[Reprinted from The Medical News, December 16, 1893.] 
AN ESOPHAGEAL STETHOSCOPE: WITH 
REMARKS ON /NTRA-THORACIC 
AUSCULTATION } 
SOLOMON SOLIS-COHEN,vM.D., 
PROFESSOR OF THERAPEUTICS AND CLINICAL MEDICINE IN THE PHILA- 
DELPHIA polyclinic; one of the physicians to the 
PHILADELPHIA HOSPITAL, FTC. 
The instrument that I have here is a modification of 
one suggested by Sir Benjamin Ward Richardson. In 
the course of that observer’s examination of a case of 
suspected stricture of the esophagus, in which no ob- 
struction was shown by the “water-gurgle” test, and he 
had concluded to pass the stomach-tube, it occurred to 
him that, perhaps, if he attached the terminal of his 
double stethoscope to the stomach-tube he might notice 
the presence of friction as the tube passed over the 
stricture, or the absence of friction and of stricture; in 
this particular case he found no friction and determined 
that there was no stricture. It then occurred to him that 
in many cases it might be useful to employ a similar appa- 
ratus in listening to the sounds of the heart and possible 
murmurs in the vessels, as in cases of aneurism, unmodi- 
fied by transmission through the chest-walls, and that 
possibly he might be able to hear the sounds of the lungs 
in the same manner. He also thought that certain 
sounds generated in the stomach might give infor- 
mation as to the manner in which the gastric func- 
tions were being carried on; while the sounds of the 
abdominal aorta could be heard through the stomach, 
1 Presented to the College of Physicians of Philadelphia, Novem- 
ber x, 1893. 2 
unmodified by the pressure that on external auscultation 
is so often a cause of doubt in interpreting the causation 
of murmurs. 
In attempting to repeat Dr. Richardson’s observations, 
I found that there was occasional danger of the regurgi- 
tation of fluid through the tube into the ear-pieces. To 
obviate this objection I have introduced between the 
stomach-tube and the ear-tube a rubber capsule contain- 
ing a diaphragm of gold-beater’s skin, which serves as a 
barrier and as a resonator. The capsule can be readily 
taken apart and cleansed, and new diaphragms can be 
inserted when needed. I exhibit the improved instru- 
ment, as skilfully made for me by Messrs. Tiemann & 
Co., of New York. 
Esophageal Stethoscope. 
a. Metallic conducting-tubes of “Albion” stethoscope, b. Cap- 
sule with diaphragm, c. Esophageal tube with indented scale. 
d. Soft rubber caps for ear-pieces. 
The esophageal tube is of soft rubber, No. 27 of the 
French scale, having a lateral eye near the blunt tip. 
On the same side as the eye, beginning five inches there- 
from and extending up to a distance of nineteen inches, is 
a series of indentations, one inch apart, which show how 
far the eye of the instrument is from the patient’s teeth. 
By experiments made outside of the’lbody I have found 
that the sound heard is transmitted from within a radius 
of an inch and a half or two inches from the opening in 
the tube, the sound being most distinct when the eye is 3 
in close apposition to the source of sound. I have used 
the instrument to listen to the sounds of the heart only, 
not wishing to risk the passage of the tube in cases of 
thoracic aneurism and not being able to hear through it 
the lung-sounds. 
The most striking difference between the sounds of the 
heart as heard in the ordinary way and the same sounds 
as heard through this instrument is the almost uniform 
quality of the first and second sounds—that is, the 
sharpness of the second sound, as heard by the ordinary 
method, is wanting in auscultation by this method. The 
rhythm is of course the same ; the second sound is the 
shorter, and the pause is easily appreciated. It is pos- 
sible to separate the two sounds and hear the first sound 
alone, or the second sound alone, or to hear both. At 
a distance of from eight to nine inches from the teeth, 
only the second sound is heard ; at ten or eleven inches, 
both sounds are clearly heard ; and at thirteen or four- 
teen inches only the first sound with, perhaps, an ill-de- 
fined second sound. I have not satisfied myself as to my 
ability to differentiate between the aortic and pulmonary 
sounds by varying the position of the eye of the tube. 
My largest number of observations have been made 
on persons with healthy hearts, who were under treat- 
ment for stomach-troubles, and thus accustomed to pas- 
sage of the esophageal tube ; but I have been able to use 
the instrument on other patients, with and without 
cardiac disease; among them two cases in which by 
the ordinary method of examination I had diagnosti- 
cated the existence of mitral obstruction. In one of 
these two cases mitral obstruction alone was diagnos- 
ticated by the ordinary methods of physical examina- 
tion ; and in the other, mitral obstruction and re- 
gurgitation. In both cases I failed in each of two 
examinations to hear the obstructive murmur through 
the esophageal stethoscope. The regurgitant murmur 
was heard distinctly, but I could not make out that any 4 
part of it was presystolic. Ido not know whether there 
is an acoustic reason for this, or whether it was due to 
lack of skill with the instrument. I have no doubt of 
the correctness of the diagnosis. 
I have also used the method in one case in which 
there was doubt as to the coexistence of aortic diastolic 
and aortic systolic murmurs, but the apparent murmur 
of regurgitation was not heard through the esophageal 
stethoscope, whilst the systolic murmur was heard dis- 
tinctly, and a good closure-sound was heard. This, I 
think, warranted affirmation of arterial roughening rather 
than valvular lesion. 
While speaking of the use of the tube to clear up the 
doubt in cases of suspected aneurism, Sir B. W. Richard- 
son remarks that the good sense of the physician must 
determine whether or not in given instances the method 
is dangerous and not to be used. 
As to the importance of intra-thoracic auscultation, I 
cannot as yet speak positively. Ido not know how far 
it will be applicable in cases of doubtful diagnosis—in 
others it is not needed—or what its exact limitations 
are. I consider it, however, one of the methods that we 
may usefully employ among others in making exact 
observations, and for this reason I have brought the 
subject before the College for discussion, in the hope 
that other Fellows may be led to study it. 
It is only right to say that two other communications 
on the subject of intra-thoracic auscultation, one by a 
German observer, the other by two English observers, 
have appeared since Dr, Richardson’s publication, and 
apparently as independent studies. Their conclusions 
are not cited here, as the subject still requires individual 
and unbiased work.