Stethoscope

Stethoscope

Modern stethoscope
Classification Medical device
Industry Medicine
Application Auscultation
Inventor René Laennec
Invented 1816

Stethoscope Sounds
0:00 / 0:00
Recorded auscultation of a healthy 16 year old girl's heart, as heard with a digital stethoscope on the
tricuspid valve area.

Problems playing this file? See media help.

The stethoscope is a medical device for auscultation, or listening to internal sounds of an animal or
human body. It typically has a small disc-shaped resonator that is placed against the skin, with either one
or two tubes connected to two earpieces. A stethoscope can be used to listen to the sounds made by the
heart, lungs or intestines, as well as blood flow in arteries and veins. In combination with a manual
sphygmomanometer, it is commonly used when measuring blood pressure.

Less commonly, "mechanic's stethoscopes", equipped with rod shaped chestpieces, are used to listen to
internal sounds made by machines (for example, sounds and vibrations emitted by worn ball bearings),
such as diagnosing a malfunctioning automobile engine by listening to the sounds of its internal parts.
Stethoscopes can also be used to check scientific vacuum chambers for leaks and for various other small-
scale acoustic monitoring tasks.

A stethoscope that intensifies auscultatory sounds is called a phonendoscope.

History
The stethoscope was invented in France in 1816 by René Laennec
at the Necker-Enfants Malades Hospital in Paris.[1][2][3] It
consisted of a wooden tube and was monaural. Laennec invented
the stethoscope because he was not comfortable placing his ear
directly onto a woman's chest in order to listen to her
heart.[4][5]: 186 He observed that a rolled piece of paper, placed
between the individual's chest and his ear, could amplify heart
sounds without requiring physical contact.[6] Laennec's device was
similar to the common ear trumpet, a historical form of hearing
aid; indeed, his invention was almost indistinguishable in structure This early stethoscope belonged to
and function from the trumpet, which was commonly called a Laennec. (Science Museum,
London)
"microphone". Laennec called his device the "stethoscope"[7]
(stetho- + -scope, "chest scope"), and he called its use "mediate
auscultation", because it was auscultation with a tool intermediate
between the individual's body and the physician's ear. (Today the
word auscultation denotes all such listening, mediate or not.) The
first flexible stethoscope of any sort may have been a binaural
instrument with articulated joints not very clearly described in
1829.[8] In 1840, Golding Bird described a stethoscope he had
been using with a flexible tube. Bird was the first to publish a
description of such a stethoscope, but he noted in his paper the
prior existence of an earlier design (which he thought was of little
utility) which he described as the snake ear trumpet. Bird's
stethoscope had a single earpiece.[9]

Binaural devices
In 1851, Irish physician Arthur Leared invented a binaural
stethoscope, and in 1852, George Philip Cammann perfected the
design of the stethoscope instrument (that used both ears) for Early stethoscopes
commercial production, which has become the standard ever
since. Cammann also wrote a major treatise on diagnosis by
auscultation, which the refined binaural stethoscope made possible. By
1873, there were descriptions of a differential stethoscope that could
connect to slightly different locations to create a slight stereo effect,
though this did not become a standard tool in clinical practice.

Somerville Scott Alison described his invention of the stethophone at

the Royal Society in 1858; the stethophone had two separate bells,
A Traube-type stethoscope in
allowing the user to hear and compare sounds derived from two discrete ivory
locations. This was used to do definitive studies on binaural hearing and
auditory processing that advanced knowledge of sound localization and
eventually led to an understanding of binaural fusion.[1]

The medical historian Jacalyn Duffin has argued that the invention of the stethoscope marked a major
step in the redefinition of disease from being a bundle of symptoms, to the current sense of a disease as a
problem with an anatomical system even if there are no observable symptoms. This re-conceptualization
occurred in part, Duffin argues, because prior to stethoscopes, there were no non-lethal instruments for
exploring internal anatomy.[10]

Rappaport and Sprague designed a new stethoscope in the 1940s, which became the standard by which
other stethoscopes are measured, consisting of two sides, one of which is used for the respiratory system,
the other for the cardiovascular system. The Rappaport-Sprague was later made by Hewlett-Packard. HP's
medical products division was spun off as part of Agilent Technologies, Inc., where it became Agilent
Healthcare. Agilent Healthcare was purchased by Philips which became Philips Medical Systems, before
the walnut-boxed, $300, original Rappaport-Sprague stethoscope was finally abandoned ca. 2004, along
with Philips' brand (manufactured by Andromed, of Montreal, Canada) electronic stethoscope model. The
Rappaport-Sprague model stethoscope was heavy and short (18–24 in (46–61 cm)) with an antiquated
appearance recognizable by their two large independent latex rubber tubes connecting an exposed leaf-
spring-joined pair of opposing F-shaped chrome-plated brass binaural ear tubes with a dual-head chest
piece.

Several other minor refinements were made to stethoscopes until,

in the early 1960s, David Littmann, a Harvard Medical School
professor, created a new stethoscope that was lighter than previous
models and had improved acoustics.[11][12] In the late 1970s, 3M-
Littmann introduced the tunable diaphragm: a very hard (G-10)
glass-epoxy resin diaphragm member with an overmolded silicone
flexible acoustic surround which permitted increased excursion of
the diaphragm member in a Z-axis with respect to the plane of the
Early flexible tube stethoscopes.
sound collecting area.[13] The left shift to a lower resonant
Golding Bird's instrument is on the frequency increases the volume of some low frequency sounds
left. The instrument on the right is due to the longer waves propagated by the increased excursion of
the stethophone. [1] the hard diaphragm member suspended in the concentric accountic
surround. Conversely, restricting excursion of the diaphragm by
pressing the stethoscope diaphragm surface firmly against the
anatomical area overlying the physiological sounds of interest, the acoustic surround could also be used
to dampen excursion of the diaphragm in response to "z"-axis pressure against a concentric fret. This
raises the frequency bias by shortening the wavelength to auscultate a higher range of physiological
sounds.

In 1999, Richard Deslauriers patented the first external noise reducing stethoscope, the DRG Puretone. It
featured two parallel lumens containing two steel coils which dissipated infiltrating noise as inaudible
heat energy. The steel coil "insulation" added .30 lb to each stethoscope. In 2005, DRG's diagnostics
division was acquired by TRIMLINE Medical Products.[14]

Current practice
Stethoscopes are a symbol of healthcare professionals. Healthcare providers are often seen or depicted
wearing a stethoscope around the neck. A 2012 research paper claimed that the stethoscope, when
compared to other medical equipment, had the highest positive impact on the perceived trustworthiness of
the practitioner seen with it.[15][16]
Prevailing opinions on the utility of the stethoscope in current
clinical practice vary depending on the medical specialty. Studies
have shown that auscultation skill (i.e., the ability to make a
diagnosis based on what is heard through a stethoscope) has been
in decline for some time, such that some medical educators are
working to re-establish it.[17][18][19]

In general practice, traditional blood pressure measurement using

a mechanical sphygmomanometer with inflatable cuff and
stethoscope is gradually being replaced with automated blood A doctor using a stethoscope on a
pressure monitors.[20] patient's abdomen to listen to bowel
sounds

Types

Acoustic
Acoustic stethoscopes operate on the transmission of sound from
the chest piece, via air-filled hollow tubes, to the listener's ears.
The chestpiece usually consists of two sides that can be placed
against the patient for sensing sound: a diaphragm (plastic disc) or
bell (hollow cup). If the diaphragm is placed on the patient, body
sounds vibrate the diaphragm, creating acoustic pressure waves
which travel up the tubing to the listener's ears. If the bell is placed
on the patient, the vibrations of the skin directly produce acoustic
pressure waves traveling up to the listener's ears. The bell Parts of a binaural stethoscope
transmits low frequency sounds, while the diaphragm transmits
higher frequency sounds. To deliver the acoustic energy primarily
to either the bell or diaphragm, the tube connecting into the chamber between
bell and diaphragm is open on only one side and can rotate. The opening is
visible when connected into the bell. Rotating the tube 180 degrees in the
head connects it to the diaphragm. This two-sided stethoscope was invented
by Rappaport and Sprague in the early part of the 20th century.

Acoustic stethoscope,
Electronic with the bell upwards

An electronic stethoscope (or stethophone) overcomes the low

sound levels by electronically amplifying body sounds. However,
amplification of stethoscope contact artifacts, and component
cutoffs (frequency response thresholds of electronic stethoscope
microphones, pre-amps, amps, and speakers) limit electronically
amplified stethoscopes' overall utility by amplifying mid-range
sounds, while simultaneously attenuating high- and low-
frequency range sounds. Currently, a number of companies offer
Electronic stethoscope
electronic stethoscopes. Electronic stethoscopes require
conversion of acoustic sound waves to electrical signals which can
then be amplified and processed for optimal listening. Unlike acoustic stethoscopes, which are all based
on the same physics, transducers in electronic stethoscopes vary widely. The simplest and least effective
method of sound detection is achieved by placing a microphone in the chestpiece. This method suffers
from ambient noise interference and has fallen out of favor. Another method, used in Welch-Allyn's
Meditron stethoscope, comprises placement of a piezoelectric crystal at the head of a metal shaft, the
bottom of the shaft making contact with a diaphragm. 3M also uses a piezo-electric crystal placed within
foam behind a thick rubber-like diaphragm. The Thinklabs' Rhythm 32 uses an electromagnetic
diaphragm with a conductive inner surface to form a capacitive sensor. This diaphragm responds to sound
waves, with changes in an electric field replacing changes in air pressure. The Eko Core enables wireless
transmission of heart sounds to a smartphone or tablet. The Eko Duo can take electrocardiograms as well
as echocardiograms. This enables clinicians to screen for conditions such as heart failure, which would
not be possible with a traditional stethoscope.[21][22]

Because the sounds are transmitted electronically, an electronic stethoscope can be a wireless device, can
be a recording device, and can provide noise reduction, signal enhancement, and both visual and audio
output. Around 2001, Stethographics introduced PC-based software which enabled a phonocardiograph,
graphic representation of cardiologic and pulmonologic sounds to be generated, and interpreted according
to related algorithms. All of these features are helpful for purposes of telemedicine (remote diagnosis) and
teaching.

Electronic stethoscopes are also used with computer-aided auscultation programs to analyze the recorded
heart sounds pathological or innocent heart murmurs.

Recording
Some electronic stethoscopes feature direct audio output that can be used with an external recording
device, such as a laptop or MP3 recorder. The same connection can be used to listen to the previously
recorded auscultation through the stethoscope headphones, allowing for more detailed study for general
research as well as evaluation and consultation regarding a particular patient's condition and
telemedicine, or remote diagnosis.[23]

There are some smartphone apps that can use the phone as a stethoscope.[24] At least one uses the phone's
own microphone to amplify sound, produce a visualization, and e-mail the results. These apps may be
used for training purposes or as novelties, but have not yet gained acceptance for professional medical
use.[25]

The first stethoscope that could work with a smartphone application was introduced in 2015 [26]

Fetal
A fetal stethoscope or fetoscope is an acoustic stethoscope shaped like a listening trumpet. It is placed
against the abdomen of a pregnant woman to listen to the heart sounds of the fetus.[27] The fetal
stethoscope is also known as a Pinard horn after French obstetrician Adolphe Pinard (1844–1934).

Doppler
A Doppler stethoscope is an electronic device that measures the Doppler
effect of ultrasound waves reflected from organs within the body. Motion is
detected by the change in frequency, due to the Doppler effect, of the
reflected waves. Hence the Doppler stethoscope is particularly suited to deal
with moving objects such as a beating heart.[28] It was recently demonstrated
that continuous Doppler enables the auscultation of valvular movements and
blood flow sounds that are undetected during cardiac examination with a
stethoscope in adults. The Doppler auscultation presented a sensitivity of
84% for the detection of aortic regurgitations while classic stethoscope
auscultation presented a sensitivity of 58%. Moreover, Doppler auscultation
was superior in the detection of impaired ventricular relaxation. Since the
physics of Doppler auscultation and classic auscultation are different, it has A Pinard horn used by a
been suggested that both methods could complement each other.[29][30] A U.S. Army Reserve
military noise-immune Doppler based stethoscope has recently been nurse in Uganda
developed for auscultation of patients in loud sound environments (up to
110 dB).

3D-printed
A 3D-printed stethoscope is an open-source medical device
meant for auscultation and manufactured via means of 3D
printing.[31] The 3D stethoscope was developed by Dr. Tarek
Loubani and a team of medical and technology specialists. The
3D-stethoscope was developed as part of the Glia project, and its
design is open source from the outset. The stethoscope gained
widespread media coverage in Summer 2015.

The need for a 3D-stethoscope was borne out of a lack of A 3D-printed stethoscope
stethoscopes and other vital medical equipment because of the
blockade of the Gaza Strip, where Loubani, a Palestinian-
Canadian, worked as an emergency physician during the 2012 conflict in Gaza. The 1960s-era Littmann
Cardiology 3 stethoscope became the basis for the 3D-printed stethoscope developed by Loubani.[32]

Esophageal
Prior to the 1960s, the esophageal stethoscope was a part of the routine intraoperative monitoring.[33]

Earpieces
Stethoscopes usually have rubber earpieces, which aid comfort and create a seal with the ear, improving
the acoustic function of the device. Stethoscopes can be modified by replacing the standard earpieces
with moulded versions, which improve comfort and transmission of sound. Moulded earpieces can be
cast by an audiologist or made by the stethoscope user from a kit.

See also

Medicine portal

Doppler fetal monitor

Speaking tube

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External links
The Auscultation Assistant (http://www.med.ucla.edu/wilkes/intro.html), provides heart
sounds, heart murmurs, and breath sounds in order to help medical students and others
improve their physical diagnosis skills
Demonstrations: Heart Sounds & Murmurs (http://depts.washington.edu/physdx/heart/demo.
html) University of Washington School of Medicine
"The invention of the stethoscope: A milestone in cardiology", analysis of Laennec's text
(1819) on BibNum (http://www.bibnum.education.fr/sciencesdelavie/medecine-clinique/de-l-
auscultation-mediate) [click 'à télécharger' for English version].

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