THE BINAURAL STETHOSCOPE

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AUSTIN FLINT: THE "AMERICAN LAENNEC"

Austin Flint, Sr., M.D., who was recognized as an execptional clinician and teacher, prolific writer, visionary thinker and the forerunner of modern cardiology, was regarded as the "American Laennec" (Dr. Samuel Gross).  Austin Flint was a graduate of Havard Medical School where he was a pupil of James Jackson, who was an early advocate of the use of the stethoscope for ausculattion. Dr. Flint was one of the founders of the Buffalo Medical College and Bellevue Hospital Medical College, also taught in Chicago, Louisville and New Orleans before settling in New York in 1861, serving as professor of both the Long Island College Hopsial (now SUNY Downstate Medical College) and and Bellevue Hospital Medical College (now NYU School of Medicine). He was elected president of the New York Academy of Medicine in 1872 and the American Medical Association in 1884. Dr. Flint continued to evolve the art of physical diagnosis and especially percussion and auscultation initiated earlier by Leopold Auenbrugger and Rene Laennec, respectively. His texts on diseases of the heart, respiratory system and manual on percussuoin and auscultation are considered classics. By the time of his death on March 13, 1886, he had a national and internatioal reputation as an esteemed medical professional.

In 1852, George P. Cammann, M.D. desiged a stethoscope that used both ears. This new "binaural" instrument was touted to be the preferred method of auscultation. Also in 1852, Dr. Austin Flint published his prize essay On Variations in Pitch in Percussion and Respiratory Sounds and their Application to Physical Dignosis establishing his expertise in ausculataion of the chest. At first, Dr. Flint was concerned that the transmission of sounds by the binaural stethoscope would be attenuated and that its advantages were not appreciated without considerable practice. In his text on Physical Exploration and Diagnosis of Diseases affecting the Respiratory Organs published in 1856 he stated "In making trial of this instrument, I have found it more difficult to institue comparisons as regards quality and pitch of sound with the ear alone, or the ordinary stethoscope." Ten years later in the second edition of his text publisheed in 1866, 3 years after Dr. Cammann's death, he corrected his opnion stating that "the objection on the score of the alteration of the pitch and quality of sounds I have long since found to be without foundation, and I am sure that this instrument will supplant all wooden stethosopes as soon as it is fully appreciated."

Oil portrait of Austin Flint, Sr., M.D. shown on the left was a family portrait by the New York painter John L. Harding, Sr. and is signed and dated 1865 by the artist. Dr. Flint is wearing a pin of the Freemasons on his vest and Victory of the Cross on his shirt. The Flint family donated the portrait to the New York Academy of Medicine in 1900 and was displayed in their Museum Room. The New York portraitist George R. Boynton was commissioned by the New York Academy of Medicine to paint a posthumous portrait of Dr. Flint shown in the center photo. This very portrait was preseted to the Academy on January 17, 1901 by Dr. J.E. Janeway on behalf of himself and 14 other fellows of the Academy who were the donors for the portrait. This posthumous oil portrait was signed by Boynton and based on the last known photograph of Dr. Flint by the New York portraitist photographer Benjamin J. Falk, as shown in The Medicine of the Future publication of Dr. Flint's intended address to the British Medical Association in 1886, delivered by Dr. Flint's son, Austin Flint, Jr., on April 24, 1886 after his father's death. Note that the paisley patterned ascot and stickpin in the painting are the same as in the photopgraph. The portrait was displayed in the President's Gallery at the New York Academy of Medicine. John Harding, George Boynton and Benjamin Falk were all leading New York artists that were well known for their portraits and especially their use of lighting and positioning of the subject.
           ( Photos courtesy of Alex Peck )    

Actually, the idea for a binaural stethoscope was first introduced in 1829, just ten years after the publication of Laennec's text illustrated his original instrument. The idea belonged to Nicholas Comins, who devised a stethoscope that he described as "a bent tube" that had several hinges, allowing the physician to not have to assume uncomfortable positions during the examination. He offered the suggestion of making his instrument binaural, but there are only sketches of his instrument.

Dr. C.J.B. Willaims is said to have constructed a binaural stethoscope using two bent pipes (since rubber was not yet available) attached to a wood chest piece around 1840. Arthur Leared presented a model of a "double" stethoscope made of gutta-percha at the Great Exhibition in London in 1851. The first commertcially available binaural stethoscope was made by Dr. Nathan B. Marsh of Cincinnati, patented in 1851. His model was made of india rubber with a long stem to which a flaring bell made of wood could be attached. However, it proved cumbersome, very fragile and quickly faded. 



           


The original Marsh binaural stethoscope, circa 1851. On the left the stethoscope is in its original wood box. On the right is the assembled stethoscope.
(photos courtesy of the Marsh family, Smithsonian museum)


GEORGE CAMMANN: THE BINAURAL STETHOSCOPE

In 1852, Dr. George Cammann of New York produced the first recognized usable binaural stethoscope. He was working as a physician at the Northern Dispensary in New York City and had seen Marsh's model. He also had a model of a soft metal, multiple-tubed stethoscope made by H. Landouzy in 1841, which was designed for two people to listen at the same time. And Charles J. B. Williams claims to have made a binaural stethoscope with lead tubes in 1843. Cammann did not claim to have the original idea for a binaural stethoscope, only to have developed a practical instrument that could be used in clinical practice. Interestingly, he never patented the stethoscope believing it should be freely available to physicians. The stethoscope was named Cammann's Stethoscope by the manufacturer of the original instrument, George Tiemann. Cammann's model was made with ivory earpieces connected to metal tubes of German silver that were held together by a simple hinge joint, and tension was applied by way of an elastic band. Attached to these were two tubes covered by wound silk. These converged into a hollow ball designed to amplify the sound, and attached to the ball was a conical shaped, bell chest piece.

                        
The earliest known original model Cammann binaural stethoscope made by George Tiemann, circa 1852. This is an exceptionally rare and important early 1850s initial model Cammann binaural stethoscope with the front of the yoke delicately hand-engraved Dr. Cammann's / Stethoscope. Tiemann / N. YORK is stamped on the reverse side. Note the velvet sleeves covering the very short  tubes. The metal ear tubes are made of German silver, large and flaring chestpiece was turned from ebony wood, and the earpieces are ivory. This stethoscope was obtained from the Intenational Museum of Surgical Science, Chicago, Il, when it reorganized its science collection and is the same instrument pictured in American Surgical Instruments, by James M. Edmonson , p. 106, figs. 138 and 139. It is the stethoscope shown in the above detail of Dr. Cammann's portait.
(Photos courtsey Alex Peck)

Prior to 1855 George Tiemann marked his medical instruments as Tiemann, after 1855 used the mark G. Tiemann & Co. and later used the mark Tiemann & Co. The markings on the models shown below help date these stethoscopes and are consistent with the introduction of the Cammann stethoscope in 1852.


                                         

                                           

To the left is an original Cammann stethoscope, circa 1852. The yoke of the hinge joint is hand engraved Dr. Cammann's Stethoscope and the reverse is stamped Tiemann N[ew]. York. This initial model had a large and flaring ebony chestpiece and ivory earpieces. The flexible woven tubes were covered with velvet and were very short as compared to later models. This stethoscope and the one above are the only two hand engraved Cammann stethoscopes known to exist.

The Cammann stethoscope shown in the middle photo dates to 1855. The left side of the yoke of the hinge joint is stamped Dr. Cammann's Stethoscope, but is not hand engraved. The right side is stamped G. Tiemann & Co. Note that the wood bell does not have as large a flare and the velvet covered tubes are a little longer. This is the only example of this Cammann stethoscope known to exist.

On the right is Cammann stethoscope, circa 1860. The left side of the yoke is marked Dr. Cammann's Stethoscope but is not hand engraved. The right side is marked Tiemann & Co. Note that the flexible tubes are longer, not covered in velvet and are attached by gutta percha connectors to the binaural ear tubes. The two parts of the stethoscope could be detached for carrying and reattached for auscultation.

TIPS ON DATING CAMMANN TYPE INSTRUMENTS

                                  

On the left is the only known carte-de-viste (cdv) albumen print photograph of Dr. Cammann by Matthew B. Brady & Studio in New York City, circa 1860, which appears to have been taken at the same sitting as the salt print photo mentioned above. Note the Brady backmark on the verso as well as the period ink signature of G. P. Cammann, M.D. below the backmark. Dr. Cammann developed the binaural stethoscope in 1852 while working at the Northern Dispensary. The Northern Dispensary was instituted in 1827 and built in 1831 to provide medical care to the "sick and worthy poor" and was open continuously from 1831 until 1989. The Dispensary is the only building in New York City that has two sides on one street (Waverly Place) and one side on two streets (Christopher and Grove Streets). The three sided building occupies the triangle formed by those streets. Shown above are the photos of the Northern Dispensary in 1855 after addition of a third floor to the 1831 building and in 2006 looking the same as it did in 1855, but now closed and empty for 25 years because the original deed requires that the building only be used for aiding the sick and worthy poor. Notice the young boy pausing on his bike, while trying to decide which fork in the Waverly Place road to take, which splits into a left and right street at the tip of the Northern Dispensary triangle. Dr. Cammann was appointed to the Dispensary in 1832 as an Attending Physician and worked there for 28 years until he resigned in 1859 and then contiunued to serve as a Consulting Physician until his death in 1863. Shown above are photos of pages from the June 7, 1832 and October 7, 1859 minutes of the Proceedings of the Trustees of the Northern Dispensary appointing Dr. Cammann to the Dispensary and thanking Dr. Cammann for his faithful service to the Dispensary, respectively. He was also a member of the St. James Episcopal Church, Fordham and one of the church's four Royal Bavarian Stained Glass Windows portraying Saints John and Peter healing of a man by the Jerusalem Temple's Beautiful Gate, installed when the church was built on its present site in 1864-65, was in memory of Dr. Cammann for his humanitarianism. The window dedication reads "In Memory of Geo. P. Camann M.D. dec. Feb. 14. 1863."
(Nothern Dispensary minutes courtesy of the New York University Archives, Northern Dispensary photo by Jefferson Siegel and stained glass window photo courtesy of St. James Episcopal Church, Fordham).

Cammann models were designed with different types of tension mechanisms in order to hold the binaural ear pieces together so they would be firm against the auscultator's ears. The original tension mechanism designed by Dr. Cammann was an elastic band stretched between the two ear pieces. Below are various examples of the tension mechanism.

                

To the far left is Cammann stethoscope with elastic band, which was the original tension mechanism designed by Dr. Cammann, W.F. Ford & Co, circa 1870. Next is Cammann stethoscope with spring tension mechanism, circa 1880 and a Cammann stethoscope with Ford's patented wire spring tension mechanism to hold ear peices together, Hazard, Harzard & Co, circa 1890. On the far right is a Cammann stethoscope with screw tension mechanism, Sharp & Smith, circa 1880.


The Cammann stethoscope usually came in a carrying case, although most of these were lost over time. The cases are more difficult to find than the actual stethoscopes. Two examples of such cases are shown below.


                                     

Cammann stethosope in its original tin case, circa 1870.

                  Cammann stethoscope, circa 1880, marked Dr. Cammann Stethoscope, Tiemann Co. The tooled leather case is marked Dr. John Hatton (1838-1898) who graduated the Iowa University Medical College in 1870 and practiced in Des Moines.

As the Cammann stethoscope evolved, diffirent materials were used for the metal tubes and bell. Originally metal tubes were made of German silver and chest pieces of ebony wood. Later models of the Cammann stethoscope became simplier in the shape of the bell and metal attachment of the flexible tubes to the metal tubes.

 

Cammann Stethoscope with simple bell made of hard rubber in its original cardboard box, circa 1895. The label reads Cammann Stethoscope, with elastic rubber band tension spring, Chas. Traux, Greene & Co., Chicago, Illinois.
 

Turn of the century Cammann stethoscope with small ebony bell marked Weiss, London circa 1901.

As was the case with Laennec's model, Cammann's was not embraced completely for quite some time. It was not until Austin Flint (who had previously spoken against the binaural in 1856) endorsed it in 1866 that it became widely used. During the later half of the 19th century, well educated physicians used advances in medical technology to aid their ability to diagnose diseases in their patients. The stethoscope rapidly became the main symbol of the highly skilled physician.

A photo dated May 1889 of a physician in his office with a medical text on his lap, surrounded by medical equipment including a Bauch & Lomb microscope and Cammann stethoscope on his desk. The use of the microscope and stethoscope by physicians represents the advances in technology applied to the practice of medicine in the nineteenth century.



THE HUSE COLLECTION

The Harvard Medical School (HMS) was founded in 1782 as the Massachusettes Medical College in Cambridge. John Warren, Professor of Anatomy and Surgery, and one of the three original medical college faculty, was instrumetal in moving the school to Boston. As there was no hospital in Boston at that time, teaching medical students was devoid of clinical experience. In 1811, his son, John Collins Warren,  was a leader in establishing the Massachusetts General Hospital (MGH), the third oldest hospital in the United States. Like most hospitals founded in the 19th century, MGH was intended to care for the poor. In 1869, a progressive curriculum was instituted at the school,  new departments of basic and clinical sciences were established, a three-year degree program was introduced, and the apprenticeship system was eliminated. Harvard Medical School became a professional school of Harvard University, setting the United States standard for the organization of medical education within a university.

                          
                                                        
       

Pictured above in the middle is the Bulfinch Buiding of MGH, circa 1880, with its famous ether dome on top of the buiding. Ether was first used for anesthesia during surgery at the MGH in 1846. The dome shaped and glass ceiling of the surgical theater not only enabled surgeons to operate with natural daylight but also to remain awake while performing surgery on their sleeping patients as the fumes from ether rose to the top of the domed amphitheater, as shown in the current photo of the ether dome on the left.  HMS moved off the Cambridge campus to Boston and was located adjacent to MGH from 1846 through 1883. The HMS is pictured in the foreground in the photo on right with the adjacent MGH in the background, circa 1875.  In 1886, Reginald H. Fitz, Visiting Physician at MGH and the Shattuck Professor of Anatomical Pathology at HMS, published his seminal paper on "Perforating Inflammation of the Vermiform Appendix; with special reference to its early diagnosis and treatment". For the first time the term appendicitis was used to describe the most inflammatory disease of the right lower quadrant of the abdomen which was caused by inflammation of the appendix and that treatmant was early surgical removal of the inflammed appendix. 


The unique medical collection displayed below is from Dr. Charles Archelaus Huse's medical office circa 1884 in Worcester, Massachusettes. The collection includes Dr. Huse's Cammann stethoscope, surgical instrument kit, urethral silver catheters, patient records, patient receipts, letter from the Dudley & Sheppard instrument company dated 1877 where Dr. Huse purchased his medical instruments, medical student ticket to Harvard Medical School dated 1879-80, and sign from his office in Worcester. Dr. Huse was born on August 7, 1855 in Worcester, graduated Brown University in 1878 and  Harvard Medical School in 1881. After graduation from Harvard, he served as the Boston Board of Health Assistant Port Physician for 14 months stationed at Deer Island. In the summer of 1882, he moved back to his home town of Worcester and established his practice of medicine and surgery. He was a member of the Massachusetts Medical Society and the Worcester Society for Medical Improvement from 1882-1884. Dr. Huse died prematurely at age 29 from "peritonitis" after a nine day illness on July 3, 1884, just two years prior to the publication of the classic paper by his former Harvard Professor, Dr. Fitz, identifying the cause of most cases of peritionitis as the rupture of an inflammed appendix, which required surgical resection as the definitve treatment. The Huse antique medical collection represents a truly unique look at this promising young physician and the practice of medicine in the late 19th century.   


                                         


The middle photo shows Dr. Huse's outside office sign from 136 Austin Street, Worcester, Massachusettes, circa 1884, along with a ticket for C. A. Huse to attend Harvard Medical School in 1879-80. On the left is a potrait cdv photo of Charles A. Huse as a student at Brown University circa 1878 and on the right is a cabinet photo of him with his clasmates at Harvard Medical School circa 1881. Huse is sitting on the steps of HMS in the center of his class photograph.

  
                    


Displayed are Dr. Huse's Cammann stethoscope marked Shepard & Dudley, N.Y., and surgical instrument kit, obstetrical forcep and urethral dilators all marked Shepard & Dudley, New York. Also shown is a letter from the proprietor of Shepard & Dudley, New York, dated July 14, 1877, to Friend Charles [Huse] asking if he would like to join their family for a summer vacation. The letter implies that Charles knew them because he purchased the medical equipment that he intended to use as a medical student from their store.



                    

                      

Dr. Huse kept meticulous records of each of his patients in his Physician's Day-Book & Journal shown above. Note patient # 7 on page 6 displayed to the left and in a close up of the page on the right, who Dr. Huse diagnosed as having Dyspepsia on May 4, 1883. This patient was Miss Winnie Clark whose carte-de-visite albumin photoghraph, circa 1880, is shown with her wearing a beautiful Victotian mohair wool hat and ornate gold chain. Hand written in old stlye dip pen ink on the back of the cdv is Miss.Winnie.Clark / Worcester Mass, as well as the backmark of the photographer: Fitton, 345 Main St., Worcester, Mass.




Dr. Huse's records included individual bills for each patient, a copy of each bill and a Physician's Hand-Book to keep track of payments. A routine visit to the doctor cost $1.00 !



THE NAMMACK STORY

Bellevue Hospital in New York City is the nation's oldest public hospital. It was founded in 1736 as the Alms House, a six bed infirmary for the poor, and was located at the site of the current City Hall in lower Manhattan. In 1794, the Belle Vue farm on Manhattan's East Side was used to quarantine victims of the yellow fever epidemic in New York City.  In 1811, the Kips Bay farm, just north of Belle Vue, was purchased by the city for a larger almshouse. McKim, Mead & White designed the Bellevue Hospital buildings between 1908 and 1939 that stand today on the land of the Belle Vue and Kips Bay farms on First Avenue and 27th Street. The Bellevue Medical College was established in 1861 and the first School of Nursing in the nation based on Florence Nightingale's philosophy was opened in 1873 at Bellevue. In 1841, the University Medical College was established as the Medical Department of the University of New York on First Avenue and 26th Street. The College changed its name to New York University in 1896.  In 1898, Bellevue Medical College and University Medical College of New York University consolidated as the University and Bellevue Hospital Medical College, ultimately changing its name to New York University School of Medicine in 1960.  Bellevue Hospital remains today the nation's premier public hospital and continues its long tradition of serving as a primary teaching hospital of NYU Medical Center.


                                        

On the left is a photo of the Unversity College of Medicine (NYU), 1886. On the right is a photo of Bellevue Hospital, 1886.
These photos are taken from the "University of the City of New York / Medical Department / Forty-Sixth Annual Announcement of Lectures and Catalogue / Session 1886-87 /New York: 1886." In the middle is a view of Bellevue hospital on its 275 birthday in 2011.


                                    

Photo of Women's Ward 20 at Bellevue Hospital in New York City, circa 1888.
The photo has a legend identifying the hospital, ward, physicians and nurses bearing the mark of the Bellevue Hospital Photography Department, NY City. The enlarged photo on the right shows Dr. Nammack holding a Cammann stethoscope in his left hand, Dr. Tingley taking notes, presumaby of Dr. Nammack's ausculatory findings and nurse Ried with an open chart. Note that Dr. Nammack is also holding his patient's hand, perhaps to reassure her, as he discusses his observations.

                                

Photo of Dr. Wm. H. Nammack, circa 1900, from the book A History of Long Island by William S. Pelletreau.
Dr. William H. Nammack was a 1886 graduate of Bellevue Medical College and was one of  four "successful candidates for appointment in the Bellevue Hospital ". He served as a House Physician on the 3rd Medical Division at Bellevue Hospital in 1886-1887. In September of 1887, Dr. Nammack was appointed the Medical Superintendent of the Insane Pavillion of Bellevue Hopsital. He remained a member of the outside hospital medical staff for another nine years. Dr. Nammack was a physician and surgeon who originally practiced general medicine at 11 Rutgers Street in New York City. In 1892, he established his home and surgical practice in Far Rockaway. Dr. Nammack was visiting physician and pathologist at St. Johns's Hospital in Long Island City,  and  aslo served as the Coroner of Queens for a number of years. He was a memeber of the Bellevue Hospital Alumni Society, New York State and County, Queens County and Nassau County Medical Associations, and Society for the Relief of the Widows and Orphans of Medical Men. His son Griswold D. Nammack, grandson Griswold P.D. Nammack, brother Charles E. Nammack, and nephew Charles H. Nammack were also all physicians affiliated with Bellevue Hospital. Dr. Nammack's great grandson Thomas W. Nammack is the Headmaster of The Montclair Kimberley Academy, Monclair, New Jersey, and provided part of this history of the Nammack family.

Dr. Witter Kinney Tingley was also a graduate of Bellevue in 1886 and another of the four graduates to serve as a  House Physician on the 3d Medical Division in 1887-1888. Dr. Tingley practiced General Medicine in Norwich, Connecticut and served as President of the Norwich Medical Association in 1890. He was one of the incorporaters of and Visiting Physician to Backus Hospital in 1892.

Dr. Robert Alexander Murray was a graduate of University Medical College (NYU) in 1873 and a House Physician on the 2d Medical Division from 1874-1875. Dr. Murray practiced General Medicine and specialized in Disease of Women at 235 West 23d Street , New York City. He served as Attending Physician, Diseases of Women, at the Northwestern Dispensary, New York City, from 1876-1883 and Assistant Professor of Obstetrics at University Medical College (NYU) from 1876-1886. He also served as an Instructor in Obstetrics, New York Polyclinic from 1887-1888. Dr. Murray authored various articles on obsterical subjects in medical journals.

Ms. Ried, Autisdale and Chase were Nurses at Bellevue Hospital.

                                     

Another photo of Rounds at Bellevue Hospital from the Bellevue Hospital Photography Department, circa 1891. Similar to the previous photo, a physician is using a Cammann Stethoscope to auscultate the heart of a young patient, while a medical student takes notes of the physical diagnostic findings and a nurse holds an open chart.
( Photo courtesy of the NYU School of Medicine Archives )


THE WHITE COLLECTION

Eclectic medicine was a branch of American medicine which made use of botanical remedies along with other substances and physical therapy practices, popular in the latter half of the 19th and first half of the 20th centuries. "Eclectics" were doctors who practiced with a philosophy of "alignment with nature," learning from and using concepts from other schools of medical thought. They opposed the techniques of bleeding, chemical purging and the use of mecury compounds common among the "conventional" doctors of that time.

The Eclectic Medical Institute in Worthington, Ohio graduated its first class in 1833. After the notorious Resurrection Riot in 1839, the school was evicted from Worthington and it settled in Cincinnati during the winter of 1842-3. The Cincinnati school, incorporated as the Eclectic Medical Institute (EMI), continued until the last class graduation in 1939 more than a century later. Over the decades, other Ohio medical schools had been merged into that institution. The American School of Medicine (Eclectic) in Cincinnati operated from 1839 to 1857, when it merged with the Eclectic Medical Institute.

Eclectic Medicine expanded during the 1840s as part of an large, populist anti-regular medical movement in North America. It used many principles of herbal medication but chose to train doctors in physiology and more conventional principles, along with botanical medicine. The American School of Medicine (Eclectic) trained physicians in a dozen or so privately funded medical schools, principally located in the midwestern United States. By the 1850s, several "regular" American doctors, especially from the New York Academy of Medicine, had begun using herbal salves and other preparations.

The movement peaked in the 1880s and 1890s. The schools were not approved by the Flexner Report (1910), which was used to decide on accreditation of medical schools. By World War I, states were adopting curriculum requirements that followed those articulated by the AMA. Those schools preferred pharmaceutical medicines to botanical extracts.This effectively forced the Eclectic Medical Schools to either adopt the new model or fold. Although the last Eclectic Medical School closed in Cincinnati in 1939, modern medicine now recognizes "alternative" medicine as a potentially important adjunct to "traditional" medical therapy


               

Dr. Harvey A. White was a 1882 graduate of  Eclectic Medical Institute (College) in Cincinnati.  After graduation, Dr. White practiced  in Missouri in 1882, Illinois in 1883, including in Chicago where this photo was taken in 1904, and White Plains, New York in 1909. He retired to Tampa, Florida where he died in 1917. Dr. White's Cammann binaural stethoscope is shown to the right of his photo.

Prior to becoming a doctor, Harvey A. White was a soldier in the civil war. He enrolled on December 17, 1861 as an artificer in the newly formed Battery E of the First Illinois Regiment of Light Artillery commaned by Captain A.C. Waterhouse in the 5th Division under General William T. Sherman as part of the Army of the Tennessee commaned by General Ulysses S. Grant. Battery E played a key part in one of the boodiest battles of the civil war at Shiloh, Tennessee. In March of 1861, Grant moved his Union Army up the Tennessee river into west Tennessee around Shiloh in preparation to attack and seize the Corinth rail junction that connected the eastern and western Confederate states, hoping to deal a fatal blow to the Confederacy and end the war quickly. General Albert S. Johnston also realized the strategic importance of the Corinth rail junction and poistioned his newly christened Army of the Mississippi to launch a suprise attack on Grant's forces. As an artificer, Harvey White could have been in the forward position with two artillery guns of Battery E confronting the initial suprise attack by Johnston's Confederate Army on April 6, 1862. The Confederate forces overran the Union Army's frontlines and pushed back Grant's forces back to their last line of defense at the sunken road, later described by a Union soldier as a "hornets nest" because of the sound made by the constant rain of bullets fired in that battle. The casualties on the first day of battle were immense, including the dealth of the confederate leader, General Johnston. General Grant was determined to counterattack rather than retreat. On April 7th with the arrival of General D.C. Buell's Army of the Ohio, Grant launched an aggressive counterattack defeating the Confederate forces on the second day of battle. The two day battle was costly. More Americans fell at Shiloh than the total casualties in all of the previous wars fought by the United States. According to the official records 23,746 men were killed, wounded or missing and both sides now realized that this would be a long and bloody war, just as Dr. Robinson had predicted in his letter to his father written the previous year on April 28, 1861 (see Dr. Robinson's story in the previous page).

           

Shown above in the top figure is the 1890 Prang and Thulstrupt print of the Battle of Shiloh of Union forces last line of defense at Hornet's Nest at 9am on April 6, 1862. The photo on the left is the forward position of the two guns of Battery E, First Illinois Light Artillery with a marker of the site of the initial battle of Shiloh at 6am on April 6th. The plaque on the marker reads "Waterhouses's Battery, 'E' commaded by 1. Captain Waterhouse, Wounded. 2. Lieut. A.E. Abbott, Wounded. 3. Lieut. John A. Fitch. Two guns of this battery were advanced about 300 yards but soon fell back to this position where the whole battery went into action. This ground was held from 7:00 A.M. to 9:30 A.M., when the battery lost two guns and moved back about 100 yards. Its loss in the battle was 1 man killed; 3 officers wounded and 14 men wounded; total, 18." Harvey White was given a medical discharge by order of General U.S. Grant at Monterey, Tennessee on June 10, 1862 for a neck injury suffered in the battle of Shiloh. The carnage that Harvey White witnessed at Shiloh may have ultimately lead him to become a doctor.


Several physicians came up with their own ideas for stethoscopes using materials that were commonly found in a physician's office. For example, in 1884, E. T. Aydon Smith described a stethoscope he invented:  "..the chest-piece of which is formed by a pair of ear-specula, the tubes are Jaques' India-rubbercatheters, and the ear-pieces those of an otoscope."He designed his instrument to be used as a simple binaural, a differential stethoscope (by using one of the ear-pieces and chest-pieces for each ear), a tourniquet (by wrapping the rubber around the arm) and, also as a urinary catheter for both males and females. Quite a diverse instrument!

Another modification was Dr. D.M. Cammann's modified instrument (Dr. George Cammann's son), which incorporated a chest piece with a rubber ball, which was used as a suction cup to apply it to the chest. This would leave the hands free to percuss to chest. It was found to be of little value to the untrained ear.

READ DR. CAMMANN'S SON'S ADDRESS REGARDING HIS MODIFICATION OF HIS FATHER'S STETHOSCOPE

 
New improvements to the stethoscope focused on the tension mechanism to hold the ear-pieces to the head of the physician. There was a design of a spring-tension mechanism which had a screw that could be turned to open or close the ear-pieces. The first of these new models was KNIGHT'S model, which had a characteristic design on the poles that attached to the ear-tubes. The Charles Truax catalog of 1890 states that "Knight's stethoscope does not differ materially from the pattern of Cammann. The principal change is in the form of the spring, which in this case is spiral, acting on two levers in the form of a toggle joint."

The screw mechanism became a great success and would be included in the models that followed for many years.


                    

  On the left is a late 1860s Cammann's binaural stethoscope with the additon of an adjustable tension mechanism to the ear tubes that was described Dr. Frederick Irving Knight of Harvard. The instrument is known as Knight's binaural stethoscope.  However, the credit for this design belongs to Moses G. Farmer as Knight referenced in his article in the Boston Medical Surgical Journal in 1869. The metal work is German silver, the flexible tubes covering is woven silk, the bell and junction are ebony, all characteristics of an early Knight's double stethoscope by the original maker Codman & Shurtleff, Boston. To the right is a Knight's Stethoscope with two bells and a Flint Pleximeter and Percussion Hammer that is shown with its original wood carrying box, Codman & Shurtleff, Boston, circa 1880. On the left the instruments are shown out of the box and on the right placed inside the box. The bells were interchangeable in that each could be screwed on and off the body of the stethoscope depending on the choice of the physician. The larger bell was used for auscultation of the lungs and smaller bell used to localize heart sounds. Note the metal work is now plated silver. (Photo on left courtsey of Alex Peck)                                                                                                                                                                                                      

SIR WILLIAM OSLER'S STETHOSCOPE

Sir William Osler (July12, 1849 - December 29, 1919) was educted at McGill School of Medicine and revceived his clinical training at the Montreal General Hospital in Canada. He was one of the founding professors of Johns Hopkins Hospital and founder of the medical service at the hospital, creating the first residency program for training in the specialty of internal medicine. His textbook "The Principles and Practice of Medicine" published in 1892 was considered the prototype for medical eduaction and he is often referred to as the founding father of modern medicine. Dr. Olser wrote that "When I began clinical work in 1870, the Montreal General Hospital was an old coccus and rat-ridden building, but with two valuable assets for the students - much acute disease and a group of keen teachers (The Medical Clinic, British Medical Journal, January 3, 1914 )." Dr. Olser once said he hoped his tombstone would say only,"He brought medical students into the wards for bedside teaching." And his most noteable teaching to his students at the bedside of patients was "Listen to your patient, he is telling you the diagnosis," emphasizing the importance of taking a thorough history as part of the complete examination of a patient.

A unique modification of the Cammann bell was Ware's model. This model was a practical adaption of the bell in which a smaller bell could be screwed into the larger bell such that the larger bell never had to be removed. The smaller bell was utilized for a more precise localization of sound during auscultation, most especially during auscultation of the heart. 


                      

A Knight's Stethoscope with Ware's bell, circa 1870s, that belonged to Sir William Osler while he was a student and later a faculty member at the McGill School of Medicne. Dr. Osler's stethoscope was obtained from his grand niece, Marian Grace Francis, who found it among Dr.Osler's dissecting equipment in the Francis household. Marian Grace was the daughter of William Willoughby Francis, the son of Osler's cousin Marian Osler Francis. The Francis household was a home away from home for Dr. Osler while he was at McGill and he was very close to her children and especially to his godson, William, who was most often referred to as his nephew. William W. Francis was the cataloger of the Osler library and the first librarian of the Osler Library at McGill. This stethoscope is rare in and of itself because of the Ware's bell, not to mention the provevnace through the Francis family to one of medicine's most revered physicians, Sir William Osler. The photo of Dr. Osler was taken in 1902 during his tenure as professor of medicine at Johns Hopkins. It is signed "Sincerely yours, Wm Osler." There are only three other known signed photos of Dr. Osler. Dr. Osler was an ardent "student" of pathology in the great tradition of Laennec and others who applied their post-mortem findings to better understand the pathophysiology of disease. Thus Dr. Osler's grand niece finding his stethoscope among his pathologic dissecting equipment is not suprising.
(photos courtesy of Alex Peck)

There was still a desire to improve the sound conduction through the tubes. Around 1882, Bartlett designed a stethoscope that used metal ear-tubes with silk covered rubber tubes leading to a wooden chest piece. This model was also called "Bartlett's Laennec" stethoscope and was an ingenious design. Truax describes Bartlett's Laennec model as "The Laennec stethoscope, devised by Bartlett, belongs to the heavier class of stethoscopes, the instrument throughout being stronger that those of the ordinary Cammann pattern... a heavy spring, somewhat similar to the pattern of Knight."
 
                     

Bartlett's Stethoscope shown on the left was a heavier version of the Knight model, circa 1880.
Bell's Stethoscope, circa 1875, has an all metal chest piece with rubber rim in this adaptation of the Knight model.
The Cammann stethoscope on the right has an unusual horn bell, brass ear tubes and ivory ear tips and is marked H.G. Kern, Philadelphia, circa 1860.


There were many different modifications to Cammann's original instrument. Scott Alison came up with a 'Differential Stethoscope' that consisted of two independent chest pieces, and was designed to allow the listener to compare the sounds of two areas of the chest. This instrument was also found to be impractical because it muffled certain sounds. Most references list this piece as circa 1885, but it was actually first illustrated in the John Weiss & Son catalog in 1863.


                            

Alison's Differential Stethoscope is displayed on the left, circa 1850. The close up shows the ebony bell chest pieces. It is signed "Ferguson." Mr. David Fergusson of Giltspur Street, London was the well known instrument maker for the Bartholomew's Hospital in London and introduced many of the new instruments that were used in the hospital.
On the far right is an example of a modern differential stethoscope with metal diaphragm chest pieces, circa 2000 and next to it is a differential Stethoscope with plastic bell chest pieces, circa 1930.



In 1885, Charles Denison came out with an entirely new model, based on Bartlett's. His was based on the idea of funneling sound to the ears, much like the monaurals. His earpieces were made of hard rubber which led into woven tubes and a large chest piece. It came with three interchangeable chest pieces for hearing different types of sounds. The tension between the earpieces was accomplished by a clever screw mechanism.Denison's model was widely accepted. So widely, that many makers began marketing inferior pieces of the "Denison Stethoscope." Denison became outraged at the poor quality of stethoscope being manufactured with his name. He delivered a powerful speech in which he stated precisely how his stethoscope was to be made, condemned the makers of poor instruments, and praised one American company for their quality craftsmanship.

Denison's Stethoscope, circa 1885.
Left example with multiple size bells, courtesy of the Mutter Museum. Right examples are in this collection, shown without and with large bell. The stethoscope was used withhout the bell for auscultation of children.

READ DENNISON'S "THE ESSENTIALS OF A GOOD STETHOSCOPE"

As Denison's was becoming popular, more improvements to Cammann's original design began to surface. Most of these did away with the resonating bell in favor of simpler bells. An important development was the Davis modification in which the the ear pieces were held in place by a metal tension band. Although the Cammann was still being produced at the turn of the century, most physicians were using these more convenient models. 

                    

Davis modification of the Cammann Stethoscope which incorporated a wire metal tension spring between the metal ear tubes. In this early model, the wood chest bell was attached to the ear piece by a flexible tube which inserted into the wooden ball connecting the ear piece, circa 1880. On the right is a later model Davis stethoscope with simple bell and metal tension mechanism between ear pieces, circa 1890 .

                

                       

Three examples of binaural stethoscopes with interesting tension mechanisms to hold ear tubes together.
On the left is a Down Brothers stethoscope with finger rest, interesting screw spring tension mechanism, ivory ear tips and Ford bell made of ivory, circa 1900. The ivory bell unscrews to creat a smaller bell for the examination of children. In the middle is a binaural stethoscope marked Gallante, circa 1890. The wood chest piece and ear tips are typical of French binaurals of this period. Note the spring tension mecahnism between the ear pieces. The right photo shows a Holborn stethoscope with a slender, wood bell typically used for children, Herschel's locking mechanism with lever and ivory ear tips, circa 1900.

                                               

Many binaural stethoscopes only had flexible rubber tubes connecting the ear pieces to the chest piece. The ear pieces fit into the ear inorder to hold them in place. Although the stethoscope was convienent to carry in the doctor's pocket, the ear plug method was less than optimum for stable placement of the binaural ear pieces.


                        

Binaural stethoscopes with flexible rubber tubes to connect the ear pieces to the chest piece, circa 1880.
The example on the left is Chinese and has ivory ear pieces and a reversible ivory chest piece. Each end of the reversible chest piece was a different size and shape, presumably to examine different parts of the body. The middle ivory example is Japanese. The one on the right has a gutta percha chest piece.

There were also other types stethoscopes designed to enhance the quality of ausculatory sounds. The most notable and widely copied stethoscope was the Phonendoscope developed by Bazzi and Bianchi in 1894. It was the first stethoscope to incorporate the use of a diaphragm membrane. The phonendoscope was small circular unit with two diaphrgam membranes placed next to each other.  A  small steel solid rod which had a small gutta-percha chest piece was attached to the diaphragm for locaization of chest and especially heart sounds. The unit could be used with or without the localizing rod. There were two long runner earpieces that attached to the top of the unit. It was totally collapsible and measured only three inches in diameter. The idea was that the small chest piece could fit between the ribs and convey better sounds. While the Phonendoscope was marketed in America exclusively by the G. Pilling Company of Philadelphia, it was made and used in many other countries.
                                        
                   

Examples of two American Phonendoscopes made by G.Pilling & Co. On the left the phonendoscope is in its original velvet lined, wood box, circa 1909. The photo in the middle is another phonendoscope in its original metal case with the chest piece in the case and its extension screwed onto the top for carrying. To the right the stethoscope is put together for auscultation with the ear pieces made of gutta-percha attached by flexible tubes with metal ends to the chest piece and the extension tube screwed into the diaphragm of the chest piece.

                         

Three examples of phonendoscopes made in Europe. On the left is a model with an adjustable valve to vary the intensity of sound made by Osker Skaller A.G. of Berlin. In the middle is a German model with gutta percha ear pieces and on the right a similar French model with glass ear pieces, circa 1900. All the phonendoscopes are displayed in their original, velvet lined, leather covered,carrying cases.

An interesting variation of the phonendoscope was designed by Dr. Schreiber, which could be used as either a typical monaural stethoscope or converted into a monaural phonendoscope.


                               

Schreiber's Stetheskop made of metal, circa 1900.
As shown from left to right, it could be set up as a monaural or by sliding the chestpiece down the stem to expose the shaft, a phonendoscope chestpiece could be attached to the stem. A close up of the phonendoscope chestpiece is shown on the far right.

Another intriquing example of this type of stethoscope is the WINCARNIS STETHOSCOPE. The two small discs are interchanged and placed against the small plastic diaphragm, allowing the listener to vary the loudness and quality of the sounds conveyed. The earpieces, made of ivory, are plugged into the top of the piece in the same fashion as the Phonendoscope. There are only two other known examples of this piece, one of which is located in the London Science Museum.


             

Wincarnis stethoscope, circa 1890. On the right the stethoscope chest piece is shown in its original case. On the left the flexible tubes with ivory ear pieces and the chest piece taken apart are displayed. Note the plastic diaphragm against which either of the two wooden disks would rest


Marsh's Stethoscope, or Marsh's Stethophone, is a very interesting invention. It comes with a small dial on the back which has a pointer and the letters 'L,' 'S,' and 'W' engraved on it. These stood for 'Loud,' 'Soft,' and 'Weak,' respectively. The examiner would dial in the type of sound he was listening to in order to be able to hear it better.

                                 

Marsh's Stethophone, circa 1896
This is one of two examples known. The other is in the collection of the Armed Forces Institute of Pathology.

The piece below is very interesting in that it combines the binaural ear piece of a stethoscope with a very long tube and wide bell charcteristic of a hearing aid or conversation tube. In fact, this piece is neither a stethoscope or hearing aid, but rather a "re-educative binaural tube to enable the patient to read or speak to himself and thus stimulate the dormant auditory centre by natural means of the voice" in order to treat middle ear deafness (Mayer&Phelps, circa 1931).

We are always interested in acquiring new items for the collection. If you have any items for sale or question please do not hesitate to contact us.