THE STETHOSCOPE

The French physician R.T.H. Laennec (1816).

Description:
It has four parts such as 1. Chest piece, 2. Connecting tube, 3. Head piece, and 4. Ear piece.
Chest piece—Usually with a diaphragm and a bell; only one operates at a time. There is a valve
that allows switching from diaphragm to bell and vice versa.
a) THE DIAPHRAGM : It should be stiff and smooth to damp out low-frequency sounds, and
unmask high-frequency sounds. The thin plastic disc (usually having 4 cm diameter) is kept in
position tightly by a metallic ring. The cardiac sounds best heard by diaphragm are,
1. All the diastolic and systolic mur murs due to different valvular lesion except mitral and
tricuspid stenosis (MS/TS),
2. S1 and S2, and
3. Ejection click, pericardial knock, opening snap etc.
b) THE BELL : Low-frequency sounds are best heard by the bell. The bell (diameter of 2.5 cm)
should be placed lightly on the site of auscultation (just enough to prevent room-noise leak) as
firm pressure will tighten the underlying skin as a taut diaphragm (in that situation,
low-frequency sounds will damp out and only high-frequency sounds are heard).
The sounds best heard by the bell are,
1. Low-pitched murmur of MS and TS,
2. S3or S4,
3. Foetal heart sounds, and
4. Venous hum.

(B) Connecting tube—A single or double tube connects the head piece with the chest piece via
a metal lic connector attached to the chest piece. A length of 12 inches (30 cm) is sufficient. A
tall physician may add additional 3 or 4 inches. Long tubing attenuates high-frequency sounds.
Very narrow tubes carry low-frequency sounds better, and high-frequency sounds are better
carried by wider tubing.

(C) Head piece—The two metal tubes of the head piece are attached together by a metallic
U-connector.

(D) Ear piece—The two metal tubes of the head piece end in two plastic ear pieces. Larger ear
pieces are ideal as they prevent air leak. The usual stethoscope head piece is designed in such
a way that the ear pieces point slightly anteriorly to be in the same line with the external auditory
canal.
* One should not replace the torn diaphragm with a small piece of X-ray plate because the X-ray
plate is neither thin nor stiff.

Criteria for a good stethoscope :

1. For high-frequency sounds—Smooth, thin and stiff diaphragm.
2. For low-frequency sounds—Shallow bell with a large diameter.
3. Double tubing (more efficient for high-frequencies) with a metal clip which binds the tubes
together.
4. Ear pieces should be largest possible one; soft and made of rubbery material.
5. Length and internal circumferential diameter of the connecting tubes should not cross 12
inches and 4-6 mm respectively; the inner lining of the tubes should be made smooth by 'vinyl
tubing’.
6. There should be option for rotation of the metal head pieces so that ear pieces can be placed
in the most comfortable position.
7. An extra pediatric-sized diaphragm and bell attached.

Different uses :
Though stethos means ‘chest’, and skopio means ‘to examine’, the modern stethoscope is used
to auscultate various parts of the body, such as :
1. Cardiovascular system—Heart sounds, murmur, opening snap, ejection click, pericardial
knock, pericardial rub etc.
2. Respiratory system—Breath sound, vocal resonance, crepitations, rhonchi, pleural rub, pneu
mothorax click etc.
3. Abdomen—Normal peristaltic sounds, renal artery bruit, venous hum, succussion splash and
ausculto-percussion in pyloric stenosis, hepatic and splenic rub, uterine souffle and foetal heart
sounds.
4. Head—Bruit from cerebral arteriovenous malformation may be heard over cranium or closed
eyes; bruit of Paget’s disease.
5. Neck—Carotid bruit, cervical venous hum, thyroid bruit, conducted murmur of AS.
6. Extremities—Pistol shot sound, Duroziez’s murmur, demonstration of Hill’s sign.
7. Measurement of blood pressure.
8. Miscellaneous—Subcutaneous emphysema, demonstration of parietal oedema.
* Worldwide, stethoscope symbolises a doctor. Stethoscope manufactured by renowned
companies are Littman, Harvey, Sprague, Leatham etc. Besides the conventional variety,
electronic and magnetic stethoscopes are also available.
** Except the sounds best heard by the bell, all other sounds mentioned above are best
auscultated by the diaphragm of stethoscope.