Some high pitched thoughts on chest examination

Observation reveals that about half of chest physicians use the stethoscope bell when auscultating the lungs and the other half use the diaphragm. None directly apply their ears. Despite extensive reading we have not encountered an evidence based answer to the question “Should normal mortals use the bell or diaphragm?” This unanswered question thus prompted an acoustical odyssey. Strangely the stethoscope was developed by Rene Theophile Hyacinthe Laennec not to enhance respiratory sounds but rather to avoid embarrassment! In 1816, he was called to a young lady “who presented the general symptoms of disease of the heart; the application of the hand to the chest, and percussion, afforded very little assistance, and immediate [meaning placement of his ear on the chest] auscultation was interdicted by the sex and enbonpoint [a euphemism for breasts] of the patient”.1 In 1819, after various trials with materials of different density, Laennec found a cylinder of moderately light wood most convenient. After the publication of his thesis (L'auscultation mediate) in 1819 and its translation into English by the Edinburgh trained physician John Forbes in 1824, the stethoscope rapidly increased in popularity. In 1851, at the Great International Exhibition, the first binaural stethoscope was demonstrated by Dr Leared. In the British Medical Journal of 1884, E T Aydon Smith described the “ultimate instrument” that could be employed as a monaural, binaural, or differential stethoscope, an otoscope (using the chest piece) and the tubing could be used as an enema or oesophageal tube, a catheter, or a tourniquet!2 Diaphragm stethoscopes (often termed phonendoscopes) were first introduced at the end of the 19th century but it was not until 1926 that Howard Sprague of Boston described the combined bell and diaphragm chest piece of the modern stethoscope.3 Although lacking the versatility of the “ultimate instrument”, …