickets enabled medical students to participate in the "Medical and Surgical Practice" at the hospital and "visit the Wards and Operating Theatres, and attend  Post-Mortem Examinations". W.H. Hill purchased Royal Infirmary annual ticket No. 46 1st Nov 1880 and perpetual ticket  No. 200 21st Oct 1881. An example of a Royal Infirmary Hospital Ticket is shown above (click on image to see the detail on the inside of the ticket). The Medical Registers of qualified Doctors of the Unied Kingdom record Dr. William Henry Hill at Longtown, Cumberland in 1887 and at Old Basford, Nottingham from 1888-1918. The Nottinghamshire Archives 10 Mar 1908 record articles of partnership for "William Henry Hill of Basford, surgeon and Alfred Lewis Bartram of Bulwell, surgeon, as 'Hill and Bartram' of Basford, surgeons and general medical practitioners."

    Shown to the right is an engraving of the Royal Infirmary of Edinburgh at Lauriston Place and the University of Edinburgh in old Edinburgh from the book "Old and New Edinburgh" published in 1890. The four wings in the front of the Royal Infirmary are part of the surgical hospital and the four wings in the back are part of the medical hospital. The last wing on the right in the medical hospital contained wards 31, 32 and 33 ( first, second and third floors, respectively). Aslo pictured on the left is a postcard of the Queen Mary Ward at the Royal Infirmary in 1911, looking much as it did when Dr. Hill used his stethoscope on wards 32 & 33. King George V and Queen Mary visited the Royal Infirmary on July 19, 1911 following their Coronation in London on June 22, 1911. They visited surgical ward 7 and medical ward 30, which were then named the King George V Ward and Queen Mary Ward, respectively, in commenoration of the Royal Family visit.



In general, the Piorry design was the most commonly employed form. However, there were many variations in the shape and form of different models. Some stethoscopes were designed for special purposes. And some were made from special materials that generally signified a physician with "upper class" patients. 
Monaural stethoscopes from 1850 to 1900 are shown below.    


                               

An exquisite stethoscope carved from one piece of ivory, circa 1850.  It may have been a show stethoscope. A beautiful silver plated stethoscope, circa 1860. The hollow ear piece is constucted much like the base of similar silver items and served as a chamber to enhance the ascultated sounds. An unusual monaural stethoscope made of ebony and marked "BIGG" ( click on image to see the maker's mark ) on the concave underside of the ear piece as shown on the right, circa 1850. This company was only in business until 1859.    



             

This stethoscope belonged to Dr. Gustav Lowenstein from Frankfurt, Germany. Dr. Lowenstein fled Germany to Austria in 1933 and then emigrated with his family to America in 1935. The stethoscope was obtained in 2006 from his 78 year old physician son who said that the stethoscope originally belonged to his grandfather, who was also a physician. This cedar wood stethoscope is a Hosford's type, with a large bell ear piece designed to cover the ear to exclude external sounds, circa 1900.

Burrows stethoscope with original rubber percussion ring around the ear plate, circa 1860. Stokes stethoscope with original rubber percussion ring around the ear plate, circa1880.

Interesting examples of monaural stethoscopes that have a narrow oval chest end which was intended to examine the chest in between the ribs so as to better auscultate the lungs. On the left is a completely solid model, circa 1850. On the right is a similar version, but with the central hole bored throught the stethoscope, circa 1840. Note the middle photo which shows the chest ends of the stethoscopes with and without the hole.



                 

Traube's stethoscope in a case with precussion hammer and pleximeter by H. Hauptner, Berlin, circa 1876. The Traube stethoscope, Metallstiel percussion hammmer, and ivory pleximeter are shoun out of the case on the left.  

                   
           

Very early Stokes stethoscope made of wood, circa 1860. Stokes stethoscope carved from one piece of ivory, circa 1870.      

A Roberts stethoscope made of ivory, circa 1880. On the left the stem is shown inserted thru the earpiece for easy portability and on the right the stem is screwed upright into the ear piece for auscultation.The left wooden model is known as the Dutch Stethoscope, because of the tulip shaped bell, circa 1890. This stethoscope came apart in three pieces for carrying. Brass monaural stethoscope with a swivel joint for portability, circa 1890. On the left the stethoscope is upright and on the right the swivel joint is bent at a right angle for carrying.

                                                 

The gutta-percha model on the right is a simple stethoscope, with an ear plug end, circa 1880.  Unusual wood stethoscope with a large bell ear piece, circa 1850
the typical chest end is at the top of the photo. Cedar stethoscope with curved, protruding ear piece made of gutta percha, which was intended to create a better fit in the ear, circa 1860. An interesting stethoscope with a brass rim at the ear-end and a brass lined funnel shaped chest-end. A hand carved, funnel shaped stethoscope made from a unique vermont wood.

Quain's telescoping stethoscope where the chest-end screwed onto the stem ear-end for ausculatation and could be unscrewed for ease of carrying, circa 1880.
On the left are the two parts screwed together for auscultation, on the right the two parts unscrewed and in the middle the chest-end screwed on top of the stem ear-end for carrying.

Hecker's stethoscope made of wood with a horn chest piece and a horn extension to attach a flexible tube with a horn earpiece for a student teaching.

The early development of the stethoscope took place on the wards of hospitals, where physicians could study the use of the stethoscope for mediate ausculatation. Many patients were in hospitals because they had pulmonary infections, such as pneumonia or tuberculosis. Others were poor with little previous medical attention and, therefore, had far advanced disease often from a variety of infectious diseases. Although Laennec's stethoscope was a foot long, after the introduction of the Piorry stethoscope, most stethoscopes were about 7 inches in length. Yet unusually long stethoscopes could be seen in the hands of physicians examing these hospital ward patients. These stethoscopes became known as "ward" or "pauper's" stethoscopes.

Carte-de-Viste photo of a physician posing with a Hughes monaural and Cammann binaural stethoscope as well as a Dejeurne percussion hammer, circa 1865. As shown on the backmark, the photo was taken by the well known 19th century portrait photographer Abraham Bogardus, whose studio was located at 363 Broadway in New York from 1862 to 1869. Also shown are examples of these instruments from the same period. On the left is a Hughes monaural stethoscope, and on the right a Cammann binaural stethoscope.

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