It was recently reported in the media that the stethoscope could be replaced by ultrasound devices. God forbid. How can they possibly replace stethoscopes? Having lived with them for more than three decades in the field of medicine, I cannot imagine a doctor without a stethoscope.
As a medical student, it was a great feeling to own one. Many of us could afford only locally made ones bought for Rs.25. Some rich classmates had imported Littman stethoscopes, which cost Rs.1,000.
After completing the MBBS course, I was Senior House Officer in the Department of Cardiology at the Southern Railway Hospital at Perambur in Chennai in 1977, working under Dr. T.J. Cherian. Virtually the only appliance we doctors then had was the stethoscope, and we relied on clinical skills imparted by senior cardiologists and cardiac surgeons. Even heads of department like Dr. Cherian and Dr. K.A. Abraham would study the details of each patient and commit the diagnosis.
In southern India, Christian Medical College (CMC) Hospital, Vellore and the Railway Hospital were the premier centres for cardiac surgery in the early-1970s, and both had cardiac catheterisation laboratories. After a detailed examination we would send patients to the ‘cath lab’ for confirmation of the diagnosis. Sometimes the final diagnosis would come only during open-heart surgery.
Dr. Stanley John, Dr. George Cherian and Dr. N. Gopinath of the CMCH, Dr. P. Venugopal and Dr. I.M. Rao of the All India Institute of Medical Sciences, Dr. M.R. Girinath, Dr. K.M. Cherian and Dr. K.A. Abraham of the Railway Hospital, Dr. K.V.Thiruvengadam of the Madras Medical College, Professor P. Krishnan Kutty of the Stanley Medical College, Chennai, Professor T.S. Ramadurai (who was the first to speak about Electrophysiology), Dr. K.P. Mishra (who made ECG familiar to physicians and students), all were giants in cardiology and cardiovascular surgery known particularly for their clinical skills, still in the era of the stethoscope.
Ultrasound techniques were unknown then. Through clinical examination they would arrive at reasonably good conclusions. Fairly accurate diagnosis was made by the bedside by means of physical examination, auscultation, X-ray and ECG.
One day at the Railway Hospital a small gadget arrived, and Dr. Cherian announced India’s first cardiac ultrasound device. That was probably the start of the ultrasound era in India in cardiology.
Today we have powerful ultrasound systems that can give accurate details of cardiac anomalies. Newer technologies are available to do intravascular ultrasound, 3D echocardiogram and intra-cardiac echo. But will any or all of these devices replace the stethoscope?
A stethoscope can assess heart function and any obstruction and leakage of its valves. It can predict and follow-up the effects of treatment of heart failure. Most birth defects involving the heart can be diagnosed fairly well by the use of the stethoscope, besides ECG, X-ray and echocardiogram.
Doctors can detect cardiac complications such as Papillary Muscle Rupture and Ventricular Septal Rupture with the stethoscope. It could help accurately evaluate valve function and the functioning of artificial valves. It could help assess lungs and lung diseases. The ultrasound is of no use in most of these cases.
An obstetrician can listen to foetal heartbeat during advanced pregnancy with a fair amount of accuracy with a simple foetoscope and predict foetal distress.
Can you imagine an anaesthetist without a stethoscope? He or she needs it to know if a patient’s endotracheal tube is in the wind pipe or in the food pipe. He needs to check if he is bellowing both lungs properly.
Imagine an intensivist in the intensive care unit without a stethoscope. He has to continuously monitor the heart, lungs and abdomen. The general surgeon uses a stethoscope to listen to bowel sounds during the post-operative period. What a marvellous piece of invention the stethoscope really is.
Today ultrasound is a part of the armamentarium for the medical man and woman. We do need it. Let it serve the purpose as an additional investigation tool for a specific purpose, and not as a routine test. Mind you, it will also add to the cost to the patient. An ultrasound device just cannot replace a stethoscope, which costs the patient nothing.
And in any case, the most important part of the stethoscope is the medical professional’s brain situated between the two ear-pieces. It gives immense confidence to both the patient and the doctor. It will serve the purpose for which it is invented by great clinician with great clinical knowledge.
(Professor J.S.N. Murthy is now Vice-Chancellor and Professor of Cardiology, Sri Ramachandra University & Sri Ramachandra Medical Centre, Chennai. firstname.lastname@example.org)