NEWS DIGEST VIEWPOINT


By Dr Ivor Felstein, Retired Consultant Geriatrician


Scope tales


As students back in pre-clinical classes in schools of medicine of the mid-20th century, we all looked forward to purchasing our own individual stethoscopes. After all, this traditional listening weapon for medics had already been in use for well over 100 years. We foolishly thought that, strung around our neck or hanging loose in front of the chest, it immediately identified us as the real medical McCoy. The stethoscope first emerged back in


France when a physician, named Rene Laennec, became fed up with twisting his head down onto his patients’ chests. Like other doctors before him, he did these gymnastics so that his own ear could physically and directly pick up the presence of cardiac sounds and confirm the heart rhythm and/or the presence of undesirable murmurs. Doctors with poor head and neck flexibility, or with a tendency to vertigo or even with a dislike of the unwashed human body, loathed this ear-to-chest approach. Monsieur le doctor Laennec, however, had a brainwave, so we are told, and rolled up some firm paper (possibly cardboard) into a hollow piece. He


therapists – without seeing a dentist first. Currently both the Standards for dental


professionalsand Scope of practice guidelinesmake it clear that every member of the dental team must work on the prescription of a dentist. The only exception to this is clinical dental technicians who are able to provide full dentures to patients without the need for


help GPs and healthcare staff respond quickly and effectively to patients who disclose domestic abuse. It encourages practice managers to build strong partnerships with local domestic abuse services and ensure domestic abuse training for the


SUMMER 2012


applied one roll end to his own ear and the other roll end to the patient’s lower chest. He then found it much easier to monitor the heart sounds, while almost upright, but wondered what to call his invention. In the tradition of doctors of that period, he was knowledgeable in Latin and Greek and the latter gave him ‘stethos’ (for chest) and also ‘kopein’ (for scrutiny), which were neatly joined in the name ‘stethoscope’. I once met a physics graduate, who questioned this naming tale. Instead, he suggested the name was a mis-hearing of ‘stealth-oscope’ since the patient now had no surety the physician was hearing anything at all! Stethoscope material in time moved


on from hard paper to cardboard to lightweight metal. Then, in the mid-19th century, along came an American named Nathan Marsh, who instead of a single broad ‘toilet roll’ object utilised thin, neat, lightweight rubbery tubes for carrying sounds. These tubes were in turn held in place in both ears by firm, hollowed “buttons”. Centrally the tubes were joined to a flat piece, clock-like in shape that picked up all the heart noises, and time and rhythm. The sounds had a kind of 3-dimensional quality and the central hollowed chest piece could have twin structures of greater and lesser resonance, if required. Best of all, the patient could be flat in bed


or half-sitting, or even standing for the auscultation. Some doctors still used the traditional single piece carton-shaped metal scope for babies’ auscultation. Others used a minimised version of the Marsh format, then designated it as a paediatric scope. All new scopes since that time are essentially altered or re-accommodated versions of the Marsh plan. There are some traditional stethoscope


anecdotes duly passed down by medical students. For example, a famous professorial holder of a medical school chair bequeathed his superb stethoscope (Marsh style and format) to his successor. This scope was labelled ‘With best wishes’. The new professor, very impressed, wore it to his first professorial ward round. He was asked to confirm a patient with an alleged classic murmur of valvular heart disease. “Damned if I can hear it”, he told his assistant. After three more patients were also unsuccessfully auscultated, he had an idea and unscrewed the centre piece to look inside. He smiled, as he then pulled out a large


piece of cotton wool from the centre piece innards! So did we all smile. Had the old professor bequeathed his sense of humour with his ‘gift’? Or was he never actually aware someone else had stuffed his own stethoscope to make it largely inaudible? You tell me…


a prescription. A Direct Access Task and Finish Group has been appointed and is looking for


practice team. Access at


http://tinyurl.com/6q9mxov l PAIN IN ADVANCED DISEASE UNDER-TREATED Pain caused by advanced disease remains under- treated despite a range of opioids being recommended for use in the NHS, according to clinical


views from dentists and other DCPs via a short ‘call for ideas’ questionnaire published on the GDC website. The Group has also invited a number of key stakeholders to provide evidence and has commissioned a literature review. The results from this call for ideas will be analysed and considered by the group at its meeting in July.


guidelines produced recently by NICE. The new guidelines are intended to ensure safe and consistent prescribing of opioids as a first-line treatment option for patients receiving palliative care for chronic or incurable illnesses. The guidelines offer


recommendations on discussing patient concerns such as addiction, tolerance, side-effects and fears that treatment implies the final stages of life. It also provides advice on starting treatment and maintenance therapy. Access at www.nice.org.uk


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