Stethoscope

“ Constantin Paul devised a stethoscope with two flexible tubes leading to the ears, and a hollow chamber in the chest-piece, connected with a rubber bulb by a long flexible tube. If the air in the hollow chamber is exhausted, the instrument is held firmly against the chest. ”

“ But the behaviour of everybody concerned was incredibly irrational. I produced my stethoscope, which was fitted with a diaphragm that enabled one to hear through the clothing, and, drawing the cloak partly aside, applied the chest-piece over the heart. On this the patient opened her eyes and made a movement of her hand towards the upper part of the cloak. I listened carefully to her heart—which was organically sound, though a good deal disordered in action—and moved the stethoscope once or twice, drawing aside the cloak by degrees. ”

“ Thus the stethoscope heightens and places in relief our auditory perception of the movements and conditions of deep-seated vital organs, giving prominence to the lines and shades of a picture otherwise flat and indistinct. It will, of course, conduct all sounds communicated to it from without, thus making it necessary to avoid all frictional contact with the instrument, even of the lightest clothing; and the listener will steady it deftly by thumb and finger to escape confusion from a multiplicity of sounds. ”

“ Fig. 4 is the same instrument with the sides cut out to make it lighter and more elegant, the ear-piece being the same as before, and the mouth also hollowed out. This was the stethoscope used and recommended by the late Dr. Hughes. By making the instrument still more elegant and slender we have the modern stethoscope in endless variety, as in Fig. 5. It is thus very evident how the modern instrument has been framed out of the original block of wood which was made the counterpart of Laennec's roll of paper. ”

“ In subsequent years the form of the stethoscope, as usually employed, was modified and its value augmented by a binauricular attachment, and in very recent years a further improvement has been made through application of the principle of the telephone; but the essentials of auscultation with the stethoscope were established in much detail by Laennec, and the honor must always be his of thus taking one of the longest single steps by which practical medicine has in our century acquired the right to be considered a rational science. ”

“ The latest morbid indication by the stethoscope, was simply the mucous rattle.
In exploring the state of the chest with the stethoscope, it is incumbent upon us to [Pg 28] reason carefully upon every phenomenon which we discover, and not to consider this or that circumstance as merely curious. We should weigh well the importance of the pathological indications; and form our conclusions, in great measure, from our knowledge of the anatomical structure of the particular parts of the organ which we find to be affected ”

“ As with percussion, the use of the stethoscope is founded upon a simple philosophical principle; that of ascertaining whether the cells of the lungs are healthy, and fitted for the free reception of air in the function of respiration; or whether the membranes of the chest, or the vessels, valves, and cavities of the heart, are obstructed by any disordered action, or by any permanent disease. ”

“ It is not intended that its use should supersede those established principles of our [Pg vii] art, which early and regular education, as well as experience, have pointed out to us; but that it should serve as an auxiliary in the investigation of obscure disease.
For my own part, I have no apprehension that the judicious employment of the stethoscope can, in any degree, tend to make us negligent in observing the symptoms of diseases, or indifferent to the study of the usual means of diagnosis. ”

“ In our ordinary means of investigation, it often exceeds our best powers of discrimination, to distinguish satisfactorily between functional and structural disease; and this difficulty, I apprehend, will not be removed by the use of the stethoscope, although I am well persuaded it will be very materially lessened. Both humanity towards the patient, and a regard for our own reputation, demand that we should use very great caution in forming our opinion on these occasions, and still greater in pronouncing it. ”

“ Snelling, is of advantage in applying it more closely to the inequalities of the chest. In most of the instruments now made, the rubber band which serves to draw the two tubes together is replaced by a spring. In the latest improvement the spring is placed in the screw which binds the tubes together. Great care is required in the construction of the stethoscope, and many defective ones are sold. The knobs on the ear-pieces must neither be too large nor too small; if too small, they cause pain by their pressure; if to large, they allow external sounds to enter the ear. ”

“ Lee slid off the examining table and began buttoning his shirt. He had had a medical examination every six months of his adult life, and it always seemed strange to him that, despite the banks of machines the doctor had which could practically map a man from a single cell outward, each examination always entailed the cold end of a stethoscope against his chest. ”

“ Forget to look at it, or, rather, to take any particular notice of it;—but what is that white object, with the long arm stretching up as if pointing to the sky, just as Vesalius and Spigelius and those old fellows used to put their skeletons? I don't think anything of such objects, you know; but what should he have it in his chamber for? As I had found his pulse irregular and intermittent, I took out a stethoscope, which is a pocket-spyglass for looking into people's chests with your ears, and laid it over the place where the heart beats. ”

“ By slipping it beneath the patient’s back a fairly accurate idea of the breathing over the bases of the lungs behind can often be obtained.
Stethoscopes have been made of many forms and materials. They usually consist of a hollow stem of wood, hard rubber or metal, with an enlarged tip slightly funnel-shaped at one end, and an ear-plate with a hole in the middle, fastened perpendicularly to the other end. ”

“ The first employment of the stethoscope by rolling up sheets of paper is of itself a sign of his readiness of invention. He made his own stethoscopes by hand and liked to spend his leisure time fashioning them carefully and even ornately. One of the stethoscopes certainly used by him and probably made by himself is to be seen at the Museum of the College of Physicians of Philadelphia.
After three years of study and patient investigation of the use of auscultation in pulmonary and cardiac diagnosis, Laennec wrote his book on the subject. ”

“ How strange it is to look down on one's venerated teachers, after climbing with the world's progress half a century above the level where we left them! The stethoscope was almost a novelty in those days. The microscope was never mentioned by any clinical instructor I listened to while a medical student. Nous avons changé tout cela is true of every generation in medicine,—changed oftentimes by improvement, sometimes by fashion or the pendulum-swing from one extreme to another. ”

“ At the beginning of the nineteenth century a young medical practitioner, working faithfully in the wards of his hospital in Paris, pitying especially the patients who suffered from pulmonary disease, and realizing how hopeless was their treatment, since medical science knew so little of the real nature of the ailment from which they suffered, invented the stethoscope and established the principles on which modern physical diagnosis is based in a method so complete that after the lapse of three-quarters of a century very little has been added to what was then discovered. ”

“ It is probable, however, that the most skilled physicians of all find a special use in each form, the monaural non-resonating type being more sensitive to high-pitched sounds, and of greater assistance in differentiating the sounds and murmurs of the heart, the ordinary binaural form being more useful in examining the lungs and other organs. In using the stethoscope, it must be applied very carefully, so that the edge of the funnel makes an air-tight connexion with the skin, and in the monaural form the ear must be but lightly applied to the ear-plate, not pressing heavily on the patient. ”

“ Under such circumstances, it is of the utmost importance that we should be able to ascertain the exact seat of the inflammation; and when, as commonly happens in pneumonia, the patient cannot direct us by any sensation of pain, but is labouring under a general sense of oppression and suffocation; we resort to the stethoscope as a positive and most valuable source of instruction. ”

“ With the stethoscope suitably placed, a distinctly audible murmur will be detected. On observing the rhythmic succession of "first" and "second" sounds the murmur will be found to occur exactly with or in place of the latter, whose sudden click will at least be notably weakened. The murmur is found over the position of the semi-lunar valve and extending downward in a line toward the middle of the chest; it is slightly prolonged after the "second sound." No other murmurs are discovered. These are sufficient data for a diagnosis. ”

“ On applying the stethoscope over the upper part of the right side of the chest, at every point, and also over the whole of the right shoulder blade, I heard acute sounds similar to those produced by air strongly passing through a key-hole. I considered that these sounds indicated active inflammation in the whole ramifications of the bronchiæ of the right lung. A large quantity of blood was drawn from the right arm; and cupping was also freely employed, both on the chest and shoulder blade. A saline draught with tartar emetic and nitre was administered every two hours. ”

“ In my own practice, I have derived the [Pg 18] utmost advantage from the use of the stethoscope in cases of pneumonia, with regard to local treatment. When we find a patient ill with severe symptoms arising from inflammation of the lungs, we do not require the aid of auscultation to determine us in employing the lancet as our first and most important remedy; but we may desire immediately to join with the general bleeding, local depletion; and, most commonly, the period arrives when we wish to use local treatment exclusively, by cupping or leeches, and blisters. ”

“ Here we are accustomed not only to tell the students that they will find certain signs and symptoms in the patient, if they will take the trouble of looking for them, but we place the stethoscope ourselves on the spot indicated, and by personal efforts endeavour to make the student realize exactly what he is in search of. It is astonishing how often mistakes will occur when least to be expected; and a pupil will sometimes say he hears a particular sound, and in reality thinks he hears it, when all the while his attention is directed to a different direction. ”

“ To keep up his character, a new man ought perpetually to carry a stethoscope—a curious instrument, something like a sixpenny toy trumpet with its top knocked off, and used for the purpose of hearing what people are thinking about, or something of the kind. In the endeavour to acquire a perfect knowledge of its use he is indefatigable. There is scarcely a patient but he knows the exact state of their thoracic viscera, and he talks of enlarged semilunar valves, and thickened ventricles with an air of alarming confidence. And yet we rather doubt his skill upon this point ”

“ The stethoscope and the mirror held in front of the patient's mouth are usually sufficient to demonstrate that the patient is alive and we should want more conclusive evidence than such as has been brought forward up to the present, to feel that cataleptic patients have been consigned to their coffins before life was totally extinct. ”

“ Garnier turned; the examination was over, and the doctor, the stethoscope swinging still from his neck, was buttoning the top button of the nightdress. This accomplished, he stood just for a second with hands folded, overlooking the patient295 from head to feet; one might almost have imagined him measuring her with his eye. ”

“ Settling in Finsbury Square on his marriage in 1841, he enjoyed for many years a good position as a consultant, especially in connection with chest diseases, having been one of the first to introduce into this country the use of the stethoscope. ”

“ At La Charité, the best informed students are great enthusiasts in the practice of this discovery, and regard it as an indispensable source of information in the diagnosis of the diseases of the chest. Such reliance on [Pg 10] the stethoscope is very natural, when constant proofs are afforded of the accuracy of opinion formed by M. Laennec, and others, who are competent in using it. The proofs of sure diagnosis are derived from dissection; as, necessarily, the diseases of the lungs and of the heart, allow frequent opportunity of obtaining this test of the physicians’ judgment. ”

“ Vide "Prize Essay on Variations of Pitch in the Sounds obtained by Percussion and Auscultation," Transactions of the American Medical Association, 1852.
With reference to the auscultatory signs in cases of phthisis, it is to be premised that often, owing to the importance of studying the sounds derived from a limited area and of localizing morbid conditions, the use of the stethoscope is indispensable. It is impossible to meet all the requirements of physical diagnosis by immediate auscultation. ”