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| EDITORIAL |
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| Year : 2022 | Volume
: 9
| Issue : 4 | Page : 445-447 |
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Story of stethoscope—Are we near the end of the story?
Sushil Kumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to Be University), Navi Mumbai, Maharashtra, India
| Date of Submission | 08-Nov-2022 |
| Date of Acceptance | 09-Nov-2022 |
| Date of Web Publication | 29-Dec-2022 |
Correspondence Address:
Dr. Sushil Kumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to Be University), Navi Mumbai 410209, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mgmj.mgmj_215_22
How to cite this article:
Kumar S. Story of stethoscope—Are we near the end of the story?. MGM J Med Sci 2022;9:445-7 |
| Introduction | |  |
One of the objects that give instant recognition to “medical doctors” and nurses is a stethoscope hanging around their neck. It gives a sense of immense pride to young medical professionals and gives them a bit of differential treatment from the patients and onlookers alike. As a child, I was always fascinated to be doctors examining patients with a stethoscope; I always thought of it as a magic wand that may cure the patients. Perhaps, this fascination propelled me toward a career in medicine. I grew up in the era of thorough physical examination of patients and minimum investigations for the final diagnosis. However, during my 40 years of journey through clinical medicine, I realized that there has been a tectonic shift in the art of clinical examination. Extensive lab investigations and the use of ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) scans are ordered instead of clinical examination. No doubt these tests are more accurate, but it also increases the cost to the patients and is often not available in village and small towns. During our time as a student in the 70s and 80s, a stethoscope was the most important piece of equipment used to arrive at a diagnosis. Over the years, the uses have been declining. Thequestion often asked is “Will it someday be relegated to a museum shelf?” Before announcing the judgment, let us look at the journey of this wonderful piece of equipment.
| History of stethoscope | | |
The stethoscope, what does it mean? The stethoscope is the combination of two Greek words: “Stethos” means chest and “Scopos” means examination. Therefore, it is obvious that it was invented to hear heart and lung sounds. The stethoscope was invented in 1816 by a French physician named Rene Laennec.[1] As the story goes one day Laennec was to examine the chest of a breathless young woman. He was an extremely shy person and considered it improper to place his ears directly over her chest and listen to heart and lung sounds. After considerable thought, he came up with a rolled-up paper tube and tried to listen to her chest through it. He discovered that the lung and heart sounds were magnified. Later, he replaced the paper tube with a wooden one. His innovation to use a hollow tube to examine the chest was gradually accepted by the medical world and thus revolutionized clinical medicine for almost two centuries.[2] Unfortunately, Laennec died at the young age of 45 because of pulmonary tuberculosis, but his name as the “father of clinical medicine” will remain forever. The stethoscope has been as much a hero as Laennec was. Many stamps have been issued depicting stethoscopes. The first one was the 10 “Yen” stamp from Japan in 1958, then from Czechoslovakia in 1952, and doctors without borders in 2003.
| ANATOMY, PHYSIOLOGY OF STETHOSCOPE AND ITS VARIANTS | | |
The original stethoscope by Laennec was a hollow wooden tube. On similar principals, “voice pipes” were used in “war ships” to transmit the captain’s instructions to the wheelhouse to give the orders to the person, steering the ship. Being in the Navy I was posted to a ship as a Surgeon lieutenant and I had firsthand experience of these hollow tubes. They could carry a very clear message for a reasonably long distance and were found extremely useful during power failure. Many changes were made to the design of the single-tube Laennec stethoscope. Over the years, it acquired a bell and a diaphragm and two flexible tubes to transmit the sounds to both ears. The material and length of the tube have also seen many changes over the years.
A stethoscope has two different receivers of sound: a bell and a diaphragm. The bell is used for low-frequency sounds and the diaphragm for high-frequency sounds. However, this concept is also challenged by some.[3] Different variants of stethoscopes have evolved over the past two centuries. Some of the important ones are: (a) the original Laennec single tube wooden stethoscope (1816), (b) Cammann binaural stethoscope (1852), (c) the Kerr symballo phone (1940), (d) Rappaport-Sprague stethoscope (1960), (e) Littmann stethoscope, and (f) Littmann electronic stethoscope.[4]
| JUGAAD USES (UNCONVENTIONAL OR MAKE-SHIFT USES) OF THE STETHOSCOPE | | |
The stethoscope was also used for many other purposes that are beyond the known uses in clinical medicine. The doctors have used it as a tourniquet, as a paperweight, as a binder of boxes with loose lids for retrieving objects fallen behind the drawers and some used it as suspenders to keep the pants up in position. Some of the young doctors who were short of money occasionally used it to siphon the petrol from others’ cars to his own car.[5] Some of the so-called registered medical practitioners (RMPs) use the stethoscope to convince the patient that the doctor is taking their complaint very seriously. As I grew up in the Garhwal hills of Uttarakhand, India, I had seen these so-called RMPs making novel use of a stethoscope. They use to place the diaphragm of the stethoscope on almost every part of the body. If the patient had a headache they will place it on the head, if it was knee pain then on the knee. Surprisingly, they use to spend considerable time examining these organs. I still wonder “what was it that they were hearing through a stethoscope by putting on an inert organ.” Probably placing the stethoscope on the concerned organ had some placebo effect.
| The traditional uses of the stethoscope and their newer alternatives | | |
The most common use of a stethoscope is the auscultation of the heart and lungs and at times the auscultation of the abdomen for bowel sounds. The stethoscope is the oldest equipment or device used to listen to heart sounds. Even today it is used to screen patients for heart ailments. Heart rate, rhythm, opening, and closing of valves, and congenital heart diseases, all were diagnosed by simple auscultation with a stethoscope. The art of listening to the heart and diagnosing various murmurs was considered essential for a medical graduate until the arrival of echocardiography (ECHO). Today, the final diagnosis is made by the ECHO, which is more accurate and gives us a more comprehensive idea about the flow of blood through the heart. Therefore, ECHO has become the primary tool for diagnosing as well as ruling out cardiac disorders; the only condition is that it should be available and affordable. The stethoscope is used to take blood pressure (BP) readings manually with a sphygmomanometer. Though today we have easy-to-use electronic BP machines, manual BP recordings are still considered more accurate. However, there is a note of caution; excessive pressure on the stethoscope while taking BP reduces the diastolic BP by 10 mm of Hg. For the examination of lungs, a stethoscope still has a role to play. Hearing of normal vesicular breathing, bronchial breathing in cases of cavities, wheezes, crackles in cases of asthma, and crepitations in case of pulmonary edema, bronchitis, or pneumonitis may be detected with reasonable certainty. However, more sensitive tools for the diagnosis of lung ailments are x-rays, CT scans, MRIs, and ultrasounds. Studies are showing that a combination of auscultation and one of the imaging modalities gives a better diagnosis. One of the current modifications of the stethoscope is the “Blue tooth stethoscope” that converts the sound waves into a digitized form that in turn can be transmitted anywhere in the world (midday July 29, 2022). This device has been designed by an Indian entrepreneur and was used effectively during the COVID epidemic. This could also be used as a tool of telemedicine to provide medical aid to far-flung areas. Auscultation of bowel sounds is almost a routine in patients with abdominal symptoms or immediate postoperative period after abdominal surgery. An electronic stethoscope has been used for the diagnosis of intestinal obstruction, but the results still need validation.[5] Stethoscope was commonly used to auscultate fetal heart sounds in pregnant patients. Today, this is generally replaced by fetal Doppler based on ultrasound principles.
| Electronic stethoscope | | |
The electronic stethoscope has been introduced recently but has not become very popular. It does have certain advantages over a standard stethoscope. It reduces noise, amplifies the sound, and can store or transmit the sound. However, there are differences in sound characteristics between electronic and acoustic stethoscopes; therefore, senior physicians find it difficult to convert from acoustic to the electronic stethoscope.[6]
| Risk of infection transmission from the stethoscope | | |
The transmission of infection through a stethoscope, both bacterial and viral, is possible. However, its role has never been conclusively proved. I asked several of my colleagues and students “how often do they clean or sterilize their stethoscope?” most of them answered “almost never,” though the COVID-19 pandemic has changed some of them. It is the diaphragm of the stethoscope that can carry the infection. Cleaning of the diaphragm with alcohol-based wipes or hydrogen peroxide wipes is recommended.[7]
| ARE WE REALLY AT THE END OF THE STORY? | | |
There has been no doubt that the stethoscope has been a game changer as far as modern medicine is concerned. For almost the last 200 years, it was the sole instrument used for the clinical diagnosis of chest diseases. Getting a degree in modern medicine was considered an impossible task unless one has mastered the techniques of chest auscultation and could differentiate between the different sounds emanating from the chest. There is no doubt that modern medicine has better and more accurate tools to diagnose chest disease, but they are expensive and beyond the means of the majority of the world’s population, especially in third-world countries. Therefore, my final verdict is that “The stethoscope will remain a primary weapon in the hands of a physician like a rifle is in the hands of a soldier” for quite some time in the future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vatanoğlu-Lutz EE, Ataman AD Medicine in philately: Rene T. H. Laënnec, the father of stethoscope. Anatol J Cardiol 2016;16:146-7.  |
| 2. | Roguin A Rene Theophile Hyacinthe Laënnec (1781-1826): The man behind the stethoscope. Clin Med Res 2006;4:230-5. |
| 3. | Tietze KJ Clinical Skills for Pharmacists: A Patient-Focused Approach. 3rd ed. Amsterdam, Netherlands: Elsevier; 2011. Available from: https://www.sciencedirect.com/book/9780323077385/clinical-skills-for-pharmacists. [Last accessed on 25 Jul 2022]. |
| 4. | O’Donnell M The world is round: Salute to the stethoscope. BMJ 2008;336:1326. |
| 5. | Ching SS, Tan YK Spectral analysis of bowel sounds in intestinal obstruction using an electronic stethoscope. World J Gastroenterol 2012;18:4585-92. |
| 6. | Rennoll V, McLane I, Emmanouilidou D, West J, Elhilali M Electronic stethoscope filtering mimics the perceived sound characteristics of acoustic stethoscope. IEEE J Biomed Health Inform 2021;25:1542-9. |
| 7. | Patel L, Gandhi D, Beddow D Controversies on the stethoscope during COVID-19: A necessary tool or an unnecessary evil? Am J Med Sci 2021;361:278-80. |
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