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The Stethoscope
No Longer Holds a Monopoly over Our Hearts
Medicine
Almost two centuries after its invention, the doctors’ undisputed symbol is about to be replaced
by the ultrasound device. Victory of the technological progress? Distance from the patient’s
body? Practitioners seem divided.
NATHANIEL HERZBERG
Close your eyes, hold your breath and imagine. He is a doctor, with a George Clooney smile,
wearing a white coat. And around his neck … nothing. No rubber tube hanging from his ears or
ostensibly coming out of his pocket. You can breathe now, because you will have to get used to
it. The stethoscope, due to celebrate its 200th anniversary in two years, is no longer doing very
well. If we are to believe some, it is even doomed. A matter of time, they say. But their forecast
leaves no room for doubt: in one generation, at most, the doctors’ undisputed symbol, which in
itself sets them apart from other white-coat caregivers, will have disappeared.
The diagnosis, as it often happens, was made by Americans. One after the other, Global
Heart, the journal of the World Heart Federation, and the prestigious New England Journal of
Medicine published editorials writing the obituary of the celebrated tool. "As certainly as
cassettes and CDs in music," professors Jagat Narula and Bret Nelson, a cardiologist and an
emergency medicine physician at Mount Sinai Hospital in New York, respectively, claimed in
Global Heart, stethoscopes are headed for certain death. On the forums, doctors lashed out at
each other, some swearing never to give up their precious aid, others professing allegiance to the
new king.
And this is the very crux of the matter. The stethoscope braces itself against the attack of
a younger, more efficient, more reliable rival, a competitor that, as a sign of the times, resembles
a smart phone, with a flip cover and a screen. In one gesture, the doctor opens it and places the
probe on the patient’s chest or abdomen and gains access to the movements of the heart, details
of the lung, or the condition of the bladder. Introduced 5 years ago, this ultraportable ultrasound
device was tested by some US hospitals. It has become common practice in medical schools, on
the other side of the Atlantic. In Europe, its use continues to remain modest. The market leader,
General Electric, sold 3,000 Vscan devices, mainly in Germany, Italy, Spain, and Great Britain.
France comes next with 200 scanners. "But this is a new market, and it is growing very well,"
says the US manufacturer.
In Europe, this movement continues to remain modest. General Electric sold 3,000
of its Vscan devices, of which only 200 were in France.
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This change impacts other specialties. in addition to obstetrician/gynecologists and
cardiologists, who were the first ones to take ultrasound out of radiology practices. Urologists,
pulmonologists, internists, and above all emergency-medicine and intensive-care physicians are
discovering the potential of these compact tools. "It’s eight months since I got one. and it has
completely changed my practice, says Jean-Luc Dinet, emergency medicine physician at Sens
(Yonne) and vice-president of SOS Médecins. It is a considerable aid in decision-making. After
one week of using the device, I examined a young girl who was feeling tired and presenting
significant weight gain. I felt her thyroid, then I did an ultrasound. She had nodules. Three days
later, she had a scan, and the following week she had surgery. Before, I would have done a
check-up and told her to see her general practitioner ... How much time would we have lost?"
Managing time. Detect the emergency and correctly guide patients. Jean-Luc Dinet
continues: "There was hardly any equipment to help us with pulmonary pathologies. Coughing
and fever: we could prescribe antibiotics, order a chest X-ray ... and we could have missed it.
Now, we make a diagnosis. It’s even truer for elderly people. You get a call on Friday at 6 p.m.,
a patient with swollen legs. No phlebology office open until Monday. Should you send her to the
emergency room? If it is phlebitis, yes. Otherwise, you will make her go there, wait for hours and
undergo examinations for nothing. And this would overcrowd the hospital. too. Now, I have the
answer."
"It took us a while at first, doctor Xavier Bobbia, emergency medicine physician at the
Nîmes University Hospital Center, elaborates. But now, it takes two minutes per examination to
answer the simple questions we are asking. And the diagnosis is clear."
Or very likely, at any rate. In a study carried out in the United States and published in the
American Journal of Cardiology, first-year medical students faced with sixty-one patients
identified 75% of existing heart pathologies with the help of a small ultrasound device. Equipped
with just a stethoscope, qualified cardiologists had identified only 49%. Another study carried
out on the liver led to similar results.
Is the die cast? Are we going to actually witness the disappearance of the tool invented by
René-Théoplile-Hyacinthe Laennec in 1816, after watching two children play in the courtyard of
the Louvre? Are we going to stop teaching this incredible semiology, which is exhausting to
students but enthralling to poets? The "sibilant" resembling "the air released by piercing an
opening into a balloon," typical of asthma; the "rhonchus," "a deeper sibilant, as if blowing into
a bottle," indicating bronchial obstruction or an infectious lung disease; the "crepitation" and its
"sound of salt in the fire or footsteps in the snow," sign of an infection or pulmonary edema; not
to be confused with the "subcrepitation," which is specific to excessive bronchial mucus, closer
to "popping popcorn." And what will take the place of the rite of passage for new students when
the newcomer’s stethoscope earpieces are plugged with cotton before asking them to detect a
suspicious noise?
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"It is certainly the way the world is going, Nicolas Danchin, professor of cardiology at
the Georges-Pompidou European Hospital, admits. The enema syringe is gone, the stethoscope
may be gone one day, too. In a department like ours, we use it less and less. But it does allow us
to correct certain diagnoses. Aortic stenosis, for example. It looks very severe on the ultrasound,
but through the stethoscope, if you can still hear the second heart murmur, you can state that it is
not as tight as that."
At the pulmonary section of the Regional Hospital Center of Créteil, the ultrasound
device has become "a critical working tool," Professor Bruno Housset insists. Every resident
passing through this section is trained to use it by doctor Gilles Mangiapan. The latter, however,
dampens his boss’s enthusiasm. "It’s true, in all pleural pathologies, pleural effusion [fluid in the
pleural cavity], pneumothorax [air in the pleural space], the ultrasound device has replaced the
stethoscope, he explains. But, in pneumonia, the images are not specific enough, whereas a
crepitant rale is heard immediately."
But there is another warning that this early fan wants to issue. Basically, the
following: "The ultrasound must complement, enrich the examination. Ever since Laennec, the
clinical examination has been palpation-percussion-auscultation and it should become
palpation-percussion-auscultation-visualization. We can miss asthma, because we do not
auscultate the patient. Or we can overlook a tumor, because we haven’t performed palpation."
Do not deprive yourself of a technique which "was based on two hundred years of
medical practice." And, above all, preserve "the complexity of the examination." A general
practitioner and writer, Martin Winckler also calls for caution. "We look at the patient, we listen
to the patient and touch him. His posture. How he walks. It is the person in its entirety that we
are examining. In a direct relationship. And it is because it actually brings us closer to the
patient, because it is an extension of our ear, that the stethoscope is so valuable." Is Martin
Winckler a bit of a fetishist? Like everybody else, he remembers his first stethoscope, the one
that his father, a pulmonologist, had given him; then the second one, "with a red tube to entertain
the children." He has kept it to this day. "To be honest, I am not attached to symbols. My concern
is that technology should not distance us from the patients."
A pioneer of nuclear imaging, physician and philosopher, Henri Atlan adds: "We cannot
afford to be afraid of technology. Technology has facilitated considerable progress in medicine.
Healthcare is better, a lot better now than before. But these technologies that show everything,
sometimes show too much. We may think that something is pathological, when in fact it is simply
a case of individual variation." As for André Grimaldi, former head of the Diabetes Section at
the Pitié-Salpêtrière Hospital, opponent of the “hospital as a business” concept and of "industrial
medicine," he puts it in even stronger terms: "The power of medicine is not only costly, but also
potentially dangerous. The multiplication of examinations may easily lead to mistakes. Perform a
pancreas scan on the entire population and you will find many suspicious lumps. But is it
cancer? How far should we go with the checkups? Don’t we end up artificially creating
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patients? Medicine is not about that. It is a process made up of hypotheses and inferences, and
above all. a unique dialogue, an exchange with the person before us."
"A new technology becomes necessary when the old one is approximate,
painful or dangerous. Which is not the case here."
MARTIN WINCKLER
General Practitioner
The history of medical progress is also the history of separation from the patient, Céline
Lefève recalls. The assistant professor of the philosophy of medicine at the Paris-Diderot
University quotes Michel Foucault (Message or noise? 1966): "When doing his job, the physician
does not deal with a sick person, or with someone in pain, and least of all, thank God, with a
“human being.” He does not have to deal with the body, or with the soul, or with the two taken
together or combined. He deals with noise. And through that noise, he must hear the elements of
a message." As such, the ultrasound device; in Ms. Lefève’s opinion; "comes as a continuation
of the stethoscope, not as a break from it." It all depends on how it is used. It is what Jacques
Lucas, vice-president of the French Medical Council, cardiologist and manager of new
technology, admits to as well: "The image presents the risk-creating distance from the patients.
Or, on the contrary, it can also be an opportunity to get closer. We can explain an image to a
patient, we couldn’t have him listen through the stethoscope. However, doctors must be trained
in this respect."
Training. The buzz word, or rather the big gap. For Jacques Lucas, "it is certain that in a
few years’ time, the initial training of general practitioners will include the use of ultrasound
devices as a first resort." Meanwhile, it is limited to the teaching of certain specialties:
radiology, cardiology, gynecology ... and to the emergency-medicine physicians at state-of-theart university hospital centers, such as Amiens or Nîmes. "If we settle this issue, we will have
removed one of the two main obstacles in replacing the stethoscope by the ultrasound device,"
states doctor Xavier Bobbia, who is in charge of teaching these subjects at Nîmes. The second
one? "The price," he says smiling. “Now, you have to spend between 7,000 and 10,000 euros to
purchase an ultraportable ultrasound device. One hundred times the cost of a stethoscope.”
Which makes Martin Winckler smile: "The manufacturers may very well claim that this
device will be perfect for the Indian countryside doctor, far away from any ultrasound center.
But how is he going to pay for it? A new technology becomes necessary when the old one is
approximate, painful, or dangerous, which is not the case here. And the strength of the
stethoscope lies in its simplicity." He ponders: "Will books disappear because of iPads? I don’t
think so. It’s the same here. Let’s not be too quick to bury the stethoscope, it will hang in there
for the time being." A writer’s faith, and a doctor’s.
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[photo caption:]
At the Museum of Medicine, in Paris, a modern stethoscope, next to the prototypes
invented by Laennec, including a notebook rolled up into a cylinder.
ÉMILE LOREAUX FOR "LE MONDE"
FILE TWO
"The Role of the Physical Examination is being Eroded"
Bret Nelson is an emergency medicine physician and a professor at the Mount Sinai Hospital in
New York City. In December 2013, he co-signed an article announcing the death of the
stethoscope, which was published in the American journal Global Heart.
How was your editorial in the "Global Heart" received?
In a, let’s say ... controversial manner. Those who were already using mobile ultrasound devices
supported us. Others, in love with their stethoscopes, resisted this change, and they gained the
support of a third category, made up mainly of radiologists and cardiologists, worried to see the
technology that they had spent years learning become accessible to everybody. But, at the end of
the 19th century, when the use of the stethoscope was truly democratized, the specialists of that
time reacted in the same manner.
Are all students at the Icahn School of Medicine of Mount Sinai Hospital, trained to use the
ultrasound device?
Yes. Just like at the University of California at Irvine, at the University of South Carolina, at the
University of Ohio, and also at several others ... It is used as a visualization method in the firstyear anatomy course, but also in learning physical examination in the first and second years,
together with the stethoscope. Many students find the ultrasound device more practical, more
accurate, and more reliable.
With this new device, don’t we run the risk of distancing the patient from the doctor even
more?
I think it’s exactly the opposite. The scans and tests that were done outside the medical office
had this effect. Because they are more reliable than simple auscultation, they have actually
contributed to eroding the role of the physical examinations for thirty or forty years. Ultrasound
can, on the contrary, bring the patient and the practitioner closer together. They will look at the
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images, assess the results, discuss the consequences together, and the examination becomes all
the more valuable as it is done by the very person who knows the patient and his history.
It is also a symbol that you suggest should disappear ...
I remember that once, here in the United States, one of the physicians’ symbols was the circular
mirror they used to wear on their head to examine the throat. It is gone. Physicians in the United
Kingdom no longer wear white coats for fear that they carry infections – another symbol that is
extinct. In Star Trek, doctor McCoy prepared us already in the 1960s, to see a physician waving
a wand over a patient: the ultrasound device matches this image perfectly.
REMARKS COLLECTED BY N.H.
FILE THREE
Inspired by child’s game, Laennec lays the foundation of modern
medicine
To invent something, all you need to do is look in the right direction. And, if possible,
outside your field of competence. The invention of the stethoscope by René Laennec is a perfect
illustration of this principle. One day, in 1816, as he was walking across the courtyard of the
Louvre, the doctor observed two children playing around a wooden beam. One of them tapped its
end with a pin; the other one, his ear pressed against the other end, listened closely. Sometime
later, consulting "a young woman presenting the general symptoms of heart disease, in whose
case the application of the hand and the percussion yielded poor results due to her being
overweight," Laennec remembered the two children. He grabbed a notebook, rolled it up and
placed the cylinder formed this way on the patient’s chest. "I was both surprised and pleased to
hear the heartbeats in a manner that was both clearer and more distinct than I had ever been
able to hear them by the immediate application of the ear." The stethoscope was born.
A year later, Laennec was developing his technique and reviewing various materials. On
February 23, 1818, he presented his invention at the Academy of Science: a 30 cm x 3 cm
wooden cylinder, with a 6 mm central channel and the shape of a funnel, with the end intended
for the patient. In time, he added a shutter to adjust his instrument: cylindrical to listen to the
voice and the heart, and funnel-shaped for the lungs. As for the name, it was one of his students
who came up with it, from the Greek works stethos (chest) and scopio (to examine).
A trained ear
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In 1819, the first edition of his major work was published: L’Auscultation médiate ou
Traité du diagnostic des maladies des poumons et du cœur, fondé principalement sur ce nouveau
moyen d’exploration [On Indirect auscultation or Treatise on the diagnosis of diseases of the
lungs and heart, Based mainly on this new means of examination]. Nearly one thousand pages of
classification and examination methods of pulmonary, respiratory and vocal pathologies. To
achieve that, Laennec multiplied his auscultations, but also his corpse dissections. Convinced
that every disease has an organic cause and that each abnormal sound results from an injury, he
set out to establish the connections.
A skilled flute player, Laennec took advantage of his trained ear to achieve descriptions
of rare accuracy. Here is how he described the auscultation of a woman presenting "some signs
of tuberculosis." Listening to the right carotid artery, he heard "instead of the noise of bellows,
the sound of a musical instrument playing a rather monotonous tune (...). At first, I thought that
there was someone playing in the apartment located below. I strained my ear; I placed the
stethoscope on other points: I could not hear anything. After making sure that the sound came
from the artery, I studied the tune: it unfolded on three notes forming an interval close to a
major third; the highest note was off-key and a little too deep, but not enough to be marked with
a flat." In the manuscript, he even goes as far as to write staffs, where he indicates notes and
times.
He does not stop, however, at drawing on his experience as a musician. Further on, he
mentions a wheezing sound similar to "the voice of a ventriloquist or of a chimney-sweeper
heard from afar, without being able to make out the words, due to the narrowing of the flue of
the chimney." This new method, this new vocabulary, contributed to the foundation of modern
medicine. The physician can now describe an injury without any contribution from the patient.
The patient takes second place to the disease.
The work was enthusiastically received, with a few exceptions, among whom François
Broussais. A Breton, like Laennec, as much of a republican and an atheist as Laennec was a
Catholic and a monarchist, Broussais, was convinced that the seat of the disease was "an
irritation," roared "the man with the horn." Except that, a few years later, Laennec’s work
prevailed. The treatise was translated into several languages.
As for the stethoscope, it continued to evolve. It became bell-shaped in 1828, flexible in
1832, binaural in 1870 ... many innovations that the physician, who became a professor at the
Collège de France, did not live to witness. In 1826, after having also discovered melanoma and
cirrhosis, he died of the disease he had spent his entire life fighting: tuberculosis. The story goes
that he contracted it during a dissection and that it was his cousin, Meriadec, who diagnosed it,
using his very own stethoscope.
N. H.
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