In this video, Rohin Francis, MBBS, recounts how a young woman’s generous shape led to a significant leap in medical technology.
The following is a transcript of this video; note that errors are possible.
Francis: I’m in Paris and I’m actually on the Champs-Élysées. You can probably just make out the Arc de Triomphe behind me. It’s not the greatest of places to choose to film because it’s very noisy here. But while the traffic stopped, I thought I’d quickly tell you where I’m going. I’m going on a pilgrimage and Paris is my joint favorite city in the world. I absolutely love visiting, but I’m normally with my wife. In fact, that was where we first came on our very first holiday when we were 18. Oh God, this is starting to sound like a vlog, isn’t it? Normally, when I come with the family, I don’t want to subject them to my particular strange tourist attractions. Because I’m here on my own, I’m making a pilgrimage to an unassuming part of the city where the history of medicine changed forever just over 200 years ago.
This is the Necker Hospital in the 7th arrondissement. Back in 1816, a young doctor called René Laënnec was working here in the tuberculosis wards. Unfortunately, interloping tourists aren’t allowed to wander through hospitals in these plagued times, so I can only show you the outside. But while it is now an enormous modern hospital occupying an entire city block, you can still see the old buildings where history was made.
To explain what momentous thing happened here, I thought I would wander across town from my hotel where I was attending a cardiology conference. It was a glorious day when I set off, but… Heavens have opened on the Champs-Élysées. There was a beautiful sunny day earlier, which has changed, and I don’t carry an umbrella because it’s an unnatural abomination that goes against an act of God so I’m getting wet.
But our story starts here in the Jardin des Tuileries next to the Louvre where Laënnec was walking early one morning — I think he was considerably less wet than me — and he saw two children playing a game with a stick, where one of them put the stick to his ear and the other one scratched the other end and, of course, the sound was transmitted. They understood the acoustics involved, transmitting a quiet sound to the ear in a different way. They gave Laënnec an idea, hence becoming history’s first child StickTok influencers.
Sometime later, back in the Necker Hospital, Laënnec was called to see a young woman with general symptoms of heart disease. He described that she was particularly generously proportioned and an overweight young lady. The traditional way of listening to her heart he felt wasn’t entirely appropriate. Being a bashful gentleman with a young female patient, which was for thousands of years, doctors had just put their ear on the patient’s chest and listen to the heart. Realizing this might not be appropriate nor indeed effective, he remembered the kids from here in the Tuileries Garden and rolled up a wad of paper, formed a cylinder, and placed it to her chest.
I was hoping my actually French friend, Barris, would do the voice over here, but he decided to go on holiday.
Kent Brockman: Very unprofessional, Phil.
Francis: “I was surprised and elated to be able to hear the beating of her heart with far greater clearness than I ever had with direct application of my ear. I immediately saw this might become an indispensable method for studying not only the beating of the heart, but all movements able of producing sound in the chest cavity.”
I made a whole video about why the heart has such an important role in the development of how we use sound in medicine and why I, as a cardiologist, am particularly passionate about the history of this tool that has become the very symbol of my profession. But if there is one person who thinks about the history of the stethoscope more than even me, it’s my friend, Dr. Adam Rodman, who works out in Boston. He has a fantastic podcast about medical history called Bedside Rounds that is honestly one of my favorites. If you like the kind of historical stuff I make, you’ll love his podcast.
I started by asking Adam about the history of sound in how doctors make diagnoses and how, like some of the best things in life, it began with wine.
Rodman: Sound as part of diagnosis is actually very, very old. In the Hippocratic Corpus, we have this idea of this succession splash.
Francis: Adam, old chap, the succession splash I think is what happened when Kendall crashed into a river. But what I’m sure you meant to say was the succussion splash, which is the oldest known method of using sound in diagnosis. It wasn’t particularly elegant. You literally just shook the patient and listened for a splash coming from the stomach, which might suggest distension.
Rodman: I will say that sound in medicine certainly took a backseat until the 18th century. Now, if you want to talk about smell or taste in medicine, which is rather gross, uroscopy and even examination of the stool was very common, but not necessarily sound until Auenbrugger. He is working in the Spanish Military Hospital and everyone is dying — this is in the 1760s — of tuberculosis and end-stage tuberculosis, so people have very large pleural effusions, fluid in their lungs. This is at, let’s say, the dawn of pathologic anatomy. These patients would die, he would autopsy them and there would be a ton of fluid in their lungs.
The story goes that his father was an innkeeper and he would keep wine in the basement. A lot of people would come and you got to find the barrel of wine that has enough to give libations to everybody.
Francis: What his father, the innkeeper, did was to tap on the side of a barrel to listen to how much liquid is inside. I’m going to try and demonstrate using some paint pots. It’s the nearest I have got to wine barrels sadly that I have got lying around.
Now, this one is full, so let’s hear what it sounds like. That’s what we call dull. If a chest is full of fluid, then we refer to this as a kind of stony, dull sound. Whereas this one is about two-thirds empty. Let’s have a listen and contrast. It’s still kind of dull at the bottom, but as we move up it’s got a much more hollow sound. I can demonstrate it on myself if I just come close to the mic. You can hear as I tap over my lungs it’s a hollow sound, as I hope it should be, but it isn’t always the case.
Rodman: Auenbrugger remembered what his dad had done and he started to do that on his patients who were dying of tuberculosis. Now, the difference is actually very similar. His father would confirm where his tapping was by tapping the barrel and getting the wine out. Auenbrugger would tap out where he felt the pleural effusion was and then when they died he would perform an autopsy and see where the fluid level was.
Francis: This is an examination technique called percussion. It’s exactly what we still do to listen for fluid that’s collected in the chest. It may seem obvious to you now, but this was the advent of modern pathological anatomical diagnosis. Up until then, apart from some basic external clues, we really had to rely on post-mortems, autopsies, to know what was going on inside the body. But this was really the advent of figuring out what pathological processes, what was going wrong, while the patient was still alive.
Rodman: This is really I think the first modern example of sound being used in diagnosis. He should have been a legend, but in fact he was not. He was fired, right? He was disowned by his mentor. The world was not ready for his ideas. He actually did quite well for himself. Again, he was wealthy, I know he was friends with Mozart, and he commissioned an opera, so I don’t feel too bad for him. But that was basically the end of his career in medicine.
Francis: Fast-forward some years to our hero, Rene Laënnec, in Paris and by now the idea of recording examination findings during life and then correlating them after death had become commonplace. After that momentous day that we have already heard about when he first listened, he begins to hone his craft.
Rodman: He auscultates. He listens with his stethoscope. When his patients died — and you can still read his book today, you can see what they died from, they are horrific diseases — he performed an autopsy. He was very, very careful to link all of the findings that he heard with his ear to what he found on autopsy.
Francis: Here is some trivia for you. Did you know that the stethoscope being invented at the Necker Hospital by a man called Laënnec is actually the reason we were it around the neck?
Rodman: He experimented with different types of wood. He turned them on his lathe to see which type of wood would allow for the best auscultation. If you want to do show and tell, this is a recreation of Laënnec’s original cylinder. I got it from… this is 3D printed. I actually still listen with a wooden stethoscope. This is my stethoscope. This is cherry, which is the same wood that Laënnec ended up deciding that was the best for cardiac auscultation.
Homer Simpson: Names!
Rodman: Unfortunately, he died in his home at Brittany of tuberculosis. One of the great ironies is he was actually a very humanistic physician, very concerned about his patients, and very devastated when they died, and dedicated his career to them, and ended up dying of the same disease that he was treating.
Francis: Why are Adam and I so obsessed with the history of this one particular item from a doctor’s bag?
Rodman: From my perspective, the stethoscope was really the first diagnostic test. It is the first test that a physician… it’s a technology, right? It’s the first test that a physician could use to make a diagnosis beyond effectively talking to the person. Yes, there was percussion before that, but you’re still using your hands.
From a like 21st century perspective, this was the first use of technology in diagnosing a patient. If you think about the tests that we order today — like the fact that I can order a PET scan, that we put a radiotracer in a person to literally look at metabolism of cancer cells and then get a 3D recreation of that — the stethoscope is the beginning of that long, technological journey.
Francis: The stethoscope itself has come on a journey from the hollow, wooden cylinder to the ubiquitous rubber tubes. This is the Littmann Master Cardiology because of course it is. What else would I use? To something like this. This is the Eko DUO. It’s an electronic stethoscope, which can wirelessly send the sound via Bluetooth to my phone where I can record it and use it for teaching.
Some people say that the handheld ultrasound device, like the one I used in my zero-gravity video, is the natural evolution of the stethoscope. It’s many times more expensive, but of course at the end of the day it does still use sound so it really is a direct descendant.
If you want to hear the whole unedited conversation with Adam whose enthusiasm I think is evident even from these clips, it’s available as a separate video exclusively over on Nebula with a few extra bits as well. This video is there with an entirely different ending.
Rohin Francis, MBBS, is an interventional cardiologist, internal medicine doctor, and university researcher who makes science videos and bad jokes. Offbeat topics you won’t find elsewhere, enriched with a government-mandated dose of humor. Trained in Cambridge; now PhD-ing in London.
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