The Stethoscope and the Art of Listening
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《新英格兰医药杂志》
Many physicians cling to Asclepios's staff as the quintessential insignia of our craft, no doubt debating endlessly whether it should have one or two ascending snakes. Some doctors cherish instead the symbolism of the white coats they don daily, which impart a hygienic air. Still others tightly clutch their beaten black-leather doctor's bags, once indispensable accessories for bygone house calls.
But with all due respect to these and a host of other treasured tokens, I contend that the stethoscope best symbolizes the practice of medicine. Whether absentmindedly worn around the neck like an amulet or coiled gunslinger-style in the pocket, ever ready for the quick draw, the stethoscope is much more than a tool that allows us to eavesdrop on the workings of the body. Indeed, it embodies the essence of doctoring: using science and technology in concert with the human skill of listening to determine what ails a patient.
Many doctors will gladly bore you with the details of their first stethoscope, and I feel compelled to make a disclosure of sorts. Mine was actually a "gift" from one of the pharmaceutical-industry representatives who clogged the corridors of my medical school during the 1980s, routinely tempting medical students with coveted freebies that are now strictly and deservedly prohibited. Just before graduating, however, I did the honorable thing and purchased a top-of-the-line doctor's stethoscope, with all the bells and diaphragms, which I still own. Alas, I do not use it much these days, but I still cling to the clinical conceit that I can distinguish between a diastolic murmur and a split second heart sound.
Long before Hippocrates (ca. 460–380 B.C.) taught his disciples the importance of listening to breath sounds, references to its usefulness appeared in the Ebers papyrus (ca. 1500 B.C.) and the Hindu Vedas (ca. 1500–1200 B.C.). Nevertheless, it was not until the early 19th century that physicians began to explore in a systematic way the precise clinical meanings of both breath and heart sounds by correlating data gathered during patient examinations with what was ultimately discovered on the autopsy table.1
This was the period when Paris reigned as the international center for all things medical. Drawing from a system of hospitals affording limitless access to what was then referred to as "clinical material," the Paris medical school boasted a talented faculty that represented the vanguard of medicine.
One of the brightest stars in this firmament was the man credited with creating the stethoscope, René Théophile Hyacinthe La?nnec (1781–1826). Long before he assumed the position of chief of service at the teeming Necker Hospital in 1816, La?nnec became adept at a technique called percussion, which involves striking the chest with one's fingertips in search of pathologic processes. Leopold Auenbrugger, the physician-in-chief of Vienna's Holy Trinity Hospital, first described the method in his 1761 treatise Inventum novum, but it was largely ignored until 1808, when La?nnec's professor and Napoleon's favorite physician, Jean-Nicolas Corvisart, translated Auenbrugger's text into French and began teaching it to his students and colleagues.
Yet neither percussion nor the time-honored technique of listening to breath sounds by placing an ear against a patient's chest satisfied La?nnec's demand for diagnostic precision. He was especially critical of physicians' inability to hear muffled sounds emerging from the chest of an obese person, and he balked at what he described as the "disgusting" hygiene of his patients, many of whom were unwashed or lice-ridden.
We do know that one day in the fall of 1816, La?nnec was scheduled to examine a young woman who had been "laboring under general symptoms of diseased heart."2 He was running late, according to the most charming version of the tale, and so took a shortcut through the courtyard of the Louvre, where a group of laughing children playing atop a pile of old timber caught his attention. La?nnec became especially entranced by a pair of youngsters toying with a long, narrow wooden beam. While one child held the beam to his ear, the other tapped nails against the opposite end; all had a jolly good time transmitting sound.3 Whether or not this instructive event ever occurred, La?nnec would later record that his invention was inspired by the science of acoustics and, in particular, the fact that sound is "conveyed through certain solid bodies, as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other."2
Fortunately, all can agree that what eventually transpired was one of the great "Eureka!" moments in the history of medicine. On entering his patient's room, La?nnec asked for a quire of paper and rolled it into a cylinder. Placing it against the patient's chest, the doctor was amazed to find how well he could "perceive the action of the heart in a manner much more clear and distinct than ever been able to do by the immediate application of the ear."2
Between 1816 and 1819, La?nnec experimented with a series of hollow tubes that he fashioned out of cedar or ebony, arriving at a model approximately 1 ft in length and 1.5 in. in diameter, with a 1/4-in. central channel. He would name his invention the stethoscope, derived from the Greek stethos, meaning chest, and skopein, meaning to observe.
(Figure)
From the National Library of Medicine.
A superb flautist who often used music to console himself during his own long and ultimately losing battle against tuberculosis, La?nnec pursued his studies with a vigor that belied the frailty of his frame. He became the first physician to distinguish reliably among bronchiectasis, emphysema, pneumothorax, lung abscess, hemorrhagic pleurisy, and pulmonary infarcts. He also opened the door to our modern understanding of cardiac maladies by describing their associated heart sounds and various murmurs.4
Initially, his magnum opus, De l'Auscultation Médiate, published in 1819, caused hardly a stir in the medical world — even at the price of 13 francs, with a stethoscope thrown in for an extra 3 francs. By the late 1820s, however, the book had been reprinted and translated into other languages and had managed to triumph over poor publicity and distribution. This success, combined with the gradual acceptance of the stethoscope by practicing physicians, allowed La?nnec to revolutionize clinical medicine.5
Although historians of medical technology consider the golden age of the stethoscope to have run from the publication of La?nnec's treatise to the death of Sir William Osler in 1919, the tool continues to be of great clinical value to those who take the time to learn how to use it. But as with all technological advances, its days were numbered from the start. To be sure, the stethoscope has not yet achieved quaintness, like the medieval physician's urine flask, but it is safe to assume that it, too, will someday be relegated to a museum shelf.
Yet even the stethoscope's predicted obsolescence is instructive and cautionary. After all, its creation initiated an irreversible trend in medicine by physically separating diagnosing physicians from their patients, albeit only by the length of a hollow tube. Today, with our advanced capabilities for noninvasive imaging and a host of other techniques that afford stunningly accurate glimpses into the human body, that distance has grown exponentially. Perhaps, then, as a reminder of how separation can alter the enduring task of physicians — listening to our patients — we ought to hang on to our stethoscopes a bit longer than practical usefulness dictates.
Source Information
Dr. Markel is a professor of the history of medicine and of pediatrics and communicable diseases at the University of Michigan Medical School, Ann Arbor, where he directs the Center for the History of Medicine.
References
Bishop PJ. Evolution of the stethoscope. J R Soc Med 1980;73:448-456.
Laennec RTH. A treatise on diseases of the chest. J. Forbes, trans. London: Underwood, 1821:284-5.
Sigerist HE. The great doctors: a biographical history of medicine. New York: W.W. Norton, 1933:283-90.
Nuland SB. Doctors: the biography of medicine. New York: Vintage Books/Random House, 1995:200-37.
Duffin J. To see with a better eye: a life of R.T.H. Laennec. Princeton, N.J.: Princeton University Press, 1998.(Howard Markel, M.D., Ph.D)
But with all due respect to these and a host of other treasured tokens, I contend that the stethoscope best symbolizes the practice of medicine. Whether absentmindedly worn around the neck like an amulet or coiled gunslinger-style in the pocket, ever ready for the quick draw, the stethoscope is much more than a tool that allows us to eavesdrop on the workings of the body. Indeed, it embodies the essence of doctoring: using science and technology in concert with the human skill of listening to determine what ails a patient.
Many doctors will gladly bore you with the details of their first stethoscope, and I feel compelled to make a disclosure of sorts. Mine was actually a "gift" from one of the pharmaceutical-industry representatives who clogged the corridors of my medical school during the 1980s, routinely tempting medical students with coveted freebies that are now strictly and deservedly prohibited. Just before graduating, however, I did the honorable thing and purchased a top-of-the-line doctor's stethoscope, with all the bells and diaphragms, which I still own. Alas, I do not use it much these days, but I still cling to the clinical conceit that I can distinguish between a diastolic murmur and a split second heart sound.
Long before Hippocrates (ca. 460–380 B.C.) taught his disciples the importance of listening to breath sounds, references to its usefulness appeared in the Ebers papyrus (ca. 1500 B.C.) and the Hindu Vedas (ca. 1500–1200 B.C.). Nevertheless, it was not until the early 19th century that physicians began to explore in a systematic way the precise clinical meanings of both breath and heart sounds by correlating data gathered during patient examinations with what was ultimately discovered on the autopsy table.1
This was the period when Paris reigned as the international center for all things medical. Drawing from a system of hospitals affording limitless access to what was then referred to as "clinical material," the Paris medical school boasted a talented faculty that represented the vanguard of medicine.
One of the brightest stars in this firmament was the man credited with creating the stethoscope, René Théophile Hyacinthe La?nnec (1781–1826). Long before he assumed the position of chief of service at the teeming Necker Hospital in 1816, La?nnec became adept at a technique called percussion, which involves striking the chest with one's fingertips in search of pathologic processes. Leopold Auenbrugger, the physician-in-chief of Vienna's Holy Trinity Hospital, first described the method in his 1761 treatise Inventum novum, but it was largely ignored until 1808, when La?nnec's professor and Napoleon's favorite physician, Jean-Nicolas Corvisart, translated Auenbrugger's text into French and began teaching it to his students and colleagues.
Yet neither percussion nor the time-honored technique of listening to breath sounds by placing an ear against a patient's chest satisfied La?nnec's demand for diagnostic precision. He was especially critical of physicians' inability to hear muffled sounds emerging from the chest of an obese person, and he balked at what he described as the "disgusting" hygiene of his patients, many of whom were unwashed or lice-ridden.
We do know that one day in the fall of 1816, La?nnec was scheduled to examine a young woman who had been "laboring under general symptoms of diseased heart."2 He was running late, according to the most charming version of the tale, and so took a shortcut through the courtyard of the Louvre, where a group of laughing children playing atop a pile of old timber caught his attention. La?nnec became especially entranced by a pair of youngsters toying with a long, narrow wooden beam. While one child held the beam to his ear, the other tapped nails against the opposite end; all had a jolly good time transmitting sound.3 Whether or not this instructive event ever occurred, La?nnec would later record that his invention was inspired by the science of acoustics and, in particular, the fact that sound is "conveyed through certain solid bodies, as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other."2
Fortunately, all can agree that what eventually transpired was one of the great "Eureka!" moments in the history of medicine. On entering his patient's room, La?nnec asked for a quire of paper and rolled it into a cylinder. Placing it against the patient's chest, the doctor was amazed to find how well he could "perceive the action of the heart in a manner much more clear and distinct than ever been able to do by the immediate application of the ear."2
Between 1816 and 1819, La?nnec experimented with a series of hollow tubes that he fashioned out of cedar or ebony, arriving at a model approximately 1 ft in length and 1.5 in. in diameter, with a 1/4-in. central channel. He would name his invention the stethoscope, derived from the Greek stethos, meaning chest, and skopein, meaning to observe.
(Figure)
From the National Library of Medicine.
A superb flautist who often used music to console himself during his own long and ultimately losing battle against tuberculosis, La?nnec pursued his studies with a vigor that belied the frailty of his frame. He became the first physician to distinguish reliably among bronchiectasis, emphysema, pneumothorax, lung abscess, hemorrhagic pleurisy, and pulmonary infarcts. He also opened the door to our modern understanding of cardiac maladies by describing their associated heart sounds and various murmurs.4
Initially, his magnum opus, De l'Auscultation Médiate, published in 1819, caused hardly a stir in the medical world — even at the price of 13 francs, with a stethoscope thrown in for an extra 3 francs. By the late 1820s, however, the book had been reprinted and translated into other languages and had managed to triumph over poor publicity and distribution. This success, combined with the gradual acceptance of the stethoscope by practicing physicians, allowed La?nnec to revolutionize clinical medicine.5
Although historians of medical technology consider the golden age of the stethoscope to have run from the publication of La?nnec's treatise to the death of Sir William Osler in 1919, the tool continues to be of great clinical value to those who take the time to learn how to use it. But as with all technological advances, its days were numbered from the start. To be sure, the stethoscope has not yet achieved quaintness, like the medieval physician's urine flask, but it is safe to assume that it, too, will someday be relegated to a museum shelf.
Yet even the stethoscope's predicted obsolescence is instructive and cautionary. After all, its creation initiated an irreversible trend in medicine by physically separating diagnosing physicians from their patients, albeit only by the length of a hollow tube. Today, with our advanced capabilities for noninvasive imaging and a host of other techniques that afford stunningly accurate glimpses into the human body, that distance has grown exponentially. Perhaps, then, as a reminder of how separation can alter the enduring task of physicians — listening to our patients — we ought to hang on to our stethoscopes a bit longer than practical usefulness dictates.
Source Information
Dr. Markel is a professor of the history of medicine and of pediatrics and communicable diseases at the University of Michigan Medical School, Ann Arbor, where he directs the Center for the History of Medicine.
References
Bishop PJ. Evolution of the stethoscope. J R Soc Med 1980;73:448-456.
Laennec RTH. A treatise on diseases of the chest. J. Forbes, trans. London: Underwood, 1821:284-5.
Sigerist HE. The great doctors: a biographical history of medicine. New York: W.W. Norton, 1933:283-90.
Nuland SB. Doctors: the biography of medicine. New York: Vintage Books/Random House, 1995:200-37.
Duffin J. To see with a better eye: a life of R.T.H. Laennec. Princeton, N.J.: Princeton University Press, 1998.(Howard Markel, M.D., Ph.D)