A memoir of Sir John Forbes (1787–1861)

Introduction

Even though we live in an age of ‘evidence-based medicine’ modern cardiologists, chest physicians and that rare breed, the general physician, may still learn from medical history. John Forbes was not an innovator like the French physician RTH Laёnnec (1781–1826) who was the ‘father of thoracic medicine’ and who had invented the monaural stethoscope in 1816 in Paris. This was a crude cylinder for application directly to the chest wall in order to listen to the heart and breath sounds. Originally called a ‘sthenoscope’, a primitive monaural model was brought back from Paris to Forbes by his friend James Clark (1788–1870) in 1818. At Clark’s suggestion, Forbes wrote an English translation of Laёnnec’s classical work on auscultation, first published in 1819. ¹ Forbes’ translation was written while practising at the Public Dispensary in Penzance in Cornwall and it appeared in 1821. ²

Chichester (1822–1840)

Although he was criticized for altering the terminology of Laёnnec’s original description of the lung sounds, Forbes’ translation was a success; it inspired three further editions – in 1827, 1829 and 1834. These were published after Forbes moved to Chichester in what is now West Sussex. They helped spread Laёnnec’s teaching to the medical world (Figure 1). OPEN IN VIEWER

While working at the Chichester Public Dispensary, Forbes extended his knowledge of the practical use of the stethoscope. He was also instrumental in raising funds for the modernization of the old Dispensary buildings that were re-opened for patients in 1826. They became the Royal West Sussex Hospital in 1913 and are now a block of retirement flats for the elderly.

Within two years of his arrival in Chichester, Forbes published the results of his further experience of auscultation as well as of the new technique of percussion of the chest wall ³ ; based on his translation into English of the Parisian physician Jean Nicolas Corvisart (1755–1821) who had first translated into French (1808) the original discovery of the Austrian physician Leopold Auenbrugger (1722–1821), described by him as the inventum novum and first published in 1761.

Original cases

In the preface Forbes commented that, although Laёnnec’s original work had been generally hailed as a major diagnostic advance in medical circles, curiously not a single case had been reported illustrating the practical use of the stethoscope. On account of this peculiar lack of interest ‘… (with the exception of my friend Dr Duncan Jun. of Edinburgh), I am lead to fear that the impression made was more lively than profound, and that through the influence of prejudice, theory and indolence – one or all – the greatest medical improvement of the present age, is in danger of sharing the fate of those thousand idle and useless projects which daily spring up among us, and which, after obtaining a temporary notoriety through the patronage of inexperienced and over-zealous individuals, soon sink into merited oblivion’. ⁴

The preface

The preface is 12 pages long and is a forceful introduction to the main work. Forbes intended it to be an expansion of his previous translation of Laёnnec’s ‘invaluable work’ on Mediate Auscultation but with the addition of the art of percussion as a diagnostic tool. He gives a brief biographical note of ‘Leopold Auenbrug [sic] or Avenbrugger’ ⁵ and acknowledges his debt to Corvisart’s translation of the pioneer work of the Viennese physician. Forbes strongly advised caution in the interpretation of physical signs, especially by the inexperienced, and stressed the importance of autopsy as the final arbiter. ⁶

The Scottish physician pointed out that he had omitted any reference to ‘Phthisis’ and that he proposed to consider his ‘Cases’ under the headings of Diseases of the Heart and Pericardium, Chronic Pleurisy, Hydrothorax, Chronic Peripneumony and Asthma. ⁷

Modern readers may query the terminology used by Forbes in Original Cases … especially with regard to Peripneumony. In fact, from his descriptions one is left in no doubt that the patients in this category were suffering from inflammation of the lungs or ‘pneumonia’. The inclusion of terms such as Haegophonism and Pectoriloquoy takes us back to our medical student days; with crepitous rattle we are on firmer ground. In later ‘Remarks’, Forbes mentions PneumoThorax and quotes Avenbrugger’s [sic] gloomy prognosis on percussion: ‘the destitution of sound over one whole side, is generally a fatal sign’. ⁸

Percussion

The next section, comprising 59 pages, is Forbes’ English translation of ‘Avenbrugger’s Original Treatise on Percussion of the Chest’. In addition, there is a ‘Selection of the more important Commentaries of Corvisart’ on that work, the first published in 1761 and the latter in 1808. The text is augmented by Corvisart’s comments and Forbes’ additional remarks for which the modern reader must be grateful. The technique of percussion is described in detail on pages 8–10. His astute ‘Observations’ are exemplified in the case of Dropsy of the Chest; in modern terms, he describes a pleural effusion with 15 symptoms including orthopnoea and, on the affected side, dullness on percussion. ⁹

Corvisart concluded that, considering the incomplete medical knowledge at the time it was written, Auenbrugger ‘has done great things for the improvement of the art in one of the least advanced departments of practical medicine’. ¹⁰

On mediate auscultation

This short section of 17 pages is a resumé of Laёnnec’s original treatise published in 1819. The early model of Laёnnec’s stethoscope is illustrated on the back pages of Original Cases … in which the Printer, Mason of Chichester, has transposed Plates II and III. James Clark, a close friend of Forbes since their schooldays in Aberdeenshire, had attended Laёnnec’s clinics in Paris but had not met him as ‘Dr. Laёnnec was indisposed’. ¹¹ Clark’s favourable opinion of the clinical use of the stethoscope in the diagnosis of diseases of the chest and heart is echoed in an excerpt from an article in the Edinburgh Journal of July 1820 by Dr Andrew Duncan (1773–1832) quoted on the same page.

In his introduction, Forbes takes great pains to point out to his readers that his observations are based on the pioneer studies of ‘M Laennec’. He describes the wooden cylinder used for mediate auscultation, ‘called the Stethoscope’, ¹² emphasises the correct method for the application of the cylinder to the chest wall and differentiates the models to be used for listening to the heart sounds as opposed to the voice and respiration: ‘On all occasions, the cylinder should be held in the manner of a pen and the hand of the observer should be placed very close to the body of the patient, to insure [sic] the correct application of the instrument’. ¹³

Cases with dissections and remarks

This is the principal part of the book: it contains descriptions of the case histories and physical signs of 39 patients seen personally by Forbes between 1821 and 1824. In fatal cases the stethoscopic signs were usually verified at autopsy, performed by himself. This was an innovatory technique. In the original preface he made it clear that there is some degree of overlap in the cases he describes and explains his reasons for giving minute details of their histories on the grounds of the importance of the pathological findings at postmortem. ¹⁴

Classification of the 39 cases

There are 19 patients with diseases of the heart, one of aortic aneurism [sic], seven with hydrothorax, five with chronic pleurisy, two with pleuro-peripneumony, two with chronic peripneumony and one each of bronchitis, emphysema and asthma – the differences between ‘chronic pleurisy’ and ‘pleuro-peripneumony’ are delphic to this author.

Thirty male and nine female patients are described; their ages ranged from 14 to 63 years of whom 26 were in the age range 30–50. Fifteen autopsies are recorded but in 24 cases autopsy was not performed, four of whom refused permission.

Case IV ¹⁵ is of interest as the patient was first seen by Dr Forbes at Penzance Dispensary on 21 September 1821 when 30 years old – later she was the sole patient included in his series of cases at Chichester who was not living in the vicinity and she was one of the first patients in whom Forbes used the stethoscope. ¹⁶ At Penzance she gave a history that she had noticed ‘a short tickling cough attended by pain under the lower end of the sternum, and dyspnoea’ for 10 years. Forbes noted there was a past history of injury to the chest following a severe fall when she was 10 years old. Recently she complained of recurrent vomiting of blood and rectal bleeding with difficulty in sleeping on her side at night.

On clinical examination he found oedema of all limbs. Stethoscopy revealed accentuated heart sounds and a ‘sort of hissing very distinct … over the whole chest anteriorly’ loud enough to muffle the heart sounds. Forbes diagnosed ‘Dilatation of the heart with Hypertrophia; disease of some of the valves. Prognosis Death’. At follow-up one month later, she complained of severe pain in the precordial region and ‘had some slight convulsive fits’. Forbes observed visible ‘great pulsation in the throat. Pulse 130, sharp and small’. Stethoscopy revealed accentuated heart sounds but with a diminished impulse on palpation. He diagnosed ‘Hypertrophia only moderate’.

He had treated her by repeated venesection from which she experienced great relief of symptoms ‘and this had always been the case from the beginning of her illness’. At follow-up on 26 October, the cardiac sounds and impulse were both accentuated. Just before leaving Penzance to move to Chichester, he saw her for the last time in early February 1822 when he found her suffering from intractable heart disease and only receiving temporary relief from venesection ‘which she was constantly begging to have repeated’.

She died on 23 February having suffered cough, palpitations and increasing signs of heart failure. Postmortem examination by a physician at Penzance (at Forbes’ request) revealed bilateral pleural effusions but without significant lung disease. There was thickening of ‘one of the semilunar valves of the aorta’; ‘within the right auricle we found a considerable coagulum of a fatty appearance, yellowish’.

The heart was felt to be enlarged and flabby … it was soft and pale and its cavities appeared larger than natural. There was no ulceration of the stomach in spite of the history of haematemesis.

In his Remarks (pp. 108–109) Forbes commented ‘As this was one of the first cases in which I used the Stethoscope, and as the explorations were always very incomplete, I should not have been much disappointed …’ by the unsatisfactory help afforded in diagnosis antemortem. He believed this to be due to the length of time of the patient’s survival between his last clinical examination at Penzance and her death 16 months later. He speculated:

Was the occasional excessive pain, referred to the cardiac and epigastric regions, in this case, owing to the temporary superfluity of blood in the cavities of the heart, unable, yet striving, to propel it; and of which the Haematemesis was, at once, the effect and the remedy?

The problems of prognosis are seen in Case XXXII, ¹⁷ a 21-year-old man who presented in May 1824 with a two-month history of cough and intermittent left-sided pleuritic pain. Forbes did not use his stethoscope until four weeks later when he noted slight reduction of breath sounds on the left side. His general condition at home deteriorated so that, by the time Forbes saw him on 22 June, he had cough with ‘very thick mucus, which is occasionally tinged with blood’. He was afebrile, pulse rate ‘under 90’. Percussion and auscultation were normal over the right side of the chest but diminished on the left to the extent that Forbes diagnosed an acute pleural effusion compressing the lung and for which he gave a fatal prognosis. In spite of this, the patient improved so that by 10 July he was less dyspnoeic and could lie on either side. The physical signs in the chest remained the same however and treatment was continued with repeated blisters and ‘Antim/Tart mixture in saline’ by mouth. We are not told the end result of this ‘masterly inactivity’ but in his ‘Remarks’ on the case Forbes mentions the benefit of paracentesis thoracis, an operation dating back to the ancient times of Hippocrates (c460–359 BC). ¹⁸ Not only does it afford symptomatic relief but it also distinguishes the presence of a purulent effusion (empyema). He concludes that percussion followed by paracentesis is invaluable in diagnosis of chest disease. ¹⁹

A more satisfactory case as regards the confirmation of the antemortem physical signs with those at autopsy is Case XXI. ²⁰ A 53-year-old housewife presented to Dr Forbes at Chichester on 22 January 1824. She had a trifling cough for several winters but without haemoptysis. Six months earlier she had a chest infection severe enough to warrant venesection by her doctor. During the past two months the severity of her cough had increased and sputum had been slightly bloodstained.

She complained of recent dyspnoea on exertion but without chest pain. She was unable to lie on her right side. Forbes found marked dullness on percussion on the right but the left side of her chest was normal. On stethoscopy he found almost complete absence of breath sounds on the right with distinct aegophony. He diagnosed a right-sided pleural effusion and gave a very poor prognosis. At follow-up in May, her general condition had deteriorated and Forbes believed she was ‘taking some quack medicine’. He saw her for the last time in June when her dyspnoea had got worse and she was orthopnoeic. Clinical signs on percussion and auscultation of the chest were the same; she died on 4 July.

At autopsy the large right pleural effusion was confirmed, the fluid resembling ‘souchong tea’. The underlying lung had the external appearance of cirrhosis, the liver being very indurated. It was ‘whitish’ in colour but there was no evidence of tuberculosis or abscess formation. Apart from slight serous fluid in the left pleural cavity, the underlying lungs and pleura were normal.

In his Remarks on the case ²¹ Forbes gave his diagnosis as idiopathic pleural effusion with lung fibrosis as described by Avenbrugger [sic] and patted himself on the back for his astute diagnosis and prognosis. ²² Clearly an exact cause for the ‘Pleurisy’ and ‘Scirrhus’ was impossible without modern methods of diagnosis.

Appendix: Essay on the physical diagnosis of diseases of the chest

Just after completing his Original Cases, Forbes received a pamphlet from a young Parisian physician named Victor Collin (1796–?1830–1836). ²³ Forbes’ translation of the original French title was ‘On the different modes of exploring the Chest, and their application to the Diagnosis of its diseases’. ²⁴ This is divided into two sections, the first on the classical forms of Inspection, Palpation, Percussion and Auscultation and the second on the application of these methods in diagnosis.

Forbes remarks that the work depended on previous publications by others as regards the first part but he was more impressed by Collin’s second section which, he felt, might be useful in the teaching of students. Clearly Collin’s treatise forms a well written and comprehensive summary of the subject; it appeared in the same year (1824) as Forbes’ Original Cases but may reflect the workings of a more agile mind, the author of which had had the advantage of attending the clinics of the master, Laёnnec, in Paris.

Conclusions

John Forbes proceeded to election to Fellowship of the Royal Society in 1829. He continued in medical practice at Chichester where he commenced his career in medical journalism in 1832. He extended this in London after leaving Sussex in 1840. In 1841, on the recommendation of his old friend James (now Sir James) Clark, Forbes was appointed Physician to the Royal Household. He became sole Editor of the British and Foreign Medical Review until its demise in 1848. His editorship contributed greatly to the promotion of sound medical literature both at home and abroad. ²⁵ In 1846 he was appointed Consultant Physician to the Brompton Hospital for Consumption and Diseases of the Chest and was considered to be ‘one of the first authorities in England on consumptive cases’. ²⁶ His services to the Court, especially to Albert (1819–1861), Prince Consort, were rewarded by a knighthood in 1853.

Between 1856 and 1859, Sir John lived in the same street as Florence Nightingale (1820–1910); there is no record that they met with each other but they corresponded and shared a mutual respect. ²⁷

A final publication Of Nature and Art in the Cure of Disease was an expression of his belief that doctors should never underestimate the healing powers of Nature, the vis medicatrix naturae, and he concluded that the practice of Medicine must be based on a combination of Art and Science. ²⁸

His final two years were spent at the home of his only son at Whitchurch-on-Thames; they were marred, after 1859, by several minor strokes. He died peacefully just before his 74th birthday and is buried in the local churchyard. ²⁹ There is an exquisite stained glass window in Chichester Cathedral in memory of Sir John and his wife, Eliza Mary (1787–1851), who founded the Dorcas Charity in the city (Figure 2). OPEN IN VIEWER