Wednesday, 26 October 2016

The Stethoscope. Is auscultation obsolete?

   On the occasion of the 200th anniversary of the invention of the stethoscope, one of our National newspapers featured a piece debating whether the stethoscope is, or soon will be obsolete.  Now that we have ultrasound, CT scans and MRIs should we be throwing away the stethoscope?   That's like saying now that we have calculators and computers should we stop learning 'times tables'.  Some would say yes, and that has been a part of  our decline.  I think  the same about the art of auscultation, a vital tool in the understanding and diagnosis of what is going on in various parts of the human body.  

Invention of the stethoscope

René Laennec wrote the classic treatise De l'Auscultation Médiate, published in August 1819.[2] The preface reads:

In 1816, I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [direct auscultation]  (i.e. putting the ear directly on the patient's chest) being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, ... the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.
 Here's a picture of Laennec's stethoscope:


 Here's a picture of my stethoscopes:

So they have changed a bit with the passage of time!

 When I read some of the comments made by many of my modern colleagues I have the uncomfortable feeling that they are not physicians st all.  Admirable technicians and scientists, yes, and much more capable than I at interpreting computer data aimed at many complex diagnostic problems.  On the 200th anniversary of the invention of the stethoscope some doctors have already written it off an obsolete diagnostic instrument.  Many of us who have used the stethoscope over a lifetime found it to be a valuable diagnostic instrument that is portable, inexpensive, noninvasive and capable of giving much information to those who have learned to use it efficiently.   Many doctors and nurses can pull out their stethoscope at any time of the day or night and get an immediate answer to the pressing question they need the answer to right at that moment and not just in auscultation of the chest, but of the bowel and other locations.   No waiting around to find the right piece of equipment and sometimes the right technical expert to interpret what it may mean. 
  Another and perhaps tenuous relationship is the real-time connection between between the doctor and the patient, the conduit between the physician's brain and the patient's body, during which the doctor can modify and localize the examination in accordance with his findings.  It is only after a careful clinical examination that  high tech instruments should be introduced in an appropriately directed manner, bearing in mind that inappropriate use is not only expensive but can be dangerous in unleashing the medical cascade that has cost more than one patient his life.
   Let me finalize my feelings for the humble stethoscope with an ode I composed a couple of years ago on the occasion of hanging up mine:

     Ode to a Stethoscope

I lay you, faithful stethoscope to rest,
Against how many hearts have you been pressed?
 The secrets of the airways all laid bare,
As you measured sounds of heart and air,
No MRI or CAT scan will astound,
The way you did, just listening to the sound.

Oh mighty stethoscope you told me so much,
And confidence exuded from your touch.
Now relegated to a lowly role.
I still think that you head the Honour Roll!


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