A Life in Medicine

by Robert Coles

  Long before Laënnec, physicians listened to hearts by simply placing the ear directly on the patient’s chest. But the technique was not utilized that often because of concerns about modesty and hygiene. Then came the stethoscope, one of the earliest instruments to be physically interposed between doctor and patient. Laënnec’s invention, however, despite its rudimentary form, was like the modern version in one important way: There was a human being at either end. As Dr. Dickinson Richards insisted in 1962, to use the stethoscope, “the doctor has to be within thirty inches of the patient,” close enough to ensure the intimacy and laying on of hands often said to be lacking in medicine today.

  The modern stethoscope—the word derives from the Greek stethos, meaning “chest”—evolved with new knowledge about the physics of sound transmission. Thus, the tubing between doctor and patient is of a prescribed bore and length. The earpieces must fit snugly. On the other end, the “heads” of the stethoscope, usually two or occasionally three in number, filter the sound. The flat piece, the diaphragm, picks up high-pitched sounds; the domed piece, the bell, registers low frequencies.

  What kinds of music, or noise, arrive at the listening end of the stethoscope? The most common use of the instrument is in the measurement of blood pressure, as the arterial blood column strains to thump under the cuff tightened around the arm. But the stethoscope is useful in decoding all the sounds of the body at work: the tick-tock of the fetal heart tones from the uterus; the rumblings of the gut under the abdominal wall (sounds that carry the aptly onomatopoeic Greek borborygmos, meaning “to rumble”); the rush of blood in narrowed vessels, notably the carotid arteries leading to the brain. In Laënnec’s time, the stethoscope was most frequently employed to monitor the lungs: fully a third of the patients hospitalized in Paris were there because of tuberculosis. But the most dramatic use of it is in sorting out the cacophony of sound from the heart. Use of the stethoscope in this way is called “auscultation” (L. auscultare, “to listen”).

  The normal heart tones, a poet would note, are iambic in rhythm: a weaker followed by a stronger stress—lup-dup, lup-dup. These sounds, the “lup” and the “dup,” are called the first and the second heart sounds, S-1 and S-2. They are due basically to the rhythmic paired closing of the four heart valves (tricuspid and pulmonary valves in the right side of the heart, mitral and aortic valves in the left side). The valves work gracefully and ingeniously to direct blood flow—from the right heart to the lungs, from the left heart to the body. The time between the lup and the dup defines systole (sis’toll-ee), the interval of contraction of the heart. The interval between the second sound and the subsequent first sound defines diastole (dye-as’toll-ee), the interval of relaxation. The flow of blood through the heart is often made turbulent (e.g., after exercise or with structural abnormalities of the heart); it is this turbulence that produces cardiac “murmurs.” A murmur is often musical in character, and may occur in systole, diastole, or throughout both intervals, depending on the cause.

  Many, perhaps most, heart murmurs are not pathological at all. An estimated 50 percent of all children, if their hearts are examined often enough, will have a murmur at some point. The turbulent blood flow in their active, growing bodies is one explanation of such “innocent” murmurs. These are the happiest sounds, joys to find. Similarly, many pregnant women develop murmurs as the torrential blood flow to the gravid uterus places an extra workload on the maternal heart. The revved-up circulation that occurs with anemia or an overactive thyroid may also produce such murmurs.

  But what of pathological murmurs? The valves of the heart may dysfunction for many reasons. Basically, dysfunction takes one of two forms: a narrowing of the valve (“stenosis”) or a leakage (“insufficiency” or “regurgitation”). Stenosis of the aortic valve, situated between the left ventricle and the aorta, is a good example. With cardiac contraction, the three pliable leaflets of a normal valve are thrown open abruptly, like swinging doors, allowing blood to pass from the left ventricle to the aorta. After contraction, the leaflets recoil and close, halting any retreat of the aortic blood back into the ventricle. If the valve is narrowed by disease and scarring, however, the squeezing of blood through it may produce enough turbulence to cause a systolic murmur.

  The loudness of murmurs is graded from 1 to 6 (6 is loud enough to be heard with the stethoscope completely off the chest). Rarely, a murmur is loud enough to be heard several feet away without using a stethoscope. Opening and closing “clicks” of certain artificial heart valves may be audible to others in a quiet waiting room.

  A sense of rhythm is helpful in the interpretation of complex cardiac sounds. Generations of medical students, learning auscultation, have used a rhythmic, exaggerated pronunciation of the word Ken-tuck-y, Ken-tuck-y, to help time the gallops of the heart. Some conditions produce extra cardiac sounds: a variety of clicks, “rubs,” and murmurs. Inflammation of the sac around the heart—pericarditis—results in a distinctive “scratchy” rub (the quality of the rub can be simulated by taking a small punch of hair near the ear and rubbing the fingers together briskly). One of the most dramatic sounds in medicine is called “Hamman’s crunch,” after the physician who described its typical features. Auscultation of the heart after air has been introduced into the center of the chest (after a stab wound, for example) may reveal a crackling and crunching of the air and fluid around the beating heart, sounds that reminded Hamman (and thousands of clinicians since) of the crunch of snow under heavy boots.

  Auscultation is usually done with the patient lying down. But listening with the patient sitting tilts the pendulous heart toward the chest wall, facilitating diagnosis. Listening with the patient standing, squatting, or with his feet elevated off the bed all may be used in special circumstances.

  A complete examination of the lungs also includes auscultation: as the patient breathes deeply, air rushing through the bronchial tree may pass over abnormal fluid within the bronchi (in pneumonia, for example), causing soft bubbling sounds.

  Another valuable technique for examination of the lungs (less valuable for the heart) is that of percussion. In percussion, the long finger of one hand is laid flat against the chest wall while the long finger of the other hand taps or percusses it. Changes in the quality or “timbre” of the thumping sounds thus generated can help detect abnormal collections of fluid at the base of the lungs. Leopold Auenbrugger (1722–1809), a Viennese physician, is the father of percussion; applying the technique to the human chest was suggested to him by wine testers who drummed their fingers over the kegs to check the level of fluid within them.

  Years ago, as fledgling medical students in St. Louis, Luis Vasconez and I were assigned to examine the heart and lungs of a patient. While I stood in front of the (patient) patient, attempting to make sense out of his heart sounds, Luis was trying out his newfound technique of percussion over the patient’s back: Luis’ drumbeats sounded like thunder in my stethoscope. Needless to say, the techniques of auscultation and percussion are not intended to be carried out simultaneously!

  Despite the long history of the stethoscope, there is much more to learn about auscultation. Until the 1960s, for example, a click or clicks heard between the lup and the dup were thought to be noncardiac in origin. Sophisticated studies have now shown that such clicks often arise from the mitral valve in a condition called “mitral valve prolapse.” Newer techniques help us understand what we’re hearing: these include echocardiography (viewing the heart with ultrasound) and magnetic resonance imaging, a noninvasive technique that gives clear views of cardiac anatomy without the injection of dyes. Thus, as the stethoscope keeps the physician near the bedside of the patient, its messages are continually reinterpreted in light of new information.

  Recently, I and my older son, a medical student in Boston, spent a morning at the hospital decoding the heart sounds that emanated from a wondrous electronic teaching mannequin called “Harvey.” Harvey can be programmed to simulate a wide variety of murmurs (and pulses). I
envy my son the process of discovery that lies before him. It will take some time. Only with time, only after moving the stethoscope like a metal detector over the landscape of countless hearts, does one truly learn how to be still and listen. Such training of the ear comes only with experience. The art of auscultation is remarkably like listening to Mozart’s clarinet quintet—after so long a time, one is able to follow the voice of the cello and thus appreciate its individual music within the ensemble.

  Physicians and patients, of course, are not the only ones interested in the arcane language of the heart. John Ciardi wrote a fine poem called “Lines From the Beating End of the Stethoscope.” And W. H. Auden, in “Lay your sleeping head, my love,” speaks knowingly of the “knocking heart.” The very first auscultator, surely, was a lover—head pillowed on the drum of the lover’s chest—who heard the murmurs and murmurings of the heart and worried what they might mean long before—and long since—Laënnec.

  Alyson Porter

  LARGE WOMAN, HALF

  Leaning down and touching, palpitating, and listening to another human being are necessary parts of developing the skills to perform a complete physical examination. The practitioner works with patients to develop and refine these skills. But how often are these procedures done without regard for the person, the person whose heart we cannot really hear, cannot really appreciate?

  ALYSON PORTER had her first writing—a story about space aliens—published by Cricket magazine when she was eight years old. Today she is a resident at the University of New Mexico School of Medicine. She lives in Albuquerque with her husband who is also in medical school.

  Large woman, half-sitting,

  wrecked among the creased sheets, tubes, sharp needles, blue blankets,

  incurious.

  Her loose white and rain gray hair stripes pillows.

  She has the preoccupied jelly gaze of fish.

  Under the gown, she has been cracked

  down her center

  and shut tight again. There is dried blood

  traveling the long barbed seam.

  Bent to listen, there are gusts

  newspaper crackling against the wire fence of suture

  new wine bubbling up

  a door banging open into an empty room

  heavy trucks on an unfamiliar stretch of highway

  branches gnashing the tin roof of a shed

  or the settling of birds in zoo cages at dusk?

  She breathes like a runner

  with hard purpose.

  I move the stethoscope again

  and again.

  Again

  pressing

  it stamps the warm freckled flesh.

  Even the fabric murmurs

  explaining

  Well, I am new to this

  I cannot fully appreciate your heart sounds.

  Constance Meyd

  THE KNEE

  The skills required in a complete or limited physical examination are demonstrated and practiced daily in a variety of teaching settings. In almost all instances, the practice and demonstration are done with live patients. Many medical institutions are structured to provide students with multiple opportunities to practice their emerging skills. But do the demonstrations, repeated examinations, and procedures done by the least skilled rather than the most skilled violate patients’ rights in the interest of learning or education? This essay takes a hard look at what else is learned in the process of a routine knee examination—by both patient and studying intern.

  CONSTANCE MEYD is an assistant professor, Department of Neurology at Johns Hopkins University. She is also a member of Pi Chapter, Sigma Theta Tay International Honor Society of Nursing Past Executives.

  We are on attending rounds with the usual group: attending, senior resident, junior residents, and medical students. There are eight of us. Today we will learn how to examine the knee properly. The door is open. The room is ordinary institutional yellow, a stained curtain between the beds. We enter in proper order behind our attending physician. The knee is attached to a woman, perhaps 35 years old, dressed in her own robe and nightgown. The attending physician asks the usual questions as he places his hand on the knee: “This knee bothers you?” All eyes are on the knee; no one meets her eyes as she answers. The maneuvers begin—abduction, adduction, flexion, extension, rotation. She continues to tell her story, furtively pushing her clothing between her legs. Her endeavors are hopeless, for the full range of knee motion must be demonstrated. The door is open. Her embarrassment and helplessness are evident. More maneuvers and a discussion of knee pathology ensue. She asks a question. No one notices. More maneuvers. The door is open. Now the uninvolved knee is examined—abduction, adduction, flexion, extension, rotation. She gives up. The door is open. Now a discussion of surgical technique. Now review the knee examination. We file out through the open door. She pulls the sheet up around her waist. She is irrelevant.

  Jean-Dominique Bauby

  from THE DIVING BELL AND THE BUTTERFLY

  A patient in a French hospital, completely stripped of any ability to move or speak, offers an extraordinary perspective on the skillfulness of the doctors who attend to him, and on the world of the hospital, giving the reader of this excerpt a full measure of an utterly helpless patient’s resentment and anger in the face of indifferent, “ungracious” care.

  JEAN-DOMINIQUE BAUBY was the forty-three-year-old editor-in-chief of Elle when he suffered a stroke that decimated his brain stem. After weeks in a coma, he awoke to find that he suffered from a rare condition known as “locked-in syndrome,” which left his mind intact but his body almost completely paralyzed. Bauby “dictated” this story by blinking his one still-functioning eye, one letter at a time. He died two days after The Diving Bell and the Butterfly was published in France.

  I have known gentler awakenings. When I came to that late-January morning, the hospital ophthalmologist was leaning over me and sewing my right eyelid shut with a needle and thread, just as if he were darning a sock. Irrational terror swept over me. What if this man got carried away and sewed up my left eye as well, my only link to the outside world, the only window to my cell, the one tiny opening of my diving bell? Luckily, as it turned out, I wasn’t plunged into darkness. He carefully packed away his sewing kit in padded tin boxes. Then, in the tones of a prosecutor demanding a maximum sentence for a repeat offender, he barked out: “Six months!” I fired off a series of questioning signals with my working eye, but this man—who spent his days peering into people’s pupils—was apparently unable to interpret a simple look. With a big round head, a short body, and a fidgety manner, he was the very model of the couldn’t-care-less doctor: arrogant, brusque, sarcastic—the kind who summons his patients for 8:00 A.M., arrives at 9:00, and departs at 9:05, after giving each of them forty-five seconds of his precious time. Disinclined to chat with normal patients, he turned thoroughly evasive in dealing with ghosts of my ilk, apparently incapable of finding words to offer the slightest explanation. But I finally discovered why he had put a six-month seal on my eye: the lid was no longer fulfilling its function as a protective cover, and I ran the risk of an ulcerated cornea.

  As the weeks went by, I wondered whether the hospital employed such an ungracious character deliberately—to serve as a focal point for the veiled mistrust the medical profession always arouses in long-term patients. A kind of scapegoat, in other words. If he leaves Berck, which seems likely, who will be left for me to sneer at? I shall no longer have the solitary, innocent pleasure of hearing his eternal question:“Do you see double?” and replying—deep inside—“Yes, I see two assholes, not one.”

  I need to feel strongly, to love and to admire, just as desperately as I need to breathe. A letter from a friend, a Balthus painting on a postcard, a page of Saint-Simon, give meaning to the passing hours. But to keep my mind sharp, to avoid descending into resigned indifference, I maintain a level of resentment and anger, neither too much nor too little, just as a pressure cooker has a safety valve
to keep it from exploding.

  And while we’re on the subject, The Pressure Cooker could be a title for the play I may write one day, based on my experiences here. I’ve also thought of calling it The Eye and, of course, The Diving Bell. You already know the plot and the setting. A hospital room in which Mr. L., a family man in the prime of life, is learning to live with locked-in syndrome brought on by a serious cerebrovascular accident. The play follows Mr. L.’s adventures in the medical world and his shifting relationships with his wife, his children, his friends, and his associates from the leading advertising agency he helped to found. Ambitious, somewhat cynical, heretofore a stranger to failure, Mr. L. takes his first steps into distress, sees all the certainties that buttressed him collapse, and discovers that his nearest and dearest are strangers. We could carry this slow transformation to the front seats of the balcony: a voice offstage would reproduce Mr. L.’s unspoken inner monologue as he faces each new situation. All that is left is to write the play. I have the final scene already: The stage is in darkness, except for a halo of light around the bed in center stage. Nighttime. Everyone is asleep. Suddenly Mr. L., inert since the curtain first rose, throws aside sheets and blankets, jumps from the bed, and walks around the eerily lit stage. Then it grows dark again, and you hear the voice offstage—Mr. L.’s inner voice—one last time:

  “Damn! It was only a dream!”

  Lucia Cordell Getsi

  LETTER FROM THE REHABILITATION INSTITUTE

  On a children’s rehabilitation ward, a skillful observer describes the particulars of a set of lives, including those of her own daughter. In so doing, she offers a succinct set of histories, diagnoses, and prognoses, and an understanding of how the patients’ conditions affect her own moral condition.