THE JAMES HOPE PRESENTATION STETHOSCOPE
By Eric Rackow and Erik Soiferman 

After 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), stethoscopy and mediate auscultation were mistrusted in England for quite some time. John Forbes, who translated Laennec's text into English, stated "that it will ever come into general use, notwithstanding its value, I am extremely doubtful" (Forbes 1821). The noted physician and teacher John Elliotson, in his Lumleyan Lectures to the Royal College of Physicians of London in 1829, said that the stethoscope and mediate auscultation "open a new set of symptoms to our notice" and asked physicians to "examine carefully and patiently, not anxious to find auscultation a deception, but hoping to find the promise of new information fulfilled; not unwilling to learn because we are no longer in statu pupillari" (Elliotson 1830). Henry Clutterbuck, who was a vigorous proponent of the usefulness of blood letting, discounted the value of the information acquired by use of the stethoscope because "supposing it to be correct, comes too late, in general, to be of any practical use" (Clutterbuck 1839). And even the distinguished physician Pierre Louis minimized the importance of the stethoscope in his lectures where he stated "in opposition to Laennec, it is now allowed that the naked ear perceives sounds as well as when aided by the stethoscope; and, indeed, it often happens that it distinguishes shades of sound which had escaped it when assisted by this instrument. The cases in which we ought to prefer mediate auscultation are very rare, and it is often necessary to have recourse to immediate auscultation to determine with clearness what would otherwise be obscure" (Louis 1837).   Several physicians in England were responsible for changing the attitude about this new diagnostic technique. James Hope was especially important advocate for the use of the stethoscope in medical practice. He showed that doctors could make accurate diagnoses with the use of the stethoscope for auscultation.

James Hope was born on February 23, 1801.  He began the study of medicine in October, 1820 at the University of Edinburgh. In his second year of medical school he joined the Royal Medical Society and presented his first paper on heart disease. At the end of his third year, he was elected one of the four annual presidents of the Society, an honor obtained by only the best of students. Stethoscopes had begun to be introduced in England in 1817. Hope’s first introduction to auscultation mediated by the stethoscope came in 1824 when he served as the house physician to the Royal Edinburgh Infirmary. He was made aware of the stethoscope by fellow house physician Alexander Hannay who had studied mediate auscultation with Laennec in Paris (Hope 1839). By this time the stethoscope was somewhat commonplace at Edinburgh. Indeed, William Stokes, while still a student at Edinburgh, wrote a concise treatise on the use of the stethoscope (Stokes 1825). Hope’s candidate thesis was on the diagnosis of aneurysm of the aorta by auscultation even though Laennec was pessimistic about making such an auscultatory diagnosis (Coope 1952). Hope took his final exams in August, 1825 and passed as one of the two best students of the year. Interestingly, Sir James McGrigor, who received an honorary degree that year at Edinburgh, was the guest at a public dinner that Hope also attended as one of the best graduating students. McGrigor was the father of the Royal Army Medical Corps and introduced the stethoscope to military practice in 1821 (Forbes 1821). In 1825, Hope left Edinburgh to study surgery at St. Bartholomew’s Hospital and in the spring of 1826 passed his examination at the College of Surgeons.

After completion of his studies in England, Hope traveled to Paris to further his medical education. In France, medical "revolutionaries" held the radical view that medical studies should be completely transferred from the academic lecture theatres of the Faculty to the bedside of the hospitals and that anatomy was relevant to clinical diagnosis. Indeed, the French medical faculties were abolished in 1789 and the Paris school did not reopen until 1794. By this time, the revolutionaries were able to implement their ideas, and in 1799 clinical teaching was officially recognized with the creation of a Chair at the Hopital de La Charite and Jean Nicholas Corvisart was appointed the first Professor of Clinical Medicine. The most famous of Corvsart’s student was Laennec. In Paris, Hope became a clinical clerk to Auguste Francois Chomel, a professor of clinical medicine at La Charite who was the successor to Laennec. It was during this experience that Hope learned the technique and value of the stethoscope and mediate auscultation (Bluth 1970). Hope also did many colored drawings of post-mortem specimens as part of his duties. Although very time consuming, it was valuable training in comparing pathological anatomy to the signs and symptoms of the patient.

Hope returned to London in 1828 after studying abroad for two years. He planned to write two books in his first seven years in London, one on heart diseases and the other on morbid anatomy. He became a medical clerk to Dr. Chambers at St. George’s Hospital and in 1834 was elected first physician assistant to St. George’s. In 1836, he was appointed to the lectureship on practice of physic at the School of Medicine on Aldersgate Street, one of several private school’s of medicine that were popular at that time. It was a rival to neighboring Bartholomew Hospital’s school. As the hospital schools became more important to the clinical teaching and practice of medicine, the private school’s declined.  After three years, he left that school in 1839 when he was elected physician to St. George’s Hospital. There he was renowned as a great professor of medicine. He made constant use of the stethoscope in clinical diagnosis.

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 (Irvine 1957). This paper was so well received that it was suggested he write a book on the subject. In 1831, he published his Treatise on Diseases of the Heart. In 1834, he published his book on Morbid Anatomy with abundant illustrated plates. Hope taught that "a physician in looking at his patient ought, in imagination, to turn him inside out" (Coope 1952). Hope’s name became well known in the medical profession and he began to be recognized as a physician, as well as an expert on diseases of the chest and especially those of the heart. He was very proud of his work on auscultation and afew years later announced that he was one of the first physicians to introduce ausculatation into England (Hope 1838).

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 Aldersgate Street during the years that Dr. Hope belonged to that school, and one at St. George’s.  The total number being so small, owing to the premature fate of him who awarded them (Hope died of tuberculosis at the age of 40 on May 31, 1841), their value is now very much increased" (Mrs. Hope 1842). These stethoscopes were made of cherry wood, with ivory banding and earpiece with a silver band for engraving the name of the recipient and were designed by Hope and made by James Gumbridge, a wood and stethoscope turner in London.

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 May 27, 1839 and this case had already been printed as part of Dr. Hope's text which was scheduled to be published in June of 1839. Thus, Dr. Hope inserted an appendix containing the autopsy findings of this patient and stated "the diagnosis of Mr. Freeman, and the remarks on it by the writer, were verified in every particular......I cannot but call attention to the circimstance that this singularly complex case was completely unraveled by a young student, who, three months previously had no knowledge of valvular diagnosis" (Hope 1839).

Charles James Freeman was born on February 4, 1818. His studies were not in order to become a physician, but rather an apothecary. He apprenticed to his father, Robert Freeman from 1832 to 1835 and with the death of his father completed his apprenticeship with Mr. A.M. Randall. His medical curriculum began in October 1837 and included courses in Anatomy and Physiology, taught by the surgeon and anatomist Mr.Skey (who was the proprietor and principal teacher at Aldersgate), Chemistry, Materia Medica, Botany, Midwifery, Forensic Medicine, and a course entitled Principles and Practice of Medicine, taught by James Hope. This course consisted of one course and one session. After his lectures, Freeman undertook 12 months of clinical experience at St. Bartholomew’s Hospital from 1838 to 1839. He qualified as a Licentiate of the Society of Apothecaries on October 24, 1839. His license allowed him to practice anywhere in England or Wales as an apothecary, but not in London or within 10 miles of the city. After qualifying for his license, however, Freeman's name disappears from the records, and is not contained in the Provincial or London Medical Directories of 1847 or 1853, nor in the medical register of 1859.

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.    

References

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, 1839, 610 and 626.

Hope, Mrs. J. Memoir of the Late James Hope.London: J. Hatchard & Son, 1842, 74 and 172.

Irvine, R.E. James Hope and the History of Aortic Regurgitation. Guy’s Hospital Reports, 106, 1957, 1-10.

James, R.R. James Hope, M.D., F.R.S. St. George’s Hospital Gazette, 19, 1911, 239.

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. London Medical Gazette, 2, 1838, 741.