Listening to the Body Moving: Auscultation, Sound, and Music in the Early Nineteenth Century
Janina Wellmann
Introduction
Does the body make sounds? And if so, do the sounds reveal something about the condition of the body? These questions seem trivial today. We do not question the soundscape of our bodies, nor do we disregard it if our bodies suddenly harbour noises we are not used to. Listening to our bodies is an experience that we learn from early childhood from any visit to the doctor. But what exactly do we hear? When did we learn to hear these sounds, to describe, represent and register them – in words, graphs and apparatuses, on paper and in acoustic media? And when did sounds become signs of health and disease?
Sound studies has become a major field of research in the past few decades, approaching the acoustic landscapes of past and present eras from an interdisciplinary perspective. The majority of such work addresses the mid-nineteenth to mid-twentieth century, a period considered to represent a major historical rupture. Not only did the possibilities and technologies of sound recording and sound transmission change dramatically during this time, but modernization, urbanization and mechanization also changed the entire environment of sound production, sound exposure and listening habits (Hui, Kursell and Jackson 2013; Morat 2014; Pinch and Bijsterveld 2004, 2011; Schoon and Volmar 2012; Sterne 2003a, 2012; Supper and Bijsterveld 2015). Naturally enough, there is a certain bias towards writing the history of sound along the trajectory of the sounds retained and captured from the past – hence the dictum that “the history of sound and auditory cultures cannot be written without taking into consideration the reproducibility of sound” (Morat 2014: 2–3).
This paper, however, is dedicated to the sounds of the body in an era before sound could be recorded as sound: the first half of the nineteenth century. How can audio objects be retained from the past? What is a past acoustic phenomenon in the first place? And what can a history-of-science perspective on acoustic phenomena contribute to the study of sounds, or, conversely, the study of sounds to our understanding of past science? To answer these questions, we must first decide whether sound was even of importance to the history of, for example, the biological and medical sciences before 1850. If so, what exactly was its role and how can it be assessed? To put it more pointedly: How can audio objects be found in scientific texts?
In classic histories of medicine, the auditory enters the scene with the introduction of auscultation into the clinic at the beginning of the nineteenth century. Among the best-studied promoters of listening to the sounds of the body is the French doctor René Théophile Hyacinthe Laennec (1781–1826), who inaugurated mediate auscultation with his 1819 treatise De l’auscultation. Listening to the sounds of the body goes back to antiquity, but only with Laennec and the invention of the modern stethoscope did the body’s acoustic signals become systematized, classified and encoded with diagnostic knowledge. Auscultation marks one of the more important moments in the history of medicine, if not the “most prominent form of medical diagnosis in nineteenth-century medicine” (Lachmund 1999: 420). With the stethoscope, a new diagnostic tool entered medical practice. Much has been written about Laennec and the introduction of the stethoscope into the clinic. Special emphasis has been placed on auscultation as a social and local practice, stemming from a particular historical medical setting and being a prime factor in changing the doctor’s status vis-à-vis the patient (see Duffin 1998; Lachmund 1997, 1999; Reiser 1978: esp. ch. 2; Sterne 2001, 2003a). Auscultation has been present in the ward ever since. A widely used diagnostic practice in medicine today, it has also frequently been the object of research in sound studies. Recent studies in particular focus on the modern clinic, on the pedagogy of learning the skill of listening, the soundscape of today’s hospitals and the role of the instrument and its skilful application in creating the professional habitus of the doctor. From this perspective, auscultation serves as an example of the enormous success and important contribution of aural techniques to the production of medical knowledge.[1]
In the following, I will examine how the soundscape of the body was perceived, described and conceptualized in the very early days of auscultation. My interest in auscultation relates, however, less to various modes of listening and their social implications than to the question of whether and how listening and body sounds produced new knowledge about the body, health and disease. How did the early nineteenth century conceive of a sounding living body? Did auscultation constitute a specific form of aural knowledge with regard to the epistemological issues of life and health, death and disease?
I will approach these questions through a focus on Laennec’s study of cardiac sounds. The reason for this is twofold. Firstly, Laennec’s studies of cardiac sounds have attracted far less scholarly attention than has his examination of the lungs.[2] Secondly, his study of the heart is considered to have been a failure. Physicians attacked Laennec’s views right from the first publication of his treatise and throughout his lifetime. Soon after his death, the discovery of the valves (and not the heart muscle, as Laennec had suggested) as the origin of the heart sounds sent medicine in new directions (Duffin 1998: 200–201). From the second half of the nineteenth century, auscultation was also increasingly flanked by new diagnostic – predominantly visual – tools such as the x-ray and the electrocardiograph.[3] Against this backdrop, Laennec’s auscultation of the heart provides a particularly suitable example to assess the epistemic value of the auditory in an era of major shifts in medicine.
Studying Laennec’s approach to cardiac sound, I will show how his conception of body sounds was schooled by musical listening. Laennec’s perception and description of sounds were tied to musical principles, most notably to the various instruments and the quality, intensity and rhythm of sound patterns. Understood as an inherently musical task, perceiving the sounds of the body required the musical skill of the listener. Placing Laennec’s medical practice in a musical tradition not only emphasizes a context neglected in the scholarship on auscultation, it also enables a more nuanced look at the history of auscultation as a diagnostic tool in the nineteenth century. I will argue that in the period following Laennec, the overall conception of the body’s soundscape shifted, making Laennec’s analogy of body and instrument, sound and musical notes and, not least, medical understanding and musical skill an obsolete hermeneutics. The history-of-science perspective developed in this paper suggests that auscultation marks a particular historical moment in which concepts of listening, of sound, of music and of the body (all inextricably entwined) were shifting: the moment that Laennec introduced sound to the study of the body, the body ceased to be studied as a musical instrument of sound.
Body music
Laennec is widely credited with having invented the stethoscope, but the practice of listening to the body’s sounds is much older. The topos of the musicality of bodily processes drew on a long tradition, going back to Greek antiquity, that focused on the human pulse.[4] In the third century BCE, the Greek physician Herophilos equated the movement of pulse (diastole and systole) with the rise and fall of the poetic line (arsis and thesis) and of music. The medieval idea of the harmony of the spheres and the musica humana, in other words the notion that the same numerical laws governed the cosmos, music, and mankind,[5] maintained the parallel between music and pulse – even if Galen, whose medical authority reached well into the modern era, did not accept the opinion that the pulse could be quantified using precisely determined numerical ratios. There had been calls in medical literature since the end of the Middle Ages for physicians to know musical theory in order to be able to measure the pulse, but in the mid-sixteenth century the doctor Josephus Struthius (1510–1568) became the first to visually represent the pulse with the help of musical notes. He founded a tradition of musical pulse notation, and only two centuries later François Nicolas Marquet (1687–1759) proposed the last systematic musical pulse notation in his Nouvelle méthode facile et curieuse pour apprendre par les Notes de Musique à connoître le Pous de l’Homme (New, Easy and Curious Method for Learning by the Notes of Music to Know the Pulse of Man) of 1747. When the mathematical and cosmological concept of music faded in the eighteenth century along with the musica humana, the study of the pulse became increasingly empirical, and in the century’s second half, attention also turned to the possible effects of different kinds of musical rhythms and tempi upon the pulse.[6]
Along with these numerous attempts since antiquity to diagnose and portray the human body’s workings, the regularity of the pulse, physical illnesses or health through the laws of music, the converse question also arose: To what extent do the laws of music follow those of the body? In the late fifteenth century, the Spanish music theorist Bartolomeo Ramos de Pareja (c. 1440–1491) proposed the human pulse as the measure of musical tempo; he was particularly interested in using the pulse’s regularity as a pattern for the timekeeping movements of the hand. Only in the mid-eighteenth century did Johann Joachim Quantz (1697–1773) set down a particular pulse rate, in the manner of a metronome, as the measure to describe musical tempi (Kümmel 1977: 54–60). Far more common were attempts to use music to describe the pulse. Marquet, for example, chose the opposite route from Quantz at almost exactly the same time, defining the pulse in terms of the minuet.
Towards the end of the eighteenth century, the physiological anchoring of musical rhythm placed the relationship of music and medicine on a new foundation. The topos of the body’s musicality now became the linchpin both of the theoretical explanation of music as a representation of life and of the new science of physiology itself. In both domains, rhythm played a similar role, as the underlying structure of a flowing movement and the guiding principle of development. This is why physiological arguments and terminology so often feature in the musical debates of the period: rhythm as the inner organization of music corresponds with rhythm as the inner organization of organic nature.[7]
Laennec’s musical approach to the heart
Laennec studied medicine in Nantes before moving to Paris in 1800. There he was a student, at the Charité hospital, of Jean-Nicolas Corvisart (1755–1821), primary physician to Napoleon. He qualified as a doctor in 1804 and was employed at the Hôpital Necker in 1816. In Paris, Laennec was part of the Paris School of medicine, of which his teacher Corvisart was one of the most prominent figures. After the French Revolution, Paris was at the centre of introducing a new empirical epistemology to medicine. Anatomy and pathology became crucial to the understanding of disease. Examination of the dead body was made the sole route of access to understanding disease in the living body. Local lesions and deviations from the normal anatomical state, made visible in the body through autopsy, accounted for various diseases.[8] Probably around 1816 Laennec had the idea of listening to the sounds of the body not by directly applying his ear to the chest of a patient, but by using a tube folded from paper (later made of wood) (see Bruyère 2006; Duffin 1998; Lachmund 1997; Saintignon 1904). In contradistinction to the ancient method of direct auscultation, he termed this method “mediate” auscultation.
In 1819, Laennec published his seminal De l’auscultation, and in 1826 a second edition appeared, which was translated into English in 1838. The treatise is divided into three main parts, the first two of which are dedicated to the sounds and diseases of the chest and lungs, with the final part studying the heart. His clinical work and examination of patients at the Hôpital Necker provided the case studies on which his treatise is based. In the hospital, Laennec carefully listened to the patients and took notes. Post-mortem, he carried out autopsies, systematically cross-referencing his notes and sounds with the tissue examined. Jacalyn Duffin, who has studied the manuscripts in Laennec’s papers at the University of Nantes, tracked the cases dealing with cardiac sound in the first and second editions, of 1819 and 1826 respectively. Of fifty case studies in the 1819 treatise, only six concerned the heart, four of which were examined with the stethoscope and on five of which a post-mortem examination was carried out. From the first to the second edition some details were added, but no complete case studies. In all, there are seven cases of cardiac disease in the two editions.[9] In the archives, Duffin finds a total of twenty-seven records and two cases published elsewhere that indicate a concern with heart disease (Duffin 1998: esp. 197–198).[10]
In his opening remarks to the second edition, here in John Forbes’s 1838 translation, Laennec classifies cardiac diseases as “among those diseases which are the most imperfectly known” (Laennec 1838: 567). Pathological changes in the heart had long been described, for example by Raymond Vieussens in the seventeenth century or Jean-Baptiste Sénac in the eighteenth century. Jean-Nicolas Corvisart, too, had only recently published the Essai sur les maladies et les lésions organiques du cœur et des gros vaisseaux (Essay on the Organic Diseases and Lesions of the Heart and Great Vessels) in 1806. Symptoms such as chest pain or palpitations were well known, as was the enlargement of the heart and its walls, but symptoms and pathological causes could not be unambiguously matched, nor could emotional and psychological causes be excluded. Knowledge remained scarce and controversial.[11] To Laennec, authors such as Corvisart “threw little light on the signs of these (i.e. lesions)” (Laennec 1838: 567). But what kinds of “signs” is Laennec referring to here? How did he listen to the body? And what did he consider a meaningful bodily sound?
Laennec begins with a study of the healthy heart muscle. He distinguishes the right and left cardiac regions, the right one yielding “a very clear sound,” the left one only “little sound” in a healthy person. Other, “very distinct,” sounds are added by “the alternate contractions of the auricles and ventricles” (Laennec 1838: 569). Altogether, four different aspects in the study of cardiac sounds are enumerated: “1st, the extent over which they can be heard by means of the stethoscope; 2nd, the shock or impulse communicated by them; 3rd, the nature and intensity of the sound; and 4th, their order of rhythm” (Laennec 1838: 570). Laennec underlines that localizing “different points of the chest” where the heart’s pulsation can be heard – the first aspect on his list – is a source of rich and important information (Laennec 1838: 571). Above all, defining the radius in which the sounds are audible allows him to draw conclusions as to the heart muscle’s size. When the sound is confined to precisely defined points, the heart “is well proportioned,” but when the distribution and intensity of the sound varies over the region, “the individual rarely enjoys good health.” It is then much more likely that “the heart is increased beyond the natural size,” and this increase is due to “the dilatation of one or both ventricles” (Laennec 1838: 573). Sound, or rather the localization of points and regions on the chest where the sounds of the heart are audible, is a means of assessing the size, proportion and anatomy of the heart muscle and its different parts – the ventricles and auricles, and the thinness and thickness of their walls (see the detailed account in Laennec 1838: 571–574).
The second aspect of interest to Laennec is the impulse delivered to the stethoscope by the heart’s movement. This impulse, too, permits conclusions as regards how thick or thin the heart’s walls are, in other words, whether the heart suffers from hypertrophy or dilatation (Laennec 1838: 567). The heart’s motion delivers not only a shock or impulse but also a “peculiar sound” (Laennec 1838: 579). The nature and intensity of that sound form his third interest.
To convey an idea of the nature of cardiac sound to the reader, Laennec uses musical imagery. To him, the body is an instrument. We are sensitive to that instrument in states of emotional excitement or distress, but also if we turn our attention inward – for example, when “lying on the side, with the ear compressed against a cushion” (Laennec 1838: 580). The sound, or more precisely, the two sounds of the heart, referring to each beat of the arterial pulse, are “distinct” in that one is “clear and rapid,” the other “dull and prolonged.” The first corresponds to the “systole of the auricles” and resembles the “sound produced by the valve of a pair of bellows,” the second to “the contraction of the ventricles” (Laennec 1838: 580). The quality of the sound gives a clue as to the degree of disease. For example, we find a “dull sound like the murmur of inspiration” in a “moderate degree of hypertrophy,” whereas no sound at all indicates a high degree of hypertrophy (Laennec 1838: 581). In the case of “considerable dilatation,” the two sounds can be distinguished “solely by their isochronism or anachronism with the arterial pulse” (Laennec 1838: 582). Loudness or feebleness, distinctness and dullness are important characteristics of the sound, directly linked to the anatomical condition of the heart. Finally, cardiac sound is characterized by rhythm. By rhythm, Laennec means “the order of the contractions of different parts of the heart; and their relative duration and succession” (Laennec 1838: 583). When it comes to judging the intervals between the contractions, Laennec attributes more precision to the ear than to the eye, the ear being capable of “judging much more correctly of the intervals of sound, than the eye of the intervals of motion corresponding to these” (Laennec 1838: 569). “Trivial expressions” convey best “an idea of the nature of the sound,” which leads him to the following characterization of the two sounds of the heart:
At the moment of the arterial pulse, the ear is slightly elevated by an isochronous motion of the heart, which is accompanied by a somewhat dull, though distinct sound. This is the contraction of the ventricles. Immediately after, and without any interval, a louder sound resembling that of a valve, or a whip, or the lapping of a dog, announces the contraction of the auricles. (Laennec 1838: 588)
Here too, rhythm serves as an indicator of changes in the heart’s size and proportion. Rhythm might indicate a moderate hypertrophy when exaggerated, or a strong one if the contractions are unnaturally prolonged, or thin heart walls due to the dilatation of the organ (see Laennec 1838: 591–592). But rhythm also suggests anomalies that need not necessarily constitute a disease “or even serious indisposition.” Those anomalies appear under the rubric of palpitations, irregularities and intermissions (Laennec 1838: 593). Studying rhythm leads Laennec to confirm his idea of the heart as first and foremost a muscle like any other. Rhythm reveals that “far from being in a state of constant action,” the heart exhibits “alternations between action and repose” (Laennec 1838: 589). He calculates that in any twenty-four hours “the ventricles have twelve and the auricles eighteen hours of quiescence” (Laennec 1838: 590).
Musical notation
Laennec subsequently elaborates on a specific type of cardiac sound anomalies, those which are perceptible only through auscultation but which are not caused by “structural lesions of the organs in which they are produced” (Laennec 1838: 600). He differentiates between the “bellows-sound,” the sound of the “saw or rasp” and the “musical or hissing bellows-sound.” The bellows sound not only matches the sound of that instrument “exactly” but can also be equally loud. It accompanies the diastole of the heart and the arteries but can sometimes change into a “continuous murmur, like that of the sea, or that which is produced by the application of a large shell to the ear” (Laennec 1838: 601–602). The sound of the saw, on the other hand, is accompanied “by the perception of roughness, conveyed by the action of these instruments” (Laennec 1838: 602). Importantly, these various sounds, if each is very distinct and not too loud, can combine to form a melody.
Laennec exemplifies various melodies, using the cases of three patients. In his perception, their heart sounds “compose a certain succession of musical tones.” This is due to the artery, which functions as “a vibrating string, from which two or three notes were drawn out in succession, by advancing and drawing back the finger upon it.” Speaking of a melody is not metaphorical for Laennec. Rather, the sound “is literally musical” (Laennec 1838: 603). It is not only the quality of the sound that is musical but also the ambiance. Laennec compares the acoustic scenery of perceiving bodily sounds to a performance of a musical piece heard from afar. He writes that he first thought the sound “to arise from an instrument in the apartment below.” On closer examination, however, he found that “the musical notes were associated with a slight vibration of the artery which, during its diastole, seemed to brush the end of the stethoscope.” From time to time the melody ceases, all at once, and is “replaced by a very strong sound of the rasp” (Laennec 1838: 603). With the replacement of a string by a rasp comes a switch in scenery as well. Laennec’s imagery shifts from a bourgeois listening experience of harmonious string instruments to the military, a soundscape dominated by the march and the rasp, and “the hoarse roll of the drum.” Laennec is cautious in evoking this soundscape, but despite his concern that the comparison might appear “ridiculous,” it was “this effect” that the alternation of sounds produced in him (Laennec 1838: 603).
Laennec’s account of the cases is noteworthy not only for its shift in imagery from string instrument to rasp, from health to disease, from a domestic listening experience in an urban setting to the battlefield. Equally remarkably, Laennec decided to present the various melodies of his patients’ hearts with the help of musical notation. This is the first use of any kind of symbolic representation of the sounds of the heart, and it is the only one in his oeuvre (Segall 1962). The notation was only inserted into the treatise’s second edition of 1826 and has attracted the slightly condescending description “as perhaps the most disarming passage in his entire opus” (Duffin 1998: 192). But such reactions are not exclusive to the history of medicine. Already in 1838, only about ten years after it first appeared, John Forbes judged the notation a “matter of mere curiosity” and omitted it from his translation (Laennec 1838: 603). Forbes, himself a distinguished doctor and physician to Queen Victoria, made more interventions than merely cutting this notation. In his translator’s preface, he warns that “I have here and there omitted a few passages which seemed to have no necessary or at least useful connexion with the subject of it” (Laennec 1838: xii). Forbes in fact not only abridged but “condensed” the text and flatters himself that this will make his translation “more valuable” than a literal one, the “original being written in a diffuse and verbose style by no means commendable in a work of science” (Laennec 1838: xii).
The account of the cases as given by Forbes differs considerably from the French text. The manner in which he sometimes changes, sometimes reduces or altogether eliminates the complex musical connotations carefully chosen by Laennec significantly changes Laennec’s stance. Forbes omits, for example, Laennec’s comparison of the “bruit sibilant des artères” with a tuning fork, or more precisely, with the tuning fork’s resonance: “la résonance du diapason dont on se sert pour accorder les instruments à clavier” (Laennec 1826: 497). Furthermore, Laennec precisely qualifies the musical intervals of this musical instrument as “intervalles d’un ton ou d’un demi-ton.” He also explicitly writes of “un musicien” who plays on the artery as on a string, whereas Forbes chooses a passive syntax and only speaks of advancing the fingers on the strings. Also missing in the translation is the importance that Laennec attributed to this finding: “ce fait étant un des plus extraordinaires de ceux que m’ait présenté l’auscultation” (Laennec 1826: 497).
Figure 1: The first line shows in musical notation the melody and rhythm of the heart sounds in a female patient whom Laennec auscultated in March 1824.
In the French original, Laennec’s first patient, whose heart sounds he notated as music, is discussed in terms of a musical piece (see figure 1). It is the case of a woman who presented herself to Laennec on 13 March 1824. Laennec’s account of this encounter gives evidence of his perceiving of the body in the manner of a highly skilled musician:
J’étudiai le chant: il roulait sur trois notes formant à peu près un intervalle d’une tierce majeure; la note la plus aigue était fausse et un peu trop basse, mais pas assez marquée d’un bémol. Sous le rapport de la valeur ou durée, ces notes étaient assez égales entre elles. La tonique seule était de temps en temps prolongée, et formait une tenue dont la valeur variait. Je notai en conséquence ce chant ainsi qu’on le trouve (Planche 7, n° 1). (Laennec 1826: 497–498)
In the attempt to give an even more precise idea of the nature of the sound, Laennec compares it to the sound of a Jew’s harp, “d’une guimbarde,” but – this still not being sufficiently exact – with the distinction “que cet instrument rustique ne peut executer que des notes pointées, et qu’ici, au contraire, toutes les notes étaient coulées.” The diastole, too, he compares to a “légère saccade que les musiciens expriment par un coulé-pointé” (Laennec 1826: 498). Even if such descriptions are included in the translation (as is the case for the passage evoking the battlefield, for example), Laennec is more specific in his French treatise by referring explicitly to the interplay of the musician with his instrument: he speaks of “instruments guerriers” and “le bruit rauque du tambour” (Laennec 1826: 498).
Of the other three patients examined by Laennec, the translation left no traces at all. Among them there were two “dont les carotides sifflaient sur deux notes à un intervalle d’un ton: (voy. Planche 7, n° 2) et un troisième chez lequel le sifflement, prolongé jusqu’à la diastole suivante, montait alors à un demi-ton: (ibid, n° 3)” (Laennec 1826: 498). From these case studies and examinations, Laennec concludes that the bellows sound is “the consequence of spasm” (Laennec 1838: 607). To qualify it as a disease, Laennec required a causal relation between exactly one specific sound and one organic lesion.[12] In the cases of the patients he discusses, however, the causes for the various melodies might be numerous, pathological and physiological.
In Laennec’s musical conception of the heart and body sounds, the listener plays a pivotal role. It has been argued that auscultation not only required “a process of perceptual standardization” but also the reciprocal conceptualization of the object and the perceptual abilities of the listener (Lachmund 1999: 439). Only the subject perceiving it and ascribing meaning to it could turn sound into a sign. In the case of Laennec, it was his musical training that framed his perception and comprehension of bodily sounds. Coming from a bourgeois family, Laennec was educated in Latin as well as natural history and mathematics, drawing and dancing. He was an accomplished flautist. He spent extended holidays in Brittany, at the Château de Couvrelles, in the company of the Pompéry family, playing music, hunting and writing the poetry that ultimately earned him admission to the Société de Belles Lettres de Soissons. He also shared a common interest in folk music with the philologist and critic Claude-Charles Fauriel (1772–1844), whose Breton songs he accompanied on the flute.[13]
To make sound speak, then, more than merely an “auditorally sensitive body” was required (Lachmund 1999: 439). In Laennec’s case, it was the elaborate, musically sensitized and schooled body of the doctor. Debates about the musical education of doctors and its value for medical diagnosis were long established and controversial. It is in this tradition that auscultation has been characterized as a reversal of the body–patient relation: in listening, it is not the doctor’s gaze penetrating the patient but “the patient’s body penetrating that of the listener” (Rice 2010: 48; see also Lachmund 1999: esp. 440). I would stress, however, that Laennec’s musical education did not merely heighten and refine his sensitivity and perceptual abilities, allowing him a more distinct and differentiated description of his experiences of sounds and rhythms and leading to his comparing of specific sounds with specific instruments. More than that, Laennec modelled the cardiac soundscape on the structure of music. The way that he listened and, more importantly, the way he conceived of the body he was listening to, was epistemologically framed by the body as instrument, the urban, bourgeois scenery of a skilled listener, the notion of sound as musical note and melody, and, conversely, disease as disruption of harmony and the dissonances of war. In Laennec’s treatise, we see the body of the patient and that of the physician in a resounding mutual dependency: the physician describes the body he listens to in terms of the instrument as which he sees himself.
Acoustical Intervention: Original sound file provided by the author Janina Wellmann overworked by Lucas Niggli, Take56 (Rainbowbells, Random Tuning), Uster/CH: Dec. 21, 2016.
After Laennec
What role did this musical assessment of the physiology and soundscape of the heart play in the understanding of the organ and its diseases? What was its part in the history of auscultation and medicine? Medical and physiological research began to move in new directions starting in Laennec’s lifetime. For physiologists, Laennec was wrong to locate the cardiac sounds in the myocardium – that is, to believe that the sounds were made by the contractions of the ventricles and the atria. Soon after his death, in the 1830s and 1840s, experimental proof was provided that cardiac sounds stem from the motion of the valves. Of the two sounds that can be distinguished and follow each other in short intervals, the first is synchronous with the closure of the valves between atria and ventricles, the second with the closure of the valves between the ventricles and the main arteries. This double beat, or “lub, dub” as it is characterized today, is followed by a pause, then the cycle begins anew.[14]
From the point of view of medical epistemology, auscultation remained inconclusive. To transform the fleeting presence of sounds into meaningful signs of the healthy or diseased state of a body, auscultation was in need of criteria, of a systematization and codification of sounds. Although auscultation soon became a tool in the physician’s kit and offered quick heuristic access to the body, it never constituted a body of universally accepted medical knowledge. Instead, auscultation was a local practice, a learned skill. The 1839 Abhandlung über Perkussion und Auskultation (Treatise on Percussion and Auscultation) by the Austrian doctor Joseph Skoda (1805–1881), a physician at the Allgemeines Krankenhaus of Vienna, illustrates how auscultation was practiced differently in different hospitals, with different consequences. In the tradition of the Paris School of medicine, Laennec causally linked a specific sound to a specific lesion found in the diseased body post-mortem via autopsy. Each and every sound discernible with the help of the stethoscope was meant to directly relate to a pathological state in the anatomy of the organ. In contrast, Skoda approached body sounds with a new interest. His treatise does not discuss clinical case studies and the specificity or differences in sounds, but is concerned with acoustic experiments. Skoda aimed to find physical explanations: to discern sound according to physical acoustic principles. Whereas sounds were ever more finely distinguished in the efforts of Laennec and his followers, Skoda and others simplified and reduced the number of sounds that were deemed to be signs of diseases.[15]
Furthermore, the practices of auscultation, albeit in different manifestations for Laennec and for Skoda, had rested on the premise that the dead body could provide much, if not all, the information needed to explicate the living one. Medicine and physiology in the nineteenth century, by contrast, turned to the living organism, studying the body in terms of the physiology of processes, of stimuli and responses, of circulation and fluid dynamics. Innovative experimental techniques and procedures marked a shift toward a more laboratory-oriented clinic. Experimental physiology invented all kinds of ingenious devices, from Karl Ludwig’s kymograph in 1847 and Karl von Vierordt’s sphygmograph to measure blood pressure, to the ophthalmoscope to look inside the body through the patient’s pupil and the 1893 discovery of x-rays. The living body was strapped to mechanical devices in order to unveil the secrets of its functioning and to inscribe bodily time, sounds and signals onto apparatuses, graphs and visualizations.[16] For the study of the heart, this meant that the organ became embedded within a different bodily soundscape. The only sounds to be heard in the healthy organ are the closing snaps of the valves. Otherwise, the blood flows smoothly around and through the heart. In the diseased body, cardiac sounds are caused by the noise of flow and its interruptions, of turbulences and obstacles due to the malfunctioning of the valves.
Conclusion
In this paper, I have argued that Laennec thought of the body and the heart in terms of a musical instrument. Consequently, his frame of reference for the sounds emanating from the body consisted of the culture, notation, techniques and rules of music. Laennec had recourse to musical notation in those cases where there was a variety of possible pathological or physiological reasons for a particular cardiac sound – a sound that might be anomalous, but was not necessarily indicative of a disease. Looking at these cases from the perspective of music, it became clear that despite his anatomical approach, his concern with lesions and post-mortem examination, Laennec practiced auscultation to access the living body. Sounds were meaningful to him not only as an acoustic gateway to the hidden depth of the living body, not only as a reference by the living organism to disease, that is, to a life-threatening condition that would ultimately be unveiled only in death. Rather, sounds were the music of the living body as well. Music provided a framework for grasping the variety and plenitude of sounds in the normal living body. Laennec focused on the size, proportion and anatomy of the heart muscle in order to grasp the materiality of the sounding body and the sound conditions and parameters of the organ, which he framed as a musical instrument. The melody of the heart he notated was the music of the living body. It is the living body that plays the variable tunes of body sounds, just as an instrument plays different melodies.
Described as an “autopsy of the living” (Sterne 2003b), auscultation played epistemologically with the body, substituting the living body for the dead and vice versa. Ironically, however, auscultation was limited in its diagnostic power and was soon marginalized by laboratory approaches, not because it was unable to explain the sick body and the diseases that led to death. Quite remarkably, it failed because it was unable to explain the living body. Laennec conceived of the living body in terms of music, of a sounding body as a musical instrument and of sounds as melodies at a time when the body was dissolving into the noises of liquids and gases, of flow and interruption – a time when the organic became the indistinct muttering of matter.
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