“No God and no religion can survive ridicule. No political church, no nobility, no royalty or other fraud, can face ridicule in a fair field, and live”
- Mark Twain
Every new technology has been a great money spinner in medicine and excited lots of doctors and patients alike. Look at the story this week in the British Medical Journal of the “Proton beam therapy might once have seemed like the magic bullet to zap cancer, the state of the art treatment we have all been waiting for. The technology is big and expensive—the world’s "most costly and complicated medical devices; looks and sounds as if a Star Trek scriptwriter might have dreamt it up. England’s health secretary, Andrew Lansley, clearly believes it represents the future of cancer services—his department announced earlier this month that it would spend £250m on two National Health Service centres for proton beam therapy. But where did he get his evidence? The treatment hasn’t been appraised by the National Institute for Health and Clinical Excellence.” Recently an audit in the USA showed that this new instrument is in no way better than the conventional therapy. The study had 12000 patients.
You will be surprised to know that similar claptrap existed even in the times gone by. History repeats itself. Cicero, the Roman thinker was right when he said that if we do not learn from history we will be condemned to relive history. That is what is happening everywhere. “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.”
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:
“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.”
What does not change is, of course, a kind doctor’s bed side touch which provokes the immune system to heal any disease. Long live a humane doctor.
“We are the children of a technological age. We have found streamlined ways of doing much of our routine work. Printing is no longer the only way of reproducing books. Reading them, however, has not changed...”
- Lawrence Clark Powell
(I have drawn heavily for this piece from my book What Doctors don’t get to study in Medical School? I thank the publishers)