“Knowledge comes, but wisdom lingers.”

Alfred, Lord Tennyson.



Paris was in the forefront of new medical awakening and afforded golden opportunities to ambitious physicians in the eighteenth Century. Taking a cue from Napoleon most physicians promoted themselves as captains of people’s destiny. They changed the traditional medical learning from “bookish knowledge and teacher’s personal sagacity to putting human bodies before books, prizing the hands-on experience gained through indefatigable bed side examinations and postmortems.” Pierre Cabanis (1757-1808) was the father of the golden rule: “read little, see much, do much.” In the milieu one man came out with an ingenious idea of a new instrument to get to know the sounds emanating from the lungs and heart in a novel way out of sheer necessity, which is the mother of all inventions.



Rene Theophile Hyacinthe Laennec (1781-1826) was a physician at the Salpetriere Hospital and later became the chief of Hospital Necker, which afforded him access to thousands of sick people. Laennec devised the first stethoscope in 1816, the leading tool of this new era of objective signs medicine in Paris until the discovery of the X-rays. The first stethoscope was detailed in a 900 page book by him Traite de l’auscultation mediate (1819)-Treatise of Mediate Auscultation. This was a single ear wooden instrument, 9 inches long and one and half inches in diameter in two pieces that could be screwed together with separate ear and chest pieces. He wrote “none of the symptoms reported by the patient suffices to characterize disease of the heart and so for a certain diagnosis we must recur to mediate auscultation.” One of the leading physicians impressed by this method was William Heberden. Laennec was an expert in interpreting pulmonary signs and could make accurate diagnosis using his stethoscope.1



Laennec wrote a treatise on tuberculosis, a classic in its time. Laennec provided the inspiration, instrument, the programme and the techniques for generations of physicians to make better diagnoses. Unfortunately, in the present day hi-tech medical world the great specialists and the divine interventionists seem to have almost forgotten the stethoscope, nay the bed side clinical methods, altogether to the detriment of poor patients. They rely only on the latest scanners and scopes to make their diagnosis. While this is a sad commentary on our present state, thinkers have come out to re- emphasize the importance of bedside medicine. In the west, especially in the US, things have gone too far to the other side that people seem to have forgotten how to listen to their patients’ story on the bed side and how to auscultate. A recent meeting of the American College of Cardiology had one of their great teachers, Proctor Harvey, to give them a key note address on “How to auscultate the heart?”



Bedside medicine, including the use of the stethoscope requires a well trained physician in the first place. The importance of the quality of the material in between the ear pieces of the stethoscope was beautifully brought our in a tongue-in-cheek poem, The stethoscope Song, in 1848, by that great thinker, Oliver Wendell Holmes-an American physician, essayist and poet, who taught anatomy at the Harvard Medical School from 1847 to 1882. He later became a famous poet:2



“There was a young man in a Boston town,

He bought him a stethoscope nice and new,

All mounted and finished and polished down,

With an ivory cap and a stopper too.



It happened a spider within did crawl.

And spun him a web of ample size,

Wherein there chanced one day to fall

A couple of very imprudent flies.



Now being from Paris but recently,

This fine young man would show his skill;

And so they gave him, his hand to try,

A hospital patient extremely ill.



Then out his stethoscope he took,

And on it placed his curious ear;

Mon Dieu! Said he, with a knowing look,

Why here is a sound that’s mighty queer!



There is empyema beyond a doubt,

We’ll plunge a trocar in his side.

The diagnosis was made out,--

They tapped the patient; so he died.



Then six damsels, slight and frail,

Received this kind young doctor’s cares;

They all were getting slim and pale,

And short of breath on mounting stairs.



They all made rhymes with “sighs” and “skies,

And loathed their puddings and buttered rolls,

And dieted much to their friends’ surprise,”

On pickles and pencils and chalk and coals.



So fast their hearts did bound,

That frightened insects buzzed more;

So over all their chests he found

The rale sifflant and rale sonore.



He shook his head. There’s grave disease,--

I greatly fear you all must die;

A slight postmortem, and if you please,

Surviving friends would gratify.



The six young damsels wept aloud,

Which so prevailed on six young men

That each his honest love avowed,

Whereat they all got well again.



This poor young man was all aghast;

The price of stethoscopes came down;

And so he was reduced at last

To practice in a country town.



Now use your ears, all that you can,

But don’t forget to mind your eyes.

Or you may be cheated, like this young man.

By a couple of silly, abnormal flies.”





Oliver Wendell Holmes was a great philosopher, in addition. The poem is a nice bit of advice to all the new enthusiasts in every area of medical technology. Just as was the stethoscope the most hi-tech stuff at that time in Paris, so are many of the newer inventions of today in medicine that are being misused and abused by our young men and women like that young man of those days in Paris. Final message is that a well trained doctor that can use his/her faculties correctly will be an asset to patients. Holmes did warn us about the drugs that are used in treatment: “if the whole materia medica could be thrown into the seas, it would be that much good for mankind and that much worse for the fishes,” he wrote. How prophetic? Adverse drug reactions did kill more than 140,000 people in one year in the US with a population of 250 million. In addition, 79 million people suffered ADRs as out-patients, which cost the payers a total of $80 billion.3



Even the simple blood pressure apparatus invented by Riva Rocci, a hi-tech at the time of its invention, is now known to have caused misery to millions, so beautifully brought out by a great physician of the 20th Century Britain, Richard Asher, in his celebrated book Talking Sense.4 He records that “Riva Rocci must indeed be grieving in his grave at the way his invention is being misused and abused by us today.” The present divine interventionists are repeating the same mistake. Werner Forssmann, the young German who thrust the ordinary urinary catheter into his own heart and then on to the pulmonary artery, a great feat at that time when any catcher in the heart was supposed to kill! He must be turning in his grave looking at the way any one with the slightest excuse is being goaded to undergo catheterization by our enthusiastic young interventionists. A recent study did show that the presence of an on site catheterization laboratory in any hospital, where a patient with heart attack gets admitted, is the leading risk factor followed only by hypertension and diabetes, for fatal strokes!5



“Art” wrote, Henry David Thoreau “is that which makes another man’s day”. One kind word on the bedside can cure many ills. The art of medicine is that which should make the patient’s day. In fact, the summit of all efforts in the field of medical care delivery is the coming together of two human beings-the one who is ill or imagines to be ill and the other in whom the first has confidence. This is called medical consultation. All else in medicine should really flow from this summit. “Know your patient better than his disease” was the opinion of the father of modern medicine, Hippocrates.6 Having worked under some of the giants of clinical medicine both in India and abroad, I feel sorry for the patients as also for the doctors of today who think that the hi-tech investigations give them the diagnosis and management strategies.



Hardly anyone talks with the patients these days. Most of the big bosses make what they call the “chart rounds” in the ward side rooms where all the details of the patients, including the scanners and X-rays, are kept. Little time is spent on the bed side. The present jargon for good medical practice is “euboxic medicine” where all the right boxes should be ticked in the computerized case sheet. Whether the patient feels better or worse is of no consequence. “Patient doing well do not interfere” wrote Sir William Osler, a great clinician of the last Century. “God give me deliverance from-treating suffering human beings as cases, not letting the well alone, and making my interventions worse than his disease,” was the daily prayer of Hutchinson. If you talk to a present day sub-specialist, he/she would say that all those ancient timers didn’t have the array of scopes and scanners that we have today!



Recently a double blind, computerized, prospective study was undertaken in London by some of the great teachers in different medical schools there-John Mitchell, John Hampton, Michel Harrison and Carol Seymour, to name a few of them- to study the role of listening to the patient and reading the referral letter from the family doctor vis-à-vis examining the patient physically and investigating the patient with all the gadgets including the positron emission tomography, in the diagnosis of medical out-patients. These giants were all students of Lord Platt at the University College Hospital London. Platt had written in 1949 that “if one were to listen to the patient long enough, the patient would give away his/her diagnosis.” Platt’s students, who now have access to all hi-tech stuff, wanted to check the veracity of his statement.7



This study was published in the British Medical Journal. The study showed, to everyone’s delight, that 80% of the accurate final diagnosis and one hundred per cent of the future management strategies could be arrived at, at the end of listening to the patient and reading the referral letter. This could only be refined 4% more by all the physical examinations and only 8% per cent by all the investigations including the PET scanner!

A good lesson for all of us. Stethoscope is no exception. One of the largest studies ever carried out was this study by three generations of cardiology teachers at the St. Andrew’s University in Dundee where such greats like Ian Hill taught cardiology. Sixty years of their documented evidence of teaching cardiology to students was audited in this study.8 The message from this study was that teaching subtleties of clinical bed side signs, like the many heart sounds, clicks, and soft murmurs, splitting of sounds-reverse split included- was highly counter productive. Many a time the teacher’s imagination was at the root of this kind of teaching. Gross things are all that one could teach for the students’ benefit.



My own observations about the second heart sound splitting at the base of the heart, published in the Journal of the Royal College of physicians of London, bears ample testimony to this.9 Similar experience in the respiratory signs was shown by another study done by a dozen senior teachers of pulmonology. Barring stony dullness, frank bronchial breath sounds, rales and rhonchi, the rest of the signs were highly unreliable. So the ubiquitous stethoscope, that is being forgotten, also has to be used with caution, but it is less expensive way of making a diagnosis than all the scanners and scopes put together. The poor stethoscope could give a clue to some rare diagnoses on the bed side, as shown in my study of mitral valve prolapse published in The Lancet and later in the German Tribune.10 After all those scanners only show the shadow. One must remember that a shadow is not the real thing and could change depending on the surroundings like one’s own shadows in the morning, noon and evening. I am making a fervent plea for parsimony in the use of any gadget.11 Nothing, not even the positron emission tomography or the Total Body Scanner, can ever replace a well trained humane bed side clinician with his stethoscope around his neck.



“The meaning of good or bad, of better or worse, is simply helping and hurting.”

Ralph Waldo Emerson.





Bibliography.



1. Porter R. Medical History of Mankind. 1997. W.W. Norton and Company, New York and London.

2. Reynolds R, and Stone J. On Doctoring. 1991. Simon and Schuster, New York.

3. Barbara S. Is US medicine the best in the world? JAMA 2000; 284: 483-485.

4. Asher R. Talking Sense. 1954, BMA publications, London.

5. Joesefson D. Early bypass surgery increases the risk of stroke. BMJ 2001; 323: 185.

6. Roy R. in What doctors don’t get to study in the medical school? Hegde BM. 2006. Paras Medical Publishers, Hyderabad, India.

7. Hampton JR et.al. Role of history taking, physical examinations and investigations in medical out patient diagnosis. BMJ 1975; ii: 486-489.

8. Finlayson et al. Cardiac diagnosis-wheat from the chaff. BMJ 1978; i: 471-473.

9. Hegde BM. Cardiological Examinations (letter) Jr. Roy. Coll. Physi. London 1998; 32: 83-84.

10. Hegde BM. Auscultation for mitral valve prolapse. Lancet 1994; 344: 1446-1447.

11. Fred HL. Hyposkillia-deficiency of clinical skills. Texas Heart Instit. J 2005; 32: 255-257.