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In the twenty-first century the Necker Hospital in Paris is a large hospital of over 800 beds providing specialist care for children and some adults. The hospital, a mixture of new and old buildings set in 22 acres, was founded in 1778 by Madam Necker a writer, philanthropist and wife of Jacques Necker who was director of finances to Louis XVI. The French physician René Théophile Hyacinth Laennec, from Quimper in Brittany, became chef de service at the Necker Hospital in 1816 and it was there that he described the stethoscope. He used the stethoscope in his practice and correlated his clinical findings with those he found at post mortem examinations.1 In 1819 he published his findings in his book Traité de l'Auscultation Médiate.
Laennec was acknowledged as an innovator and teacher and over three hundred foreign students studied with him.2 Three of the foreign students had a strong Welsh connection and their contributions to the introduction of the stethoscope to the UK are the subject of this report. The three doctors were Charles James Blasius Williams, Thomas Davies and Thomas Prestwood Lucas. Of the three, Williams made the greatest contribution to the science and art of auscultation.
CJB Williams (Figure 1) was born in Hungerford, Wiltshire, where his father the Rev David Williams was warden of the almshouse and vicar of Heytesbury. His mother was the daughter of a surgeon in practice at Chepstow. Both David Williams and his wife were Welsh. CJB Williams was the grandson of Daffydd Williams of Swyddffynnon in Cardigan, South Wales, a blacksmith and calvinistic Methodist exhorter.3
His father was an accomplished private tutor and Charles was educated at home where he had a sound classical education. In 1820 he entered the medical school at Edinburgh and was awarded the degree of md in 1824.4,5 Williams was a resident pupil of Dr John Thomson, physician, surgeon and first professor of general pathology at Edinburgh.
Williams showed early academic promise. In July 1823, while still a student, he published a paper in the Annals of Philosophy on the combustion of a candle at temperatures below those of ordinary combustion.4 His inaugural dissertation for the Edinburgh md was On the Blood and its Changes by Respiration and Secretion.
After qualifying, Williams spent some time in London, where he attended Sir Charles Bell's lectures.4 In 1825 he went to Paris to study medicine and drawing. At his drawing classes he met Henry and Charles Prestwood Lucas of Brecon6 (see below). He studied with Laennec at La Charité where Laennec was teaching the examination of the chest and the use of the stethoscope. The stethoscope complemented chest percussion, an account of which had been promoted and published in 1819 by Auenbrugger and Corvisart.7
Williams, stimulated by Laennec's teaching, returned to London to explore the value of the stethoscope in clinical medicine and to interpret his findings. By 1825 Laennec had attempted to explain the origins of sounds originating from the lungs and heart. Some of his explanations appeared flawed and CJB Williams determined to interpret the origins of heart and lung sounds. In 1828, three years after leaving Laennec, Williams wrote the volume Rational Exposition of Physical Signs,8 which was dedicated to Sir Henry Halford, another physician of Welsh origin, who was President of the Royal College of Physicians from 1820 to 1824.9 Halford never used a stethoscope.10 By the time that the book was published Williams had studied acoustics and applied this knowledge to the interpretation of chest percussion and auscultation. Williams contributed to the debate on the origin of heart sounds. At first he subscribed to the view that the first heart sound was due to muscular contraction of the heart but later concluded that it was mainly due to the closure of the mitral and tricuspid valves, with muscular contraction playing a lesser role.7 Williams considered that the origin of the second heart sound was the sudden closure of the semilunar (i.e. aortic and pulmonary) valves. This conclusion was reached after vivisection on donkeys, in which the cardiac cycle 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 pathophysiological 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 Consumption14 written with his son Dr Charles Theodore Williams, was published in 1871 and his autobiography Memoirs of Life and Work6 (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 Hospital4. 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'.6 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 Extraordinary 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 practitioner...'.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 Wales25, unveiled a plaque near his grave in the churchyard of St Botolph's without Bishopsgate. It reads:
Thomas Davies md, frcp 1792–1839
Of Carmarthen and London
Pioneer Chest Physician
Disciple and Friend of Laennec
Thomas Davies' son Herbert Davies (1818–1885) likewise became a consultant at the London26 and continued his father's interest in the stethoscope, studying its acoustic properties.27 His grandson Arthur Templar Davies (1858–1929) followed his father and grandfather in being appointed a physician at the Royal Hospital for Diseases of the Chest.28
Thomas Prestwood Lucas was born in Carmarthen, probably to Welsh parents, and qualified first at Edinburgh in 1825, proceeding md (Paris) in 1826. In Paris, where he spent two years, he attended the clinics of Trousseau and Laennec. There he also met CJB Williams. Laennec gave Prestwood Lucas one of his stethoscopes, which is now kept in the Brecon War Memorial Hospital in South Wales29 (Figure 5).
Leaving Paris Lucas was appointed assistant surgeon to the Royal Artillery and served in Canada, Malta, Gibraltar and countries along the Mediterranean coast. In 1839 he became physician to the Swansea Infirmary. Henry Lucas, his father, who was the first physician to the Brecon Infirmary, died in 1840 and Thomas then left Swansea to take over the practice in Brecon.
Thomas Lucas clearly continued his interest in clinical skills and instruments. In the Medico-Chirurgical Review (1834) he discussed work by Pierre Adolphe Poirry on `mediate percussion'. Poirry had gone so far as to incorporate a pleximeter into a stethoscope of his own design, but Lucas reckoned that the hand was far better than a pleximeter.29 In 1854 Lucas was involved in the Brecon cholera outbreak, which claimed 57 lives, and his notebooks and report on the outbreak are kept in the Powys Archives Office at Llandrindod Wells30 (catalogue reference B/D/BM/A/7/1/2). The outbreak was eventually traced to a stream which was used as a sewer and fed a nearby well that provided drinking water.31
Prestwood Lucas was prominent in the community, becoming a town councillor in 1866 and an alderman the following year. He was also a governor of Christ's College and Deputy Lieutenant of the County. He died in May 1871 and was buried in Brecon Cemetery.
Dr Llinos Owen kindly provided translations from Welsh. Biographical data on Thomas Prestwood Lucas were provided by: Miss Alison Howells, Powys Health Care Trust; Mr Malcolm Johns, Brecon Museum and Art Gallery; Miss H M Burns and Miss A Page, County Archives Office, Llandridnod Wells and Mrs Julie Beckwith, Royal College of Physicians. Dr AG Chappel, lately consultant physician and chest physician, Princess of Wales Hospital, Bridgend, provided further information on Dr Thomas Davies. The librarians at the Princess of Wales Hospital, Mrs Barbara Palluda, Mr Phillip Rawle and Mr Ray Hopkins, have assisted by finding and retrieving references.