A Very Trump of Doom
How the Simple Stethoscope Transformed Medical Diagnosis
200 years ago precisely, in 1816, a French physician called René-Théophile-Hyacinthe Laennec was struggling to examine an obese young woman who was presenting with symptoms of heart disease at the Hôpital Necker in central Paris. This scenario posed a number of challenges for the young doctor. At the time, the principal method by which Laennec might examine his patient was simply to press his ear directly against her chest in order to listen to the sounds emanating from her heart and lungs — a practice known as auscultation. Given the age and gender of his patient, however, questions of embarrassment and propriety gave Laennec pause before placing his head on her chest. Furthermore, given that the girl was obese, it was unclear in any case how distinctly the sounds of her body would be heard, especially amidst the interference produced from the friction of her clothing. To overcome these difficulties, Laennec rolled a piece of cardboard into a cylinder, placed one end at his ear and the other at her precordial region, and thus created the first stethoscope.
The stethoscope drew on a basic principle of acoustics: that sounds grow louder when they pass through solid bodies. Laennec’s sheet of cardboard was soon replaced by a hollow wooden tube, as he experimented with a range of different types and shapes of wood in order to determine the best materials for what he at first called a cylinder, but later changed to a stethoscope, from the Latin stethos, meaning ‘chest’, and scopien, meaning ‘to view’.
Relationships between abstract bodily sounds and the various diseases and pathologies of the human body were and are by no means self-evident. Nonetheless, armed with his new ‘chest-viewer’, Laennec sought to illuminate these relationships in a long and painstaking process of carefully describing and matching the sounds he detected during his assessment of patients with the physical changes in diseased organs that could be observed during autopsy. Gradually, he correlated the aural with the visual and in 1819, he published a 900 hundred page treatise on the stethoscopic art, filled with descriptions of the various sounds he had detected through use of the stethoscope and the various diseases they signified.
The stethoscope heralded a new era in clinical diagnosis. Through this simple wooden tube, the body’s inner sounds became scientifically meaningful signs of definite, pathological conditions. In its gradual adoption by medical practitioners across Europe and America, the stethoscope, a powerful symbol of modern medical practice, marked, as Jonathan Sterne has observed, an important shift in the Western history of listening, whereby the voice and the inherently subjective narrative supplied by the patient to the doctor were no longer the basis of diagnosis but now existed in relation to numerous other sounds made by and within the patient’s body. In effect, patients could now let their bodies do the talking. However, the ability to hear and to interpret those internal sounds remained exclusive to the highly trained ears of medical professionals. What then, of the stethoscope’s effects upon the increasingly objectified patient, unable to hear the sounds of his or her own body?
Although the stethoscope provided a new clarity of medical insight, it was nonetheless a source of deep confusion and anxiety to many of its earliest patients. Stanley Joel Reiser has attributed much of this anxiety to the fact that at the time, medical instruments were almost exclusively associated with surgery and the possibility of being cut open. Some physicians were themselves hesitant to use the stethoscope for fear that using such an instrument might class them with surgeons, lesser medical types who worked with their hands as mere craftsmen. More than this however, there are numerous accounts, both historical and fictional, of patients being left utterly exhausted and unable to speak after their physician has conducted what was often seen as a thoroughly draining and intrusive examination. Doctors’ debates about the best type of material to use for the stethoscope give us insight into patient complaints about the coldness of certain metals, the weight and pain of them pressed against their ribs and chests, and the various awkward positions they were requested to assume during the period when the stethoscope was not at all flexible and yet required the end to be placed flat against the body.
Not entirely trusted or fully accepted as the best method of diagnosis within the medical profession, the stethoscope was also frequently used in conjunction with other, equally tiring and painful diagnostic techniques such as percussion, which often involved using a percussor, or percussion hammer, to tap on various parts of the body and take soundings.
It was another French doctor called Pierre Piorry who invented a small ivory plate known as a pleximeter (pictured above), which was designed to be pressed against the patient’s body in order to improve the sound and also to render the process of percussion slightly less painful. He also devised a combined stethoscope and pleximeter made of ivory and cedar wood, that allowed the doctor to tap and listen more attentively.
Piorry was known in the medical profession as the “medical paganini” — Paganini of course being a famous Italian violinist of the same time period — because of his attitude to pleximetry. He tried to convince his observers that every organ of the human body had a special percussion sound, and he played on his pleximeter like a virtuoso on a musical instrument. There were many anecdotes told about Piorry in his hospital wards, perched on a high stool, bent over his patients, knocking the ivory plate with his hammer, and mapping out the patient’s organs on the skin with coloured crayons, so that the patient’s torso ended up looking like some kind of geographical map of human innards. He included illustrations of these outlines in the book he published on percussion in 1856.
Thus, being drawn on, tapped, poked, prodded, re-arranged, and also asked to say certain words and breathe in certain ways was, perhaps understandably, seen as newly invasive and often quite aggressive on the part of nineteenth-century physicians. This was so much the case that the English doctor John Forbes, an ardent supporter of the stethoscope and the first person to translate Laennec’s work from French to English, complained that the practices of mesmerism and hypnotism were becoming increasingly popular in British society because the general public preferred this much calmer method to the more intrusive nature of new diagnostic instruments. In his study of the Illustrations of Modern Mesmerism, he wrote very resentfully of clairvoyants’ alleged ability to diagnose and cure internal pathologies from a physical distance:
[In mesmerism], no doctor intrudes with his troublesome and disagreeable questions; no pulse need be felt, no tongue need be shown; no horrid percussor or more horrid stethoscope need frighten the gentle breast from its propriety. (108)
This illustration (figure 6) from The Illustrated Practical Mesmerist, a work on mesmerism published in 1854, is quite telling here in supporting Forbes’s claims. Mesmeric practice is being employed in this instance to treat consumption and tuberculosis, the two principle diseases which were frequently diagnosed in earlier stages thanks to the advent of the stethoscope. It seems that the physician’s new level of intrusion and his physical re-arrangement and handling of the body in the aftermath of the stethoscope represented a kind of culture shock — a shock to the patient so great that it may in part account for the rise in the nineteenth century of the mesmeric practice in medicine. Mesmerism itself is, in this sense, symptomatic of the patient’s determination to avoid giving a doctor what was still quite experimental access to the invisible parts of the body that were inaudible to the general public and made sounds for the ears of qualified physicians only.
And it is this concept of sounds that are only accessible to and able to be interpreted by highly trained physicians that gave rise to what was the primary cause of fear and distress relating to the new stethoscopic practice: fear of the unknown becoming real. As patients became more and more aware that their bodies had a rich soundscape that they could neither hear nor understand, and that a more accurate diagnosis was achievable by using the stethoscope to interpret those sounds, the stethoscope itself became a focal point of patients’ hopes, anxieties, dread, and horror. It augured life or death. It foretold future health, death, or suffering, and such seemingly hyperbolic language was frequently used in discussions and literary representations of the stethoscope in the mid to late nineteenth century. The stethoscope, Blackwood’s Edinburgh Magazine wrote in 1847,
Has long ceased to excite merely professional interest. There are few families to whom it has not proved an object of horror and the saddest remembrance, as connected with the loss of dear relatives […] As an instrument on which the hopes and fears, and one may also say the destinies of mankind, so largely hang, it appears to present a fit subject for poetic treatment.
And it was indeed the subject of poetic treatment. Blackwood’s followed this reflection with a poem by an anonymous poet called ‘To the Stethoscope’. It is several pages long and written in extremely extravagant, expansive verse, referring to the stethoscope throughout by a range of metaphors including a musician’s trumpet (which of course has heraldic overtones to it), a king’s sceptre, a prophet’s source of vision, and a priest’s sacrificial altar. Here is the first stanza:
Stethoscope! Thou simple tube,
Clarion of the yawning tomb,
Unto me thou seem’st to be
A very trump of doom.
Wielding thee, the grave physician,
By the trembling patient stands,
Like some deftly skilled musician;
Strange! The trumpet in his hands,
Whilst the sufferer’s eyeball glistens
Full of hope and full of fear,
Quietly he bends and listens
With his quick, accustomed ear –
Waiteth until thou shalt tell
Tidings of the war within:
In the battle and the strife,
Is it death, or is if life,
That the fought-for prize shall win?
There is, the poem makes clear, an ongoing battle being fought inside the human body that the individual sufferer is not and cannot be privy to, and the stethoscope therefore comes to operate as a kind of interface between life and death, providing significant scope for individual fears and fantasies of the occult and even the quasi-magical.
It is far from unusual for new technologies to be described as magical, wonderful, and frightful by their first users, and the association of the stethoscope with magic and with strange, supernatural happenings is found again and again in appearances of the stethoscope throughout the pages of Punch and in works such as Sheridan Le Fanu’s Uncle Silas (1864) and Willing to Die (1897), and Bram Stoker’s Dracula (1897). Not only does it mark a new way of listening in medical diagnoses, but it gave the doctors access to potentially devastating, intimate knowledge that lay beyond the limits of normal sensory perception. For the patient, it presented a delicate balance between silence and mystery in its ability to foretell the future and the hitherto unknown. A medical object of fear and of hope, the stethoscope became a broader cultural and material testimony to human frailty and the limits of human sensory perception, situated in the popular consciousness at the threshold between the physical and metaphysical, and offering simultaneously exhilarating and devastating possibilities of movement between the two.
Written by Melissa Dickson (@melissaldickson), Postdoctoral Researcher on Diseases of Modern Life: Nineteenth-Century Perspectives, an interdisciplinary project funded by the European Research Council under the European Union’s Seventh Framework Programme ERC Grant Agreement Number 340121.
This article is adapted from a talk given at the Oxfordshire Science Festival. Please follow our Medium channel for similar pieces and hit recommend if you’ve discovered something new and unusual about the stethoscope!