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Morals, Mammaries, and the Invention of the Stethoscope

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Robert A. Thom/clinmedres.org

In 1816, French physician Rene Theophile Hyacinthe Laennec had a young woman on his exam table, and no idea what to do with her. She’d come in complaining of chest pains, and their conversation and the examination up to that point suggested a diseased heart, but Laennec wasn’t sure how he would confirm that.

Since the days of Hippocrates, doctors had limited options when it came to assessing cardiac health, and mainly relied on auscultation, or listening to sounds of the body. Dulled sounds in an area of the chest that was normally more resonant, for example, could indicate extraneous fluid or a tumor. One way of doing this was to place an ear right on the patient’s chest and listen directly to the heart, lungs, and chest cavity. Another option was to tap on the chest or back and listen to the resulting sound, a method developed by an Austrian physician whose innkeeper father tapped on wine barrels to determine their fullness.

Laennec was familiar with both methods—in fact, one of his teachers (and Napoleon’s personal physician), Jean-Nicolas Corvisant, had helped popularize the percussion technique—but neither would do him any good with this patient. The young lady was on the heavier side and ample in the chest, which presented some complications.

“Percussion and the application of the hand were of little avail,” Laennec wrote of the exam, “on account of the great degree of fatness.” Putting his ear right up to her chest was also “rendered inadmissible” by the Catholic bachelor’s social unease at putting his head that close to a young woman’s bosom. He later said of examining female patients that, “direct auscultation was as uncomfortable for the doctor as it was for the patient…It was hardly suitable where most women were concerned and, with some, the very size of their breasts was a physical obstacle to the employment of this method.”

After a few embarrassing minutes, Laennec remembered “a simple and well known fact in acoustics…the augmented impression of sound when conveyed through certain solid bodies—as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other.”

He grabbed a sheet of paper, rolled it up and placed one end against the woman’s chest and the other against his ear. He was “surprised and elated to be able to hear the beating of her heart,” he wrote, “with far greater clearness than I ever had with direct application of my ear.”

Over the next few years, Laennec experimented with his improvised tool and perfected its design. A wooden tube carried sound better than paper, and pine seemed to work especially well. He struggled with a name for his invention, though, and toyed with pectrolique, medical cornet and thoraciscope before settling on stethoscope, from the Greek stethos (“chest”) + -scope (“look or examine”).

Satisfied with his design, Laennec went on to use the stethoscope to catalog and describe various sounds of the chest and correlate them to specific ailments. After three years, he published the landmark De l’Auscultation Médiate, ou Traité du Diagnostic des Maladies des Poumons et du Coeur (or, On Mediate Auscultation, or Treaty of Diagnosing Diseases of the Lungs and the Heart).

Besides having an advanced instrument for it, it seems only natural that Laennec would be drawn to treating diseases of the chest: his mother, the uncle that helped raise him, and a few of his mentors all died of tuberculosis. Laennec himself would eventually contract the disease and die from it in 1826. He left his personal stethoscope to his nephew.

Laennec’s invention received its fair share of criticism at first. Even John Forbes, the Scottish physician who translated De l’Auscultation Médiate into English, said that, “It must be confessed that there is something even ludicrous in a grave physician formally listening through a long tube applied to the patient's thorax, as if the disease within were a living being that could communicate its condition to the sense without.” Eventually, though, it gained wide acceptance. With modifications by others, like Arthur Leared and Nicholas Comins’ binaural versions, the stethoscope became an indispensable tool by the 20th century.

How much longer the stethoscope stays that way is uncertain, though. Dr. Bryan Vartabedian, MD, on his blog 33 charts, looked at a 1993 study done by researchers at the Medical College of Pennsylvania. They found, in a nationwide survey of medical training program directors and students, that only 27.1 percent of internal medicine and 37.1 percent of cardiology programs offered structured teaching of chest auscultation, and that accuracy with a stethoscope ranged from 0 percent to 56.2 percent for cardiology fellows, and from 2 percent to 36.8 percent for medical residents.

At the end of that decade, the lead author on that study conducted a similar survey, and found an uptick in the internal medicine programs teaching chest auscultation (up to 48 percent for cardiac auscultation). He didn’t check in on internal med programs again, but only 29.2 percent of family practice programs taught cardiac auscultation and 12.2 percent taught pulmonary auscultation.

This piece was originally published in 2013.

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Why Haven't We Cured Cancer Yet?
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Walkathons, fundraisers, and ribbon-shaped bumper stickers raise research dollars and boost spirits, but cancer—the dreaded disease that affects more than 14 million people and their families at any given time—still remains bereft of a cure.

Why? For starters, cancer isn't just one disease—it's more than 100 of them, with different causes. This makes it impossible to treat each one using a one-size-fits-all method. Secondly, scientists use lab-grown cell lines cultivated from human tumors to develop cancer therapies. Living masses are far more complex, so potential treatments that show promise in lab experiments often don't work on cancer patients. As for the tumors themselves, they're prone to tiny genetic mutations, so just one growth might contain multiple types of cancer cells, and even unique sub-clones of tumors. These distinct entities might not respond the same way, or at all, to the same drug.

These are just a few of the challenges that cancer researchers face—but the good news is that they're working to beat all of them, as this TED-Ed video explains below.

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6 Ways Technology Can Help Mental Health Disorders
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Today is World Mental Health Day. Mental health issues affect hundreds of millions of people around the globe; according to the World Health Organization, some 300 million suffer from depression, and another 260 million grapple with anxiety disorders. While researchers haven't developed any breakthrough mental health drugs in nearly three decades, new technological innovations are helping some patients connect with a therapist, get diagnosed, track moods, manage or mitigate symptoms, and stick to treatments. Here are just a sampling of them.

1. APPS FOR EVERYTHING FROM PTSD TO ADDICTION

The "there's an app for that" slogan is now true for the complex world of mental health care. There are thousands. Some apps are targeted at users with specific conditions, such as anxiety, schizophrenia, or depression, and are designed to assuage and manage symptoms, track moods and thoughts, or help individuals stick with treatments. Others are aimed at improving memory, coping, and thinking skills, or managing stress through meditation or mindfulness. There are also apps for post-traumatic stress disorder (PTSD), eating disorders, and addiction. The list goes on.

Mental health apps have plenty of benefits, including convenience, anonymity, and a low price. But experts caution prospective users against using them as a stand-in for professional treatment, according to the National Institute of Mental Health (NIMH). Most aren't backed by peer-reviewed research or clinical trials, partially because tech development moves faster than traditional scientific testing. Confidentiality is also a major issue, as many of these apps don't adhere to standard healthcare privacy guidelines.

Yet some preliminary studies have shown that they can yield patient improvements. Vet any app you're considering with a doctor or therapist, focusing on ones that rely on evidence-based treatment such as cognitive behavior therapy. Double-check the app developer's credentials before downloading: The most trustworthy are typically affiliated with academic research institutions or government agencies, according to the American Psychological Association. And choose one with an intuitive interface; it will be easier to stick with, so you might see better outcomes.

To learn more about the pros and cons, visit the NIMH's comprehensive report on the subject.

2. ONE-ON-ONE THERAPY THROUGH VIDEO AND TEXT

With a shortage of mental health professionals in the U.S., online or mobile therapy appears to be a good solution for prospective patients who can't find an available one in their area. It's also promising for those who simply don't have the time or resources for in-person appointments, or are afraid of stigma.

Some services or platforms allow users to connect with therapists via voice or video on a computer or phone. Others are text-based and allow patients to send unlimited messages via their phones, 24/7, for a flat monthly fee.

3. BEHAVIOR TRACKERS THAT MAY INDICATE AN IMPENDING MENTAL HEALTH CRISIS

While some mental health apps are designed to deliver outcomes (an improved mood, lessened anxiety), researchers are also working to harness mobile technology to detect suicidal inclinations, burgeoning manic episodes, or depressive episodes before they manifest.

One such scientist is Dr. Thomas Insel, a psychiatrist and former head of the NIMH. After a stint with Verily, the life sciences unit of Alphabet (the parent company of Google), Insel left the tech giant to co-found a start-up called Mindstrong. Both organizations, he told CNBC, are working on apps that monitor users' smartphone behavior—with permission from the user.

For example, if a user starts typing more rapidly than normal, their syntax changes, or they indulge in impulsive shopping sprees, that might be an indicator that they're manic. If they don't respond to texts from family and friends, they might be depressed. Together, this data collection could create what Insel calls a "digital phenotype," which could be described as a personalized mental health map. This could help users or their loved ones mitigate any potential crises through preventative treatment.

This line of research is promising, but Insel noted that it's still unclear whether the approach will yield long-term outcomes for patients—or if the tech itself is fine-tuned enough to observe behavior changes.

4. SMART SOFTWARE THAT FINDS AT-RISK PATIENTS IN MEDICAL RECORDS

Some insurance companies are now using cloud-based software platforms to review electronic medical records and insurance claims data to identify patients at risk for developing mental health conditions like depression. Then, they connect them with appropriate treatments through a network of behavioral health specialists.

5. VIRTUAL-REALITY TREATMENTS

In addition to treating PTSD with medication, therapy, and exercise, some physicians use a technique called exposure therapy, which is designed to help patients relive trauma-related phenomena in a controlled, safe environment, such as a doctor's office. This helps patients get habituated to the memories so they no longer trigger flashbacks and anxiety. Scientists have tested VR as a tool for exposure therapy in clinical trials, and a handful of clinicians around the U.S. are now trained to use it in their practices.

Headsets whisk patients back in time using a combination of images and sounds. While wearing the headsets, subjects discuss past experiences with therapists until they become desensitized to the triggers before them.

Meanwhile, researchers like Yale scientist Sarah Fineberg are using computer games and VR to understand feelings of social rejection in people with borderline personality disorder (BPD), a complicated condition in which sufferers have a hard time regulating emotions, have a distorted sense of self, and are prone to extreme mood swings, especially towards the people in their lives. 

6. A GOOGLE SCREENING THAT LETS YOU KNOW IF YOU'RE DEPRESSED

Google recently teamed up with the National Alliance on Mental Illness (NAMI), a nationwide grassroots mental health advocacy group, to offer a mental health screening questionnaire to U.S. residents who search for "depression" on their mobile phones. The top result is a box called a "knowledge panel," which has information on depression, its symptoms, and potential treatments. To get screened, click the option "Check if you're clinically depressed" to take a confidential, medically backed self-assessment quiz.

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