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... was visualized as a stethoscope was applied to the exposed heart. The work was done with the collaboration of James Hope (1801– 1841), a distinguished physician and physiologist at St George’s Hospital. Williams and Hope each claimed authorship of the work, and this led to some animosity between them. Each wrote books in which the donkey work was described. 11 Medical historians seem to support James Hope’s claims as the main originator of the work. A student, Matthew Bailie Gairdener, likewise attributed the second heart sound to the closure of the semilunar valves. He presented his opinion, which was based on extensive reading and not vivisection, to the Royal Medical Society of Edinburgh in 1830. 12 Following the work of Laennec, Williams provided a clearer description of the murmurs of mitral stenosis in 1835 and this was further improved upon by Fauvel in 1843. 10 Williams worked on the mechanics of the lung. 12 He demonstrated the contractility of the tracheo-bronchial muscles by applying a galvanic stimulus to the trachea, which was connected to a manometer filled with coloured fluid. As the galvanic stimulus was applied, the pressure recorded by the manometer rose. The experiments were done either in intact dogs or in dog-lung preparations. He exposed longitudinal segments of the trachea and bronchi to galvanic stimuli and saw the membranous part of the airway contract. Williams also directly measured the diameter of the airway and found it narrowing by up to half following stimulation. 13 CBJ Williams is thus credited with demonstrating bronchial hyperreactivity as a basic patho- physiological process of asthma. In 1830 he married Harriet Williams Jenkins, of Chepstow, and they settled in Half-moon Street in London. Williams became a successful consulting physician and his academic interests continued. He had published his first book Rational Exposition of Physical Signs in Diseases of the Chest in 1828 and the third edition, which appeared in 1840, was entitled The Pathology and Diagnosis of Diseases of the Chest . He contributed several articles to the Cyclopedia of Practical Medicine edited by Tweedie and Forbes and to the Library of Medicine . In 1843 he wrote Principles of Medicine , which became a standard text and went through several editions. His last major medical publication, Pulmonary Consumption 14 written with his son Dr Charles Theodore Williams, was published in 1871 and his autobiography Memoirs of Life and Work 6 (Figure 2) appeared in 1884. Throughout his career Williams was an accomplished teacher. Starting in 1836 he gave a course of lectures on the diseases of the chest at the Kinnerton School, which was associated with St George’s Hospital 4 . In 1839 he was elected to the chair of medicine at University College London. The chair had become vacant following the resignation of Dr Elliotson, who had upset the Senate of the University by embracing mesmerism as a form of treatment. 4,5 In 1840 Williams became a Fellow of the Royal College of Physicians of London and the following year was the Gulstonian lecturer when he spoke on ‘Inflammation increased production and adhesive action of the white corpuscles of the blood’. 6 As Lumleian lecturer in 1862 he spoke on ‘Successes and failures in Medicine’. He was elected FRS in 1835 but his contribution to the Royal Society was small, perhaps because he was annoyed that the first paper he submitted was rejected. 13 His active mind sometimes led him into controversy. He criticized the Royal Society for admitting only fifteen Fellows each year and thought that the general election process was detrimental to the advancement of science. Williams accused the Royal College of Physicians of elitism. 13 This angered some Fellows and the pages of his obituary notice in the College’s bound Lancet have been torn out. 13 Williams’ reputation as a teacher and clinician grew and he was active as the first President of the Pathological Society and the New Sydenham Society. He had earlier been president of the Harveian and Westminster Medical Societies and in 1873 toward the end of his working life he was elected president of the Royal Medical and Chirurgical Society. He was appointed Physician Extra- ordinary to Queen Victoria in 1874. In 1841 Sir Phillip Rose, a solicitor and prominent conservative, recognizing the difficulty that patients with tuberculosis had in gaining hospital admission, proposed a hospital for consumptives. 15 Williams with Sir John Forbes, the translator of Laennec, became the first two physicians at the Hospital for Consumption and Diseases of the Chest that later became known as the Brompton. Williams had an unrivalled experience of chest medicine and in thirty years at the Brompton had gathered the records of nearly 26 000 patients who had been under his care. 15 In his early seventies Williams retired to Cannes. There he studied sunspots and wrote a criticism of the New Testament. He died at the age of 84. Thomas Davies (Figure 3) was born to Welsh parents in Carmarthenshire but early in life moved to London. His maternal uncle Mr Price, an apothecary at the London Hospital, introduced him to medicine. 16 Davies practised for about two years in London’s East End but he developed tuberculosis and went to Montpelier and, on recovering, to Paris. In Paris Davies studied with Laennec at the Necker Hospital and became proficient in auscultation. In 1821 he qualified MD at Paris, and returned to London where he became a licentiate of the Royal College of Physicians in 1824. Davies was among the first to use a stethoscope in England, certainly before CJB Williams; but priority in this respect may go to Sir John Forbes, the translator of Auenbrugger and Laennec, who probably used the stethoscope in Penzance and at his Chichester dispensary before it came into regular use in London hospitals. 17 Documentary evidence supporting Forbes as the first to use the stethoscope as a physician in Great Britain was related by Agnew, who records that Professor John Craig ‘happened on two ledgers with notes of his patients taken by a Doctor about Penzance’. 18 The ledgers were clearly those of Forbes and recorded his use of the stethoscope on seven patients seen in the second half of 1821. 19 Forbes also mentions that Dr James Clark and Dr Duncan of Edinburgh were the only contemporaries who had given auscultation a fair trial. 19 Initially Forbes himself was uncertain as to the value of the stethoscope and wrote in the first edition of his book ‘ . . . That it [the stethoscope] will ever come into general use notwithstanding its value, I am doubtful . . . ’. 20 He based this opinion on the difficulty of learning to use the stethoscope and gain experience. He also wrote ‘ . . . the beneficial application requires much time, and gives a good deal of trouble both to the patient and the practi- tioner . . .’. 20 By the time the second edition of his book was published, however, he had changed his mind and acknowledged the value of the stethoscope as a diagnostic tool. 21 Who, first used the instrument in Britain remains uncertain. Weiss of London sold stethoscopes as early as November 1819. 22 Another candidate to be the first to use the stethoscope in Britain was the obstetrician Granville, who had bought a stethoscope from Laennec in 1817. 21 He had been present when Laennec introduced his ‘cylinder’ and provided an eye-witness account of its introduction. Thomas Hodgkin, the Guy’s physician, was also an early user. Hodgkin had studied with Laennec between 1820 and 1821 and in 1822 published a book on the use of the stethoscope. 23 Davies had other links with Laennec. Both were Celts and Laennec in particular had a great interest in the Breton tongue and compared it with Welsh, which Davies spoke. 24 In 1824 Davies opened a practice at his home in New Broad Street, London, where he also gave lectures on disease of the lungs and heart, which were published in the London Medical Gazette and subsequently as a book (Figure 4). As a result of these lectures and his ability as a clinician his professional reputation grew and in 1827 he was appointed assistant physician to the London Hospital. Davies became a Fellow of the Royal College of Physicians in 1838. His health deteriorated and he died a year later. In 1988 a group led by Dr John Owen of Porthcawl, South Wales 25 , unveiled a plaque near his grave in the churchyard of St Botolph’s without Bishopsgate. It ...
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In the early 1800s, the French Medical School espoused a new approach to medicine, concentrating on the vast number of hospitalized patients with their multiple manifestations of disease. Under such circumstances, the sensory skills of the examining physician attempting to discern the symptoms and signs of sickness played an essential role. With ch...
Citations
... [39] Charles James Blasius Williams, one of the followers of Laënnec, along with John Forbes, translator of Laënnec's work, became the chest physician at Brompton Hospital, which was previously known as "Hospital for Consumption and Disorders of chest." [40] In 1843 he demonstrated his design of the binaural stethoscope with a trumpet-shaped chest end, the other end of which screwed to two bent lead pipes. [41] A modified version of this was demonstrated by Arthur Leard in 1851, with flat discs on ear pieces. ...
Early physicians were taught with immediate auscultation, placing the ear directly on the patient’s chest. They showed reluctance because it was questionable when the patient is obese, nonhygiene, and modesty, especially in cases of females. In 1816, when the freshly graduated physician René-Théophile-Hyacinthe Laënnec had a consultation with a young obese woman with the symptoms of underlying heart disease, he recalled an acoustic phenomenon which is known very well beforehand for him. He rolled up a sheet of paper and placed one end to her chest and another to his ear to listen. Rest is history. He presented his invention to the world and made revolutionary changes in the art of patient care, which is valuable even nowadays. After his discovery, several scientists contributed their works to make this crucial device achieve more potential. Through many years, Laennac’s device became the stethoscope that we have today. Now, the stethoscope has become the symbol of the medical profession.
... Huard y Grmek confeccionaron una lista de estos estudiantes [42]. Uno de los más destacados fue Charles James Blasius Williams (1805-1889; Fig. 10), un pionero de la cardiología británica [43]. Williams avanzó sobre la descripción empírica de Laennec para proporcionar a la auscultación un sólido fundamento en la física acústica [44]. ...
In the first part of this work, I gave an account of the life of René Laennec until his momentous discovery of mediate auscultation. In this second part, I will deal first with his treatise on auscultation, its contribution to physical diagnosis, pneumology and cardiology, and its reception in France and abroad. Next, I will address Laennec’s retreat from Paris and his glorious return, his controversy with Broussais, his clinical and teaching activities, the preparation of the second edition of his treatise, his marriage and his untimely death. Laennec will be always remembered by his many contributions to medical sciences, and above all by mediate auscultation, for which he has been rightly regarded as one of the most influential inventors of all times.
Background
The urgent need for telemedicine has become clear in the COVID-19 pandemic. To facilitate telemedicine, the development and improvement of remote examination systems are required. A system combining an electronic stethoscope and Bluetooth connectivity is a promising option for remote auscultation in clinics and hospitals. However, the utility of such systems remains unknown.
Objective
This study was conducted to assess the utility of real-time auscultation using a Bluetooth-connected electronic stethoscope compared to that of classical auscultation, using lung and cardiology patient simulators.
Methods
This was an open-label, randomized controlled trial including senior residents and faculty in the department of general internal medicine of a university hospital. The only exclusion criterion was a refusal to participate. This study consisted of 2 parts: lung auscultation and cardiac auscultation. Each part contained a tutorial session and a test session. All participants attended a tutorial session, in which they listened to 15 sounds on the simulator using a classic stethoscope and were told the correct classification. Thereafter, participants were randomly assigned to either the real-time remote auscultation group (intervention group) or the classical auscultation group (control group) for test sessions. In the test sessions, participants had to classify a series of 10 lung sounds and 10 cardiac sounds, depending on the study part. The intervention group listened to the sounds remotely using the electronic stethoscope, a Bluetooth transmitter, and a wireless, noise-canceling, stereo headset. The control group listened to the sounds directly using a traditional stethoscope. The primary outcome was the test score, and the secondary outcomes were the rates of correct answers for each sound.
Results
In total, 20 participants were included. There were no differences in age, sex, and years from graduation between the 2 groups in each part. The overall test score of lung auscultation in the intervention group (80/110, 72.7%) was not different from that in the control group (71/90, 78.9%; P=.32). The only lung sound for which the correct answer rate differed between groups was that of pleural friction rubs (P=.03); it was lower in the intervention group (3/11, 27%) than in the control group (7/9, 78%). The overall test score for cardiac auscultation in the intervention group (50/60, 83.3%) was not different from that in the control group (119/140, 85.0%; P=.77). There was no cardiac sound for which the correct answer rate differed between groups.
Conclusions
The utility of a real-time remote auscultation system using a Bluetooth-connected electronic stethoscope was comparable to that of direct auscultation using a classic stethoscope, except for classification of pleural friction rubs. This means that most of the real world’s essential cardiopulmonary sounds could be classified by a real-time remote auscultation system using a Bluetooth-connected electronic stethoscope.
Trial Registration
UMIN-CTR UMIN000040828; https://tinyurl.com/r24j2p6s and UMIN-CTR UMIN000041601; https://tinyurl.com/bsax3j5f
The presence of a systolic murmur on cardiac auscultation is a frequent finding in the elderly patient. The origin of these murmurs may be due to insignificant causes without clinical or prognostic importance or may be caused by serious conditions that require specific treatment. The test of choice to study a murmur is currently the Doppler echocardiography. However, careful auscultation together with the performance of some auscultation maneuvers and the study of the carotid pulse are fundamental techniques in the family medical consultation that allow us to approach the diagnosis and select the patient who need an echocardiography study.
Auscultation has long been an important part of the evaluation of patients with known and suspected cardiac disease. The subsequent development of phonocardiography provided an analogue visual display that permitted a more detailed analysis of the timing and acoustical characteristics of heart sounds, murmurs, clicks and rubs. In addition, the measurement of systolic time intervals enabled a valuable non-invasive assessment of left ventricular function. Acoustic cardiography, a much more recently developed technology, has enabled the simultaneous acquisition of ECG and cardiac acoustical data. This user-friendly and cost-effective technology permits acquisition of detailed information regarding systolic and diastolic left ventricular function and provides both a computerized interpretation and a visual display of the findings. Its clinical applications include the evaluation of patients with suspected heart failure, ischaemia and cardiac arrhythmias and the optimization of cardiovascular drug and device therapies. It can also be used in a wide variety of ambulatory and inpatient monitoring applications.
Where Laennec was a true pioneer was in correlating clinical signs with pathology. In the first edition of his treatise on mediate auscultation (1819) he analysed the physical signs of percussion and auscultation and substantiated them with their pathologo-anatomical relevance; and, in the second (1823) he provided a complete description of pathology, diagnosis and treatment. Writing about three early Welsh followers of Laennec (March 2004 JRSM1), Dr Morris acknowledges that Williams, Davies and Lucas were among many foreigners who came under the French doctor's influence. In England these included Heberden, Fothergill and the ‘great men’ of Guy's Hospital—Richard Bright, Thomas Addison and Thomas Hodgkin—who fostered the attitudes that were to make Britain a leader in clinical medicine. Reference must also be made to the Irish connection—John Cheyne, Abraham Colles, Robert Adams and John Corrigan from the great Dublin School, and the two leaders Robert Graves and William Stokes. Laennec's teaching had an immediate impact in Britain by the influential work of such physicians. Graves and Stokes, both graduates of Edinburgh and subsequently professors in Dublin, collaborated in a new system of clinical instruction. Stokes in 1825 published a small treatise on the stethoscope inspired by Laennec.2
The modern practice of a complete clinical examination derives from nineteenth century methods such as auscultation and percussion. In today's world of imaging techniques and other technologies, it is a challenge for teachers to decide which of the old techniques are worthy of preservation.
Mr Hashmi and his colleagues present an excellent discussion of the problems of diagnosing and managing swallowed partial dentures (February 2004 JRSM1). Management can be challenging even when the diagnosis is straightforward. We recently saw a man of 34 who had swallowed a set of partial upper dentures which contained a wire to fix the plate to the teeth. He had swallowed them accidentally while eating a meal. The dentures lodged in the upper oesophagus, at the level of the sternal notch, and the wire was easily visible on X-ray. Oesophagoscopy revealed the dental plate just below the level of the cricopharyngeus but multiple attempts at removal, with various instruments, were unsuccessful. Sometimes the answer is to split the plate and remove it in pieces, but even with heavy denture shears the material proved too hard to cut. Therefore an oesophagotomy was performed through a lateral pharyngeal approach. The wire was seen to penetrate the lateral oesophageal wall. The patient recovered without incident and was planning to discuss more suitable dentures with his dentist.
Purpose of report: This document has been commissioned by the British Society of Gastroenterology. It is intended to draw together the evidence needed to fill the void created by the absence of a national framework or guidance for service provision for the management of patients with gastrointestinal and hepatic disorders. It sets out the service, economic and personal burden of such disorders in the UK, describes current service provision, and draws conclusions about the effectiveness of current models, based on available evidence. It does not seek to replicate existing guidance, which has been produced for upper and lower gastrointestinal cancers, hepatobiliary and pancreatic disorders, and many chronic disorders of the gut. It does, however, draw on evidence contained in these documents. It is intended to be of value to patient groups, clinicians, managers, civil servants, and politicians, particularly those responsible for developing or delivering services for patients with gastrointestinal disorders. Methods used: A systematic review of the literature was undertaken to document the burden of disease and to identify new methods of service delivery in gastroenterology. This systematic review was supplemented by additional papers, identified when the literature on incidence, mortality, morbidity, and costs was assessed. Routine data sources were interrogated to obtain additional data on burden of disease, the activity of the NHS, and costs, in relation to gastrointestinal disorders. The views of users of the service were sought, through discussions with the voluntary sector and through a workshop held at the Royal College of Physicians in December 2004. The views of professionals were obtained by wide dissemination of the document in a draft form, seeking feedback on the content and additional material. Main findings: The burden of gastrointestinal and liver disease is heavy for patients, the NHS, and the economy, with gastrointestinal disease the third most common cause of death, the leading cause of cancer death, and the most common cause of hospital admission. There have been increases in the incidence of most gastrointestinal diseases which have major implications for future healthcare needs. These diseases include hepatitis C infections, acute and chronic pancreatitis, alcoholic liver disease, gallstone disease, upper gastrointestinal haemorrhage, diverticular disease, Barrett's oesophagus, and oesophageal and colorectal cancers. Socioeconomic deprivation is linked to a number of gastrointestinal diseases, such as gastric and oesophageal cancers, hepatitis B and C infections, peptic ulcer, upper gastrointestinal haemorrhage, as well as poorer prognosis for colorectal, gastric, and oesophageal cancers. The burden on patients' health related quality of life has been found to be substantial for symptoms, activities of daily living, and employment, with conditions with a high level of disruption to sufferers' lives found to include: gastro-oesophageal reflux disease, dyspepsia, irritable bowel syndrome, anorectal disorders, gastrointestinal cancers, and chronic liver disease. However, impact on patients is neither fully nor accurately reflected in routine mortality and activity statistics and although overall, the burden of gastrointestinal disease on health related quality of life in the general population appears to be high, the burden is neither systematically nor comprehensively described. An overwhelming finding concerning evidence related to service delivery is the lack of high quality health technology assessment and evaluation. In particular, evidence of cost effectiveness from multicentre studies is lacking, with more research needed to establish a robust evidence base for models of service delivery. Waiting times form the bulk of patients' concerns, with great difficulty in meeting government standards for referral and treatment. An extensive and systematic study of the problem of access for the delivery of gastrointestinal services has yet to be carried out and significant publications reporting inequalities in the delivery of gastrointestinal services are lacking. There is also a need to increase awareness and the implementation of initiatives aimed at improving the information flow between patients and practitioners. Strong evidence exists, however, for a shift in care towards greater patient self management for chronic disease. The development of general practitioners with a special interest in gastroenterology is supported in primary care, but their clinical and cost effectiveness need to be researched. Indeed, emphasis needs to be given to developing interventions to increase preventative activities in primary care, and more research is required to determine their effectiveness and cost effectiveness. Despite strong support for the development and use of widespread screening programmes for a wide variety of gastrointestinal diseases, there is a lack of evidence about how they are managed, their effectiveness, and their cost effectiveness. In contrast, a strong body of evidence exists on diagnostic services, and the need to develop and implement appropriate training and stringent assessment to ensure patient safety. There is also a substantial amount of work detailing guidelines for care. In hospital, patients with gastrointestinal disorders should be looked after by those with specialist training, and more diagnostic endoscopies could be undertaken by trained nurses. Importantly, for service reconfiguration, there is currently insufficient evidence to support greater concentration of specialists in tertiary centres. More research is needed especially on the impact on secondary services before further changes are implemented. Consultant gastroenterologist numbers need to increase to meet a rising burden of gastrointestinal disease. Gastroenterology teams should be led by consultants, but include appropriate non-consultant career grade staff, specialist nurses, and other staff with integrated specialist training, where appropriate. More research is needed into the delivery and organisation of services for patients with gastrointestinal and liver disorders, in particular to assess the clinical and cost effectiveness of general practitioners with a special interest in gastroenterology and endoscopy; the clinical and cost effectiveness of undertaking endoscopy or minor gastrointestinal surgery in diagnosis and treatment centres; and the reconfiguration of specialist services and the potential impact on secondary and primary care and on patients.
