October 13, 2008
The Stethoscope and the Art of Medicine
Human innards are noisy: thud of heart valves, hiss of lungs, swish of blood flow, gurgle of intestines; and in disease: the thud muffles into murmur, hiss becomes crackle, swish sharpens to whistle and gurgle falls silent. For about two centuries, medical practitioners have evolved an art to discern these sounds with the help of a simple gadget: stethoscope.
In ancient times, Hippocrates would hold a patient by the shoulders and shake him to produce a splashing ‘succussion’ sound to prove that excess fluid had accumulated around the lungs. He would plant his ear directly to the chest to listen. This practice was common till 1816, when Rene Laennec, a young French physician -- who was too diffident to place his ear to the chest of a woman -- rolled twenty-four sheets of paper into a tube and placed one end to the woman’s chest and the other end to his ear. He was happy to discover that sounds were clearly audible.
Laennec was also a wood craftsman. In the workshop in his home, he carved a stethoscope from two connecting pieces of wood with hollow bores. He shaped one piece like a funnel to place against the chest and the other straight piece for his ear. He called his instrument ‘Le Cylinder’, but it became popular as stethoscope – a term that originates from two Greek words ‘I see’ and ‘the chest.’ Laennec subsequently refined the stethoscope into a tube twelve inches long and one and half inches in diameter with three-eighth inch uniform bore. He used it to describe various sounds: rales, bruit, bronchophony etc.
In 1819, he published his findings in the classic ‘The Treatise On Mediate Auscultation’. His stethoscope and the book sold together for two Francs. Laennec used his stethoscope to listen to the chest of patients with tuberculosis - the very disease that killed him a few years later.
George P. Cammann, a New York physician, improved its functionality in 1855 by attaching two tubes for both ears and a bi-aural stethoscope became the primary diagnostic tool in the late nineteenth century.
Dr Littman, a cardiologist, described the ideal stethoscope in the Journal Of American Medical Association in 1961. According to him an ideal stethoscope had an "open chest piece for the appreciation of low-pitched sounds, a closed chest piece with a stiff plastic diaphragm to filter out low-pitched sounds, firm tubing with a single lumen bore, the shortest practical overall length, a spring with precise tension to hold the ear tubes apart, and light and convenient to carry and use." The ‘Littman’ stethoscope became the most popular stethoscope in the USA.
But stethoscope lacks the output that science demands; it does not produce any quantifiable data. The last few decades has seen an explosion of sophisticated diagnostic tools: echocardiographs, ultrasound machines, CAT, MRI and many others, which produce quantifiable, replicable objective information, which has often negated many a subjective diagnosis made by the stethoscope. These superior tools have relegated the stethoscope to a secondary place in diagnostic gadgetry. It has almost become a symbolic necklace.
The rise of this simple gadget saw the rise of the art of medicine. The master practitioners of this art developed extraordinary sensitivity to the sounds of human body and made many a diagnosis with precision. The apprentice students were left in awe and emulated the master diagnosticians. A mere fifteen-inch long tube forced medical caregivers to stoop towards the patient and come closer. Figuratively, it fostered the art of medicine: listening to the patient.
The art of medicine has withered in parallel to vanishing of stethoscope. Both flourished together and now the shriveling art of medicine parallels vanishing of the stethoscope. We medical practitioners, in our pursuit of science have forgotten the art. Now we know more about the disease and less about the patient.
The fear is not new or sudden. Over 150 years ago, Armand Trousseau expressed it in the “Lectures on Clinical Medicine, The New Sydenham Society, 1869”
"Every science touches art at some points every art has its scientific side; the worst man of science is he who is never an artist, and the worst artist is he who is never a man of science. In early times, medicine was an art, which took its place at the side of poetry and painting; today they try to make a science of it, placing it beside mathematics, astronomy, and physics."
Understanding the unique individuality of the patient with compassion is the art, and treating her with morality and knowledge is the science. A patient, who is vulnerable has an asymmetric relationship with the physician – a relationship based on trust. The patient has implicit faith that humanity of the caregiver will overcome any temporal compulsions that may pollute the encounter.
It has been a long journey from the ancient to modern, from Ayurveda to Medicare. The moral implications of the ancient Ayurvedic tradition of healing expressed, "if science is only followed for money, it is wasted" and that "wealth earned from medical sciences is always contaminated as it comes from the suffering of others, thus it must be practiced with compassion and humility, and without greed or ego."
It will be wishful thinking that we physicians will ever regain this ancient attitude, when Wall Street sets the benchmarks of success. But we can definitely pull out the stethoscope and stoop to listen to the patient.
Posted by Shiban Ganju at 05:38 AM | Permalink