Tag Archives: stethoscope

Your Tool Touches Me

Posted on February 8, 2014 | Leave a comment

It is little known that René Laënnec, the Parisian physician who invented the stethoscope at the Necker Hospital in 1816, found it distasteful to place his ear to the patient’s chest.  The distastefulness of “direct auscultation” was compounded by its impracticality in the hospital where, he observed, “it was scarcely to be suggested for most women patients, in some of whom the size of the breasts also posed a physical obstacle.”[1]  The stethoscope, which permitted “mediate auscultation,” not only amplified heart and lung sounds in diagnostically transformative ways; it enabled Laënnec to avoid repugnant  ear to chest contact.

Many women patients of Laënnec’s time and place did not see it that way.  Accustomed to the warmly human pressure of ear on chest, they were uncomfortable when an elongated wooden cylinder was interposed between the two.  By the closing decades of the nineteenth century, of course, the situation was inverted:  The stethoscope, in its modern binaural guise, had become so integral to physical examination that patients  hardly viewed it as a tool at all.  It had become emblematic of hands-on doctoring and, as such, a sensory extender of the doctor.  Even now, the stethoscope virtually stands in for the doctor, especially the generalist or the cardiologist, so that a retiring physician will announce that he is, or will be characterized by others as, hanging up his stethoscope.[2]

It’s easy to argue for the “oneness” of the physician and his or her instruments when it’s a matter of simple tools that amplify sensory endowment  (stethoscopes), provide a hands-on bodily “reading” (of temperature or blood pressure), or elicit a tendon reflex (e.g., the reflex hammer).  And the argument can be extended without much difficulty to the more invasive, high-tech “scopes” used by medical specialists to see what is invisible to the naked eye.  Instruments become so wedded to one or another specialty that it is hard to think of our providers without them.  What is an ophthalmologist without her ophthalmoscope?  An ENT without his nasal speculum?  A gynecologist without her vaginal speculum?  An internist without his blood pressure meter?  Such hand-held devices are diagnostic enablers, and as such they are, or at least ought to be, our friends.

In “Caring Technology” I  suggested that even large-scale technology administered by technicians, and therefore outside the physician’s literal grasp, can be linked in meaningful ways to the physician’s person.  A caring explanation of the need for this or that study, informed by a relational bond, can humanize even the most forbidding high-tech machinery.  To be sure, medical machinery, whatever the discomfort and/or bodily bombardment it entails, is often discomfiting.  But it need be alienating only when we come to it in an alienated state, when it is not an instrument of physicianly engagement but a dehumanized object – a piece of technology.

Critical care nurses, whose work is both technology-laden and technology-driven, have had much to say on the relationship of technology to nursing identity and nursing care.  This literature includes provocative contributions that look at where nurses stand in a hospital hierarchy that comprises staff physicians, residents, students, administrators, patients, and patients’ families.

For some CCU nurses, the use of technology and the acquisition of technological competence segue into issues of power and autonomy and they, in turn, are linked to issues of gender, medical domination, and “ownership” of the technology.[3]  A less feminist sensibility informs interview research that yields unsurprising empirical findings, viz.,  that comfort with technology and the ability to incorporate it into a caring, “touching” disposition hinge on the technological mastery associated with nursing experience.  Student and novice nurses, for example, find the machinery of the CCU anxiety-inducing, even overwhelming.  They resent the casual manner in which physicians relegate to them complex technological tasks, such as weaning patients from respirators, without appreciating the long list of  nursing duties to which such tasks are appended.[4]  Withal, beginners approach the use of technology in task-specific ways and have great difficulty “caring with technology.”[5]   Theirs is not a caring technology but a technology that causes stress and jeopardizes fragile professional identities.

Experienced CCU nurses, on the other hand, achieve a technological competence that lets them pull the machinery to them; they use it as a window of opportunity for being with their patients.[6]   Following Christine Little, we can give the transformation from novice to expert a phenomenological gloss and say that as technological inexperience gives way to technological mastery, technological skills become “ready-to-hand” (Heidegger) and “a natural extension of practice.”[7]

Well and good.  We want critical care nurses comfortable with the machinery of critical care – with cardiac and vital signs monitors, respirators, catheters, and infusion pumps – so that implementing technological interventions and monitoring the monitors do not blot out the nurse’s “presence”  in the patient’s care.   But all this is from the perspective of the nurse and her role in the hospital.  What, one wonders, does the patient make of all this technology?

Humanizing technology means identifying with it in ways that are not only responsive to the patient’s fears but also conducive to a shared appreciation of its role in treatment.  It is easier for patients to feel humanly touched by technology, that is, if their doctors and nurses appropriate it and represent it as an extender of care.  Perhaps some doctors and nurses do so as a matter of course, but one searches the literature in vain for examples of nurse-patient or doctor-patient interactions that humanize technology through dialogue.  And such dialogue, however perfunctory in nature, may greatly matter.

Consider the seriously ill patient whose nurse interacts with him without consideration of the technology-saturated environment in which care is given.  Now consider the seriously ill patient whose nurse incorporates the machinery into his or her caregiving identity, as in “This monitor [or this line or this pump] is a terrific thing for you and for me.  It lets me take better care of you.”  Such reassurance, which can be elaborated in any number of patient-centered ways, is not trivial; it may turn an anxious patient around, psychologically speaking.  And it is all the more important when, owing to the gravity of the patient’s condition, the nurse must spend more time assessing data and tending to machinery than caring for the patient.  Here especially the patient needs to be reminded that the nurse’s responsibility for machinery expands his or her role as the patient’s guardian.[8]

The touch of the physician’s sensory extenders, if literally uncomfortable, may still be comforting.  For it is the physician’s own ears that hear us through the stethoscope and whose own eyes gaze on us through the ophthalmoscope, the laryngoscope, the esophagoscope, the colposcope.  It is easier to appreciate tools as beneficent extenders of care in the safe confines of one’s own doctor’s office, where instrumental touching is fortified by the relational bond that grows out of continuing care.  In the hospital, absent such relational grounding, there is  more room for dissonance and hence more need for shared values and empathy.  A nurse who lets the cardiac monitor pull her away from patient care will not do well with a frightened patient who needs personal caring.  A parturient who welcomes the technology of the labor room will connect better with a labor nurse who values the electronic fetal monitor (and the reassuring visualization it provides the soon-to-be mother) than a nurse who is unhappy with its employment in low-risk births and prefers a return to intermittent auscultation.

In the best of circumstances, tools elicit an intersubjective convergence grounded in an expectation of objectively superior care.  It helps to keep the “objective care” part in mind, to remember that technology was not devised to frighten us, encumber us, or cause us pain,  but to help doctors and nurses evaluate us, keep us stable and comfortable, and enable treatments that will make us better, or at least leave us better off than our technology-free forebears.

My retinologist reclines the examination chair all the way back and begins prepping my left eye for its second intravitreal  injection of Eylea, one of the newest drugs used to treat macular disease.  I am grateful for all the technology that has brought me to this point:  the retinal camera, the slit lamp, the optical coherence tomography machine.  I am especially grateful for the development of fluorescein angiography, which allows my doctor to pinpoint with great precision the lesion in need of treatment.  And of course I am grateful to my retinologist, who brings all this technology to bear with a human touch, calmly reassuring me through every step of evaluation and treatment.

I experienced almost immediate improvement after the first such injection a month earlier and am eager to proceed with the treatment.  So I am relatively relaxed as he douses my eye with antiseptic and anesthetic washes in preparation for the needle.  Then, at the point of injection, he asks me to look up at the face of his assistant, a young woman with a lovely smile.  “My pleasure,” I quip, slipping into gendered mode.  “I love to look at pretty faces.”   I am barely aware of the momentary pressure of the needle that punctures my eyeball and releases this wonderfully effective new drug into the back of my eye.  It is not the needle that administers treatment but my trusted and caring physician.  “Great technique,” I remark.  “I barely felt it.”  To which his young assistant, still standing above me, smiles and adds,  “I think I had something to do with it.”  And indeed she had.

[1] Quoted in J. Duffin, To See with a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998), p. 122.

[2] Here are a few recent examples:  O. Samuel, “On hanging up my stethoscope,” BMJ, 312:1426, 1996; “Dr. Van Ausdal hangs up his stethoscope,” YSNews.com, September 26, 2013 (http://ysnews.com/news/2013/09/dr-van-ausdal-hangs-up-his-stethoscope);  “At 90, Gardena doctor is hanging up his stethoscope,” The Daily Breeze, October, 29, 2013 (http://www.dailybreeze.com/general-news/20131029/at-90-gardena-doctor-is-hanging-up-his-stethoscope);  “Well-known doctor hangs up his stethoscope,” Bay Post, February 8, 2014 (http://www.batemansbaypost.com.au/story/1849567/well-known-doctor-hangs-up-his-stethoscope)

[3] See, for example, A. Barnard, “A critical review of the belief that technology is a neutral object and nurses are its master,” J. Advanced Nurs., 26:126-131, 1997; J. Fairman & P. D’Antonio, “Virtual power: gendering the nurse-technology relationship,” Nurs. Inq., 6:178-186, 1999; & B. J. Hoerst & J. Fairman, “Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing,” Western J. Nurs. Res., 22:475-491, 2000, at pp. 481-82.

[4] C. Crocker & S. Timmons, “The role of technology in critical care nursing,” J. Advanced Nurs., 65:52-61, 2008.

[5] M. McGrath, “The challenges of caring in a technological environment:  critical care nurses’ experiences,” J. Clin. Nurs., 17:1096-1104, 2008.

[6] A. Bernardo, “Technology and true presence in nursing,” Holistic Nurs. Prac., 12:40-49, 1998;  R. C. Locsin,  Technological Competency As Caring in Nursing: A Model For Practice (Indianapolis: Centre Nursing Press, 2005);  McGrath, “The challenges of caring,” op. cit.

[7] C. V. Little, “Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study,” J. Clin. Nurs., 9:391-399, 2000, at pp. 398, 396.

[8] See E. A. McConnell, “The impact of machines on the work of critical care nurses,” Crit. Care Nurs. Q., 12:45-52, 1990, at p. 51; D. Pelletier , et al., “The impact of the technological care environment on the nursing role, Int. J. Tech. Assess. Health Care, 12:35     8-366, 1996.C

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

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Posted in Doctor-Patient Communication, Medical Instruments, Medical Technology, Old & New, Nursing, Nursing and Gender

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Caring Technology

Posted on October 11, 2012 | Leave a comment

The critique of contemporary medical treatment as impersonal, uncaring, and disease-focused usually invokes the dehumanizing perils of high technology.  The problem is that high technology is a moving target.  In the England of the 1730s, obstetrical forceps were the high technology of the day; William Smellie, London’s leading obstetrical physician, opposed their use for more than a decade, despite compelling evidence that the technology revolutionized childbirth by permitting obstructed births to become live births.[1]  For much of the nineteenth century, stethoscopes and sphygmomanometers (blood pressure meters) were considered technological contrivances that distanced the doctor from the patient.  For any number of Victorian patients (and doctors too), the kindly ear against the chest and the trained finger on the wrist helped make the physical examination an essentially human encounter.  Interpose instruments between the physician and the patient and, ipso facto, you distance the one from the other.  In late nineteenth-century Britain, “experimental” or “laboratory” medicine was itself a revolutionary technology, and it elicited  bitter denunciation from antivivisectionists (among whom were physicians) that foreshadows contemporary indictments of the “hypertrophied scientism” of modern medicine.[2]

Nineteenth-century concerns about high technology blossomed in the early twentieth century when technologies (urinalysis, blood studies, x-rays, EKGs) multiplied and their use switched to hospital settings.  Older pediatricians opposed the use of the new-fangled incubators for premature newborns. They  not only had faulty ventilation that deprived infants of fresh air but were a wasteful expenditure, given that preemies of the poor were never brought to the hospital right after birth.[3]   Cautionary words were always at hand for the younger generation given to the latest gadgetry.  At the dedication of Yale’s Sterling Hall of Medicine, the neurosurgeon Harvey Cushing extolled family physicians as exemplars of his gospel of observation and deduction and urged  Yale students to engage in actual “house-to-house practice” without the benefit of “all of the paraphernalia and instruments of precision supposed to be necessary for a diagnosis.”  This was in 1925.[4]

Concerns about the impact of technology on doctor-patient relationships blossomed again in the 1960s and 70s and played a role  in the rebirth of primary care medicine in the guise of the “family practice movement.”  Reading the papers of the recently deceased G. Gayle Stephens, written at the time and collected in his volume The Intellectual Basis of Family Practice (1982), is a strong reminder of the risks attendant to loading high technology with relational meaning.  Stephens, an architect of the new structure of primary care training, saw the “generalist role in medicine” as an aspect of 70s counterculture that questioned an “unconditional faith in science” that extended to medical training, practice, and values.  And so he aligned the family practice movement with other social movements of the 70s that sought to put the breaks on scientism run rampant:  agrarianism, utopianism, humanism, consumerism, and feminism.  With its clinical focus on the whole person and liberal borrowings from psychiatry and the behavioral sciences, family practice set out to liberate medicine from its “captivity” to a flawed view of reality that was mechanistic, protoplasmic, and molecular.[5]

Technology was deeply implicated in Stephens’ critique, even though he failed to stipulate which technologies he had in mind.  His was a global indictment: Medicine’s obsession with its “technological legerdemain” blinded the physician to the rich phenomenology of “dis-ease” and, as such, was anti-Hippocratic.  For Stephens, the “mechanical appurtenances of healing” had to be differentiated from the “essential ingredient” of the healing process, viz., “a physician who really cares about the patient.” “We have reached a point of diminishing returns in the effectiveness of technology to improve the total health of our nation.”  So he opined in 1973, only two years after the first crude CT scanner was demonstrated in London and long before the development of MRIs and PET scans, of angioplasty with stents, and of the broad array of laser- and computer-assisted operations available to contemporary surgeons.[6]  Entire domains of technologically guided intervention – consider technologies of blood and marrow transplantation and medical genetics – barely existed in the early 70s.  Robotics was the stuff of science fiction.

It is easy to sympathize with both Stephens’ critique and his mounting skepticism about the family practice movement’s ability to realize its goals. [7]  He placed the movement on an ideological battleground in which the combatants were of unequal strength and numbers.  There was the family practice counterculture, with the guiding belief that “something genuine and vital occurs in the meeting of doctor and patient” and the pedagogical correlate that  “A preoccupation with a disease instead of a person is detrimental to good medicine.”  And then there were the forces of organized medicine, of medical schools, of turf-protecting internists and surgeons, of hospitals with their “business-industrial models” of healthcare delivery, of specialization and of technology – all bound together by a cultural commitment to science and its  “reductionist hypothesis about the nature of reality.”[8]

Perceptive and humane as Stephen’s critique was, it fell back on the very sort of reductionism he imputed to the opponents of family practice.  Again and again, he juxtaposed “high technology,” in all its allure (and allegedly diminishing returns) with the humanistic goals of patient care.  But are technology and humane patient care really so antipodal?  Technology in and of itself has no ontological status within medicine.  It promotes neither a mechanistic worldview that precludes holistic understanding of patients as people nor a humanizing of the doctor-patient encounter.  In fact, technology is utterly neutral with respect to the values that inform medical practice and shape individual doctor-patient relationships.  Technology does not make (or unmake) the doctor.  It no doubt affects the physician’s choice of specialty, pulling those who lack doctoring instincts or people skills in problem-solving directions (think diagnostic radiology or pathology). But this is hardly a bad thing.

For Stephens, who struggled to formulate an “intellectual” defense of family practice as a new medical discipline, technology was an easy target.  Infusing the nascent behavioral medicine of his day with a liberal dose of sociology and psychoanalysis, he envisioned the family practice movement as a vehicle for recapturing “diseases of the self” through dialogue.[9]  To the extent that technology – whose very existence all but guaranteed its overuse – supplanted  the sensibility (and associated communicational skills) that enabled such dialogue, it was ipso facto part of the problem.

Now there is no question that overreliance on technology, teamed with epistemic assurance that technology invariably determines what is best, can make a mess of things, interpersonally speaking.  But is the problem with the technology or with the human beings who use it?  Technology, however “high” or “low,” is an instrument of diagnosis and treatment, not a signpost of treatment well- or ill-rendered.  Physicians who are not patient-centered will assuredly not find themselves pulled toward doctor-patient dialogue through the tools of their specialty.  But neither will they become less patient-centered on account of these tools.  Physicians who are patient-centered, who enjoy their patients as people, and who comprehend their physicianly responsibilities in broader Hippocratic terms – these physicians will not be rendered less human, less caring, less dialogic, because of the technology they rely on.  On the contrary, their caregiving values, if deeply held, will suffuse the technology and humanize its deployment in patient-centered ways.

When my retinologist examines the back of my eyes with the high-tech tools of his specialty – a retinal camera, a slit lamp, an optical coherence tomography machine – I do not feel that my connection with him is depersonalized or objectified through the instrumentation.  Not in the least.  On the contrary, I perceive the technology as an extension of his person.  I am his patient, I have retinal pathology, and I need his regular reassurance that my condition remains stable and that I can continue with my work.  He is responsive to my anxiety and sees me whenever I need to see him.  The high technology he deploys in evaluating the back of my eye does not come between us; it is a mechanical extension of his physicianly gaze that fortifies his judgment and amplifies the reassurance he is able to provide.  Because he cares for me, his technology cares for me.  It is caring technology because he is a caring physician.

Modern retinology is something of a technological tour de force, but it is no different in kind from other specialties that employ colposcopes, cytoscopes, gastroscopes, proctoscopes, rhinoscopes, and the like to investigate symptoms and make diagnoses.  If the physician who employs the technology is caring, then all such technological invasions, however unpleasant, are caring interventions.  The cardiologist who recommends an invasive procedure like cardiac catheterization is no less caring on that account; such high technology does not distance him from the patient, though it may well enable him to maintain the distance that already exists.  It is a matter of personality, not technology.

I extend this claim to advanced imaging studies as well.  When the need for an MRI is explained in a caring and comprehensible manner, when the explanation is enveloped in a trusting doctor-patient relationship, then the technology, however discomfiting, becomes the physician’s collaborator in care-giving.  This is altogether different from the patient who demands an MRI or the physician who, in the throes of defensive medicine, remarks off-handedly, “Well, we better get an MRI” or simply, “I’m going to order an MRI.”

Medical technology, at its best, is the problem-solving equivalent of a prosthetic limb.  It is an inanimate extender of the physician’s mental “grasp” of the problem at hand. To the extent that technology remains tethered to the physician’s caring sensibility, to his understanding that his diagnostic or treatment-related problem is our existential problem – and that, per Kierkegaard, we are often fraught with fear and trembling on account of it – then we may welcome the embrace of high technology, just as polio patients of the 1930s and 40s with paralyzed intercostal muscles welcomed the literal embrace of the iron lung, which enabled them to breath fully and deeply and without pain.

No doubt, many physicians fail to comprehend their use of technology in this fuzzy, humanistic way – and we are probably the worse for it.  Technology does not structure interpersonal relationships; it is simply there for the using or abusing.  The problem is not that we have too much of it, but that we impute a kind of relational valence to it, as if otherwise caring doctors are pulled away from patient care because technology gets between them and their patients.  With some doctors, this may indeed be the case.  But it is not the press of technology per se that reduces physicians to, in a word Stephens disparagingly uses, “technologists.”  The problem is not in their tools but in themselves.

[1] A. Wilson, The Making of Man-Midwifery: Childbirth in England, 1660-1770 (Cambridge: Harvard, 1995), pp. 97-98, 127-128.

[2] R. D. French, Antivivisection and Medical Science in Victorian Society (Princeton:  Princeton University Press, 1975), p. 411.

[3] J. P. Baker, “The Incubator Controversy: Pediatricians and the Origins of Premature Infant Technology in the United States, 1890 to 1910,” Pediatrics, 87:654-662, 1991.

[4] E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (NY: Schuman, 1950), pp. 244-45.

[5] G. G. Stephens, The Intellectual Basis of Family Practice (Kansas City: Winter, 1982), pp. 62, 56, 83-85, 135-39.

[6] Stephens, Intellectual Basis of Family Practice, pp. 84, 191, 64, 39, 28.

[7] E.g., Stephens, Intellectual Basis of Family Practice, pp. 96, 194.  Cf. his comment on the American College of Surgeon’s effort to keep FPs out of the hospital: “There are issues of political hegemony masquerading as quality of patient care, medicolegal issues disguised as professional qualifications, and economic wolves in the sheepskins of guardians of the public safety” (p. 69).

[8] Stephens, Intellectual Basis of Family Practice, pp. 23, 38, 22.  In 1978, he spoke of the incursion of family practice  into the medical school curriculum of the early 70s as an assault on an entrenched power base:  “The medical education establishment has proved to be a tough opponent, with weapons we never dreamed of. . . .We had to deal with strong emotions, hostility, anger, humiliation. Our very existence was a judgment on the schools, much in the same way that civil rights demonstrators were a judgment on the establishment.  We identified ourselves with all the natural critics of the schools – students, underserved segments of the public, and their elected representatives – to bring pressure to bear on the schools to create academic units devoted to family practice” (pp. 184, 187).

[9] Stephens, Intellectual Basis of Family Practice, pp. 94, 105, 120-23, 192.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Family Doctors, Then & Now, Medical Instruments, Medical Technology, Old & New, Primary Care

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Medical Toys, Old and New

Posted on March 12, 2012 | 1 comment

“The plethora of tests available to the young clinician has significantly eroded the skills necessary to obtain adequate histories and careful physical examinations.  Day in and day out, I encounter egregious examples of misdiagnosis engendered by inadequacies in these skills.”                                ~William Silen, M.D. “The Case for Paying Closer Attention to Our Patients” (1996)

“Treat the Patient, Not the CT Scan,” adjures Abraham Verghese in a New York Times op-ed piece of February 26, 2011.  Verghese targets American medicine’s overreliance on imaging tests, but, like others before him, he is really addressing the mindset that fosters such overreliance.  Preclinical medical students, he reminds us, all learn physical examination and diagnosis, but their introduction to the art dissipates under the weight of diagnostic tests and specialist procedures during their clinical years.  “Then,” he writes, “they discover that the currency on the ward seems to be ‘throughput’ – getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge.”  In the early 90s, William Silen, Harvard’s Johnson and Johnson Distinguished Professor of Surgery,[1] made the same point with greater verve.  In one of his wonderful unpublished pieces, “Lumps and Bumps,” he remarked that “the modern medical student, and most physicians, have been so far removed from physical diagnosis, that they simply do not accept that a mass is a mass is a mass unless the CT scan or ultrasound tells them it is there.”

Verghese and Silen get no argument from me on the clinical limitations and human failings associated with technology-driven medicine.  But these concerns are hardly unique to an era of CT scans and MRIs.  There is a long history of concern about overreliance on new technologies;  Silen has a delightfully pithy, unpublished piece on the topic that is simply titled, “New Toys.”

One limitation of such critiques is the failure to recognize that all “toys” are not created equal.  Some new toys become old toys, at which point they cease being toys altogether and simply become part of the armamentarium that the physician brings to the task of physical examination and diagnosis.  For example, we have long since stopped thinking of x-ray units, EKG machines, blood pressure meters (i.e., sphygmomanometers), and stethoscopes as “new toys” that militate against the acquisition of hands-on clinical skill.

But it was not always so.  When x-rays became available in 1896, clinical surgeons were aghast.  What kind of images were these?  Surely not photographic images in the reliably objectivistic late-nineteenth century sense of the term.  The images were wavy, blurry, and imprecise, vulnerable to changes in the relative location of the camera, the x-ray tube, and the object under investigation.  That such monstrously opaque images might count as illustrative evidence in courts of law, that they might actually be turned against the surgeon and his “expert opinion”  – what was the world coming to?  Military surgeons quickly saw the usefulness of x-rays for locating bullets and shrapnel, but their civilian colleagues remained suspicious of the new technology for a decade or more after its invention.  No fools, they resorted to x-rays only when they felt threatened by malpractice suits.

Well before the unsettling advent of x-ray photography, post-Civil War physician-educators were greatly concerned about the use of mechanical pulse-reading instruments.  These ingenious devices, so they held, would discourage young physicians from learning to appreciate the subtle diagnostic indicators embedded in the pulse.  And absent such appreciation, which came only from prolonged training of their fingertips, they could never acquire the diagnostic acumen of their seniors, much less the great pulse readers of the day.

Thus they cautioned students and young colleagues to avoid the instruments.  It was only through “the habit of discriminating pulses instinctively” that the physician acquired  “valuable truths . . . which he can apply to practice.”  So inveighed the pioneering British physiologist John Burdon-Sanderson in 1867.  His judgment was shared by a generation of senior British and American clinicians for whom the trained finger remained a more reliable measure of radial pulse than the sphygmograph’s arcane tracings.  In The Pulse, his manual of 1890, William Broadbent cautioned his readers to avoid the sphygmograph, since interpretation of its tracings could “twist facts in the desired direction.”  Physicians should “eschew instrumental aids and educate the finger,” echoed Graham Steell in The Use of the Sphygmograph in Medicine at the century’s close.[2]

Lower still on the totem pole of medical technology, indeed about as low down as one can get – is the stethoscope, “invented” by René Laennec in 1816 and first employed by him in the wards of Paris’s Hôpital Necker (see sidebar).  In 1898, James Mackenzie, the founder of modern cardiology, relied on the stethoscope, used in conjunction with his own refinement of the Dudgeon sphygmograph of 1881 (i.e., the Mackenzie polygraph of 1892), to identify what we now term atrial fibrillation.  In the years to follow, Mackenzie, a master of instrumentation, became the principal exponent of what historians refer to as the “new cardiology.” His “New Methods of Studying Affections of the Heart,” a series of articles published in the British Medical Journal in 1905, signaled a revolution in understanding cardiac function.  “No man,” remarked his first biographer, R. McNair Wilson, in 1926, “ever used a stethoscope with a higher degree of expertness.”  And yet this same Mackenzie lambasted the stethoscope as the instrument that had “not only for one hundred years hampered the progress of knowledge of heart affections, but had done more harm than good, in that many people had had the tenor of their lives altered, had been forbidden to undertake duties for which they were perfectly competent, and had been subject to unnecessary treatment because of its findings’.”[3]

Why did Mackenzie come to feel this way?  The problem with the stethoscope was that the auscultatory sounds it “discovered,” while diagnostically illuminating, could cloud clinical judgment and lead to unnecessary treatments, including draconian restrictions of lifestyle.  For Mackenzie,  sphygmomanometers were essentially educational aids that would corroborate what medical students were learning to discern through their senses.  And, of course, he allowed for the importance of such gadgetry in research.  His final refinment of pulse-reading instrumentation, the ink jet polygraph of 1902 (see sidebar), was just such a tool.  But it was never intended for generalists, whose education of the senses was expected to be adequate to the meaning of heart sounds.  Nor was Mackenzie a fan of the EKG, when it found its way into hospitals after 1905.  He perceived it as yet another “new toy” that provided no more diagnostic information than the stethoscope and ink jet polygraph.  And for at least the first 15 years of the machine’s use, he was right.

Now, of course, the stethoscope, the sphygmomanometer, and, for adults of a certain age, the EKG machine are integral to the devalued art of physical examination.  Critics who bemoan the overuse of CT scans and MRIs, of echocardiography and angiography, would be happy indeed  if medical students and residents spent more time examining patients and learning all that can be learned from stethoscopes, blood pressure monitoring, and baseline EKGs.  But more than a century ago these instrumental prerequisites of physical examination and diagnosis were themselves new toys, and educators were wary of what medical students would lose by relying on them at the expense of educating their senses.  Now educators worry about what students lose by not relying on them.

Toys aside, I too hope  that those elements of physical diagnosis that fall back on one tool of exquisite sensitivity – the human hand – will not be lost among reams of lab results and diagnostic studies.  One shudders at the thought of a clinical medicine utterly bereft of the laying on of hands, which is not only an instrument of diagnosis but also an amplifier of therapy.  The great pulse readers of the late nineteenth century are long gone and of interest only to a handful of medical historians.  Will the same be true, a century hence, of the great palpators of the late twentieth?

[1] I worked as Dr. Silen’s editor in 2000-2001, during which time I was privileged to read his unpublished lectures, addresses, and general-interest medical essays as preparation for helping him organize his memoirs.  Sadly, the memoirs project never materialized.

[2] In this paragraph, I am guided especially by two exemplary studies, Christopher Lawrence, “Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain, 1850-1914,” J. Contemp. Hist., 20:503-520, 1985 and Hughes Evans, “Losing Touch: The Controversy Over the Introduction of Blood Pressure Instruments in Medicine, “ Tech. Cult., 34:784-807, 1993.  Broadbent and Steell are quoted from Lawrence, p. 516.

[3] R. McNair Wilson, The Beloved Physician: Sir James Mackenzie (New York:  Macmillan, 1926), pp. 103-104. A more recent, detailed account of Mackenzie’s life and career is Alex Mair, Sir James Mackenzie, M.D., 1853-1925 – General Practitioner (London: Royal College of General Practitioners, 1986).

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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