99% Invisible - 270- The Stethoscope

Episode Date: August 9, 2017

Imagine for a moment the year 1800. A doctor is meeting with a patient – most likely in the patient’s home. The patient is complaining about shortness of breath. A cough, a fever. The doctor might check the patient’s pulse or feel their belly, but unlike today, what’s happening inside of the patient’s body is basically unknowable. There’s no MRI. No X-rays. The living body is like a black box that can’t be opened. The only way for a doctor to figure out what was wrong with a patient was to ask them, and as a result patients’ accounts of their symptoms were seen as diseases in themselves. While today a fever is seen as a symptom of some underlying disease like the flu, back then the fever was essentially regarded as the disease itself. But in the early 1800s, an invention came along that changed everything. Suddenly the doctor could clearly hear what was happening inside the body. The heart, the lungs, the breath. This revolutionary device was the stethoscope.  

This is 99% Invisible. I'm Roman Mars. Imagine for a moment the year 1800, a doctor is meeting with a patient, most likely in the patient's home. The patient is complaining about shortness of breath, a cough, a fever. The doctor listens to the patient's complaints, asks a ton of questions, scribbles some notes. Producer Emmett Fitzgerald. And the doctor might check the patient's pulse, but unlike today, what's happening inside of the patient is basically unknowable. There's no MRI, no X-rays.

The living body is like a black box that can't be opened. The only way for a doctor to figure out what's wrong with a patient is to ask them. You needed the patient to tell you what was wrong and what they were suffering. So doctors were very interested in the patient's history, the story of what the symptom was, how long it had been there, how it had changed, what made it better, what made it worse. This is Dr. Jacqueline Duffin. I am a hematologist and a historian of medicine at Queen's University. Duffin says that because the patient's story was all the doctor had to go on, the symptoms

were often seen as... Diseases in themselves. So for example, today if you have a fever, you think of it as a symptom of some underlying disease like the flu. But back at the turn of the 19th century, the fever itself was considered the disease. There were all different kinds of fevers, and fever itself was a broad category of diagnosis. Because doctors had no way of connecting symptoms with what was actually going on inside the body. Until someone built a device that would help the doctor open the black box

and travel inside the human body. And suddenly the doctor could hear everything so much more clearly. The heart belongs, the breath. And everything changed. The inventor of this stethoscope was unsurprisingly a doctor. Renee Leineck was born in Brittany in 1781, and he went to medical school in Paris, where he learned to practice percussion, a technique in which the doctor taps their fingers against a patient's chest and listens to the sound, to determine things like if fluid is building up in the patient's lungs.

Lynek uses the technique for years, and in 1816 he's examining a patient and he precusses her torso. But she's a little bit plump, and because she's plump, he's not getting much sound back from percussing. He thought about putting his ear right against the patient's breast, but he decided that that would be inappropriate. So he took a notebook that he had with him, and he rolled it up into a little cylinder,

and he put one end on the patient's chest and one end on his ear, and he tells us he was struck by how clearly he could hear a heart beating and her breath sounds. I was satisfied to hear the beating of the heart in a manner that was clearer and more distinct than I had ever heard by direct application of the ear. He was so impressed by the quality of the sound that he set about trying to construct the perfect device for listening to the internal sounds of the body, all based on that same cylinder shape.

People said that he became a cilantro maniac, a cylinder maniac, because he was convinced that the instrument mediating between the two bodies of the patient and the doctor improved what the doctor could hear. He used a lathe to carve cylinders out of wood. And at first he wanted to call his new device the cylinder, but eventually he settled on the stethoscope, which means to explore the chest.

But Lynex original stethoscope looks pretty different from the ones we're used to today. It's a long tube-like cylinder. It looks like a small handheld telescope. Lineck started using his new invention to listen to the heart sounds and the breathing sounds of all of the patients in his hospital. And he started to invent words to describe the sounds, because nobody had heard these sounds before. Lineck had invented a way to hear the inner workings of the human body, but that wasn't enough

by itself. He wanted to connect the sounds he was hearing in his patients with what was actually happening anatomically inside their bodies. And how do you connect sounds to what's actually happening inside a body? You listen to people right before they die. He ran around the ward listening to all the patients documenting their symptoms, listening to the sounds they made, and then connecting them to the discoveries he would make at their autopsy when they died.

He thought that every abnormal sound he heard with his stethoscope should correspond to an anatomical finding during the autopsy. So that if you hear this sound, it equals that anatomical finding during the autopsy. So that if you hear this sound, it equals that anatomical finding later. So that the stethoscope was a way of practicing the autopsy before the patient became a cadaver. I mean, we're all just future cadavers, right? But the stethoscope gave us a way of looking inside of a body before it was dead to see what was causing a particular medical problem. In a relatively short period of time, Lynek made some key discoveries using his stethoscope.

For example, he figured out that when a person has fluid beneath their lungs, they make a sound kind of like a goat. Kind of bleeding sound like this. A sound he called a gofini. He also discovered sounds that tracked with the different stages of tuberculosis, the number one killer in Europe at the time. Lynac published his results, linking different diagnoses with anatomical changes

in the body that could be detected using his new stethoscope. Doctors who were his colleagues loved it. They felt that every disease would eventually be attached to an anatomical finding and anatomical change. Some doctors began using LINEX new device themselves. He even put a diagram of it in his book so you could make your own quite easily or have it made for you by any carpenter. And as these doctors used the stethoscope to make more important

discoveries about the body, new categories of disease were created. For example, before the stethoscope, a lot of different ailments were all lumped into one disease called dipsnia, which means shortness of breath. But afterline neck, shortness of breath became a symptom of various heart or lung problems that could be diagnosed using the stethoscope. Medical language completely changed, as doctors invented new anatomical words for diseases like bronchitis, which means the inflammation of the bronchial tubes, the airways that lead to the lungs.

Little by little, our entire understanding of disease shifted. It became more objective. Diseases went from being constellations of symptoms felt subjectively by the patient to anatomical or chemical alterations inside the body detected by the doctor. This shift in how people thought about disease changed the relationships between doctors and patients with the doctors suddenly having a lot more power.

So before the stethoscope, to be sick you had to feel sick. After the stethoscope, to be sick, the doctor had to find something. It didn't matter what the patient thought, what was wrong with them, it mattered more what the doctor found. Lynack himself actually worried that many doctors were taking his ideas too far. He believed that listening to what patients had to say was still important to understanding disease.

But the quest for objective information about disease was underway, and the stethoscope was just the beginning. Then we got X-rays, which do the same thing at the end of the 19th century, and now we have CP scanners and MRIs and PET scans, and all of these marvelous devices are basically trading upon the same paradigm that the stethoscope brought along that we should be able somehow to image the pathological anatomical abnormalities

inside the body to reach the diagnosis, whether the patient has any symptoms at all or not. These new technologies have led to so many important discoveries about the human body and disease. Today we can spot tumors before they become life-threatening, and diagnose problems like high blood pressure before it causes heart disease. But there are also patients today who struggle because they've got tons of symptoms, but the doctor can't find anything quote quote-unquote, wrong with them.

The paradigm shift brought on by the stethoscope has pushed doctors and patients further apart. The doctor is no longer visiting you in your bedroom, interviewing you about every tiny detail of your experience. And sometimes, patients end up feeling like just the collection of data points, rather than a whole human being. Sometimes, patients end up feeling like just the collection of data points, rather than a whole human being. Renee Linek died in 1826 at the age of 45, most likely from tuberculosis, a disease he and his stethoscope helped us understand.

It's been 200 years since he first rolled up his notebook and pressed it to that patient's chest. Medicine looks completely different than it did back then. But somehow, the stethoscope has endured. There are certain tools of the trade that we have gotten rid of. So you don't really see doctors carrying around this big black bag. This is Dr. Andrew Bontbach. He's an aphrologist, a kidney doctor, and an assistant professor at the Columbia University College of Physicians and Surgeons.

Most doctors nowadays don't carry around reflex hammers unless they're neurologists. Most doctors don't wear that light on their head, but the stethoscope has never really fallen out of practice. But of course, doctors aren't walking around with wooden cylinders anymore. In the 1840s, they began experimenting with flexible tubing, and soon after an Irish physician invented the Bynoral Stethoscope design with two earpieces that we still use. Today, there are a few kinds of specialized stethoscopes for particular types of listening,

and more recently, companies have developed electronic stethoscopes with enhanced sound quality and the ability to record. But to this day, when you walk into a doctor's office for a routine exam, you can expect to feel the familiar stethoscope sliding along your back. But that could be changing. For almost 200 years, the trusty stethoscope has been at the forefront of the diagnostic

procedure, constantly hanging around the necks of doctors and often used, but new technology is threatening to exile this old friend to the archives of medical history. Extras and ultrasound have given doctors a clearer window into the body than ever before. And with new portable ultrasound machines, doctors can see an image of a hole in a patient's heart right from the bedside. The rise of portable ultrasound has some doctors arguing that we don't need the stethoscope anymore. They say that if you have that technology, why not use it right away? But ultrasound isn't available in many developing countries. And even in the United States, it's expensive.

If we eliminated the stethoscope and everybody got an ultrasound at every visit, we would bankrupt our health care system. This is Dr. Dan Bernstein, a cardiologist at Stanford University. He says that when he hears something problematic during the stethoscope exam, he immediately orders an ultrasound.

But do I start with every patient who comes in the emergency room taking out the ultrasound machine looking at the lungs? I think that's not a good use of that technology. Right now, he says the stethoscope functions as a screening tool, so that patients don't need to go get an expensive ultrasound unless they need one. Still, there's no denying that advanced imaging

has changed the instrument's role. Dr. Andrew Bombak says that medical students today aren't as good at listening to the body as they once were. And across the board, doctors rely less on the stethoscope to make a diagnosis. It's become almost a ritual more than a actual tool of the trade in terms of helping us make diagnosis. Recently, one of Dr. Bombak's most respected colleagues asked to borrow a stethoscope. And Bombak was embarrassed because the only one he had within that day was this cheap plastic disposable thing. But he handed it over anyway.

And he said, oh yeah, thanks, that's perfect. He knew me. And as he was walking away, he's like, you know, patients just expect you to have this when you see them. He's like, I'm not gonna really need to use it. And I thought that was such a funny story, because here's someone that I consider the consummate clinician, and he was acknowledging that the step-the-scope was in many ways just sort of a prop. But it's an omnipresent prop.

If you do a Google image search for doctor, right away, you'll notice a couple of things about what a physician is supposed to look like. Most of the doctor's pictures on the first page of results are white men in white coats. Some of them are peering inside of patients' ears. Others are writing something down, an equip board, but all of them have stethoscopes. Well, what I find so intriguing about the Google Images searches for doctor is not only is every doctor wearing a stethoscope,

but they are almost all wearing the stethoscope in the exact same way, which is like a shawl around the back of the neck. With the earpieces on one side and the bell on the other, Bombak says that this way of wearing a stethoscope draped over the shoulders is a relatively recent fashion trend. The first time I can remember ever seeing that was on the television show ER. And then it on scrubs, which is another very popular medical TV show. Doctors used to wear their stethoscopes dangling down the front of the shirt like a tie. And this was practical. If you needed to use your stethoscope in a hurry, you just popped it into your ears.

It's almost like this new version of wearing it like a scarf or a shawl is almost a concession that it's more a fashion accessory than actually a tool that we're using. But even if the stethoscope exam has become something of a ritual, it doesn't mean that doctors are ready to give it up. I mean, I would never give up my stethoscope because I think in the very least, it's this conduit to connecting with the patient. Bombac says that physical contact between a doctor and a patient

has become increasingly rare. Doctors' visits are short, and physicians often spend half the time staring at a computer screen. The stethoscope provides an important opportunity for intimacy. The stethoscope is still a part of the exam that is still very much aligned with that idea

of the laying on of hands that a healer can do. When we go to do the physical exam, we move away from our desk, we move away from the computer, and we stand right next to the patient, and it's a much more intimate conversation. And even with all these powerful tools for measuring what's going on inside a body, We move away from the computer and we stand right next to the patient and it's a much more intimate conversation. And even with all these powerful tools for measuring what's going on inside a body, intimate conversations are still really important in medicine.

Dr. Bombak says he thinks that the stethoscope has come to symbolize to the patient that the doctor is there to listen. And whether we're actually listening to their heart or their lungs is probably not that important, but what they really want to know is that we're listening to what they say. 200 years ago, Renee Linex invention ushered in a new medical era. One with a patient's own understanding of their disease

gave way to more objective observation of the body. This turned put a certain amount of distance between doctors and patients. Today, maybe the stethoscope lives on to keep physicians and patients from drifting too far apart, to make sure doctors keep close to their patients, and keep listening. 99% of this will be back in a heartbeat after these messages. Hey, it's Emmett. I'm back. Okay, so real quick, before we go, remember when I mentioned that there are these new electronic stethoscopes?

Well, one is made by this company Echo, which is based right here in Berkeley. And their stethoscope can record a patient's heartbeat, display the waveform, and they're even working on software that can help doctors identify irregularities. I stop by their offices and ask them to record my heart. They press the device to my chest and a little waveform popped up on a smartphone. At the top here you see the heart start to fire. You actually see that's called the P wave right there. That's echo founder Connor Landgraph. And while he is not a doctor, he says my heart looks healthy.

Pretty normal looking waveform. Nothing really interesting looking there. Unfortunately. Unfortunately. Yeah, I guess fortunately for you. Yeah. So just to send us off a very disappointingly boring heartbeat. Sorry, boss. 99% invisible was produced this week by Emmett Fitzgerald, with production help from Delaney

Hall and Sheree Fusif. Our senior producer is Katie Mingle Kurt Colstead is the digital director, The Music, was by Sean Rial. The rest of staff includes Avery Trouffleman, Terran Mazza, and me Roman Mars. Additional music this week by our friends, Okakumi and Melodyne. Special thanks to Anna Prager, who sparked this idea for us. We are a project of 91.7 KALA-L-W and San Francisco and produced on Radio Row in beautiful downtown Oakland, California.

We are a proud founding member of Radio Topia from PRX supported by the Journalism Defending Night Foundation and coin carrying listeners, just like you. You can find the show, Enjoying Discussions, about the show on Facebook. You can tweet at me at Roman Mars and the show at 99PI at work. Or on Instagram, Tumblr, and Reddit too. But we have all the past episodes and at least two articles about design published on our

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