respirer
     edical drama, the stethoscope is omnipresent, a part of the uniform. 
      Traditionally, medical students are presented with their first good 
     e presence of the stethoscope is similar in function for both doctor 
     l cord, the stethoscope operates as a symbolic lifeline connecting th
     iagnosis. Even this, however, is very insufficient; and there are, be
     there are, besides, many reasons why it cannot be followed, as a gene
      been in the habit of using this method for a long time, in obscure c
      obscure cases, and where it was practicable; and it was the employme

     rupting the circuit of diagnosis and clinical response.

     aennec, a Parisian physician was confronted with the problem of auscu
     ltating a female patient who was overly shy and somewhat corpulent. R
      he rolled up a quire [20 sheets of paper], placed one end on the pat
      placed one end on the patient’s chest and his ear against the other.
     r against the other. 

     he physician from the contagious and verminous patients of the pauper
     ad adoption of ‘Le Cylendre’, as Laennec first called it, by younger 
     ual name when the stethoscope is so obviously an aural device but Lae
      an aural device but Laennec was practicing at a time when morbid ana

     labouring under general symptoms of diseased heart, and in whose case
     ccasion. The fact I allude to is the augmented impression of sound wh
     hrough certain solid bodies,- as when we hear the scratch of a pin at
      the other. Immediately, on this suggestion, I rolled a quire of pape
     and the other to my ear, and was not a little surprised and pleased, 
     pplication of the ear. From this moment I imagined that the circumsta
     circumstance might furnish means for enabling us to ascertain the cha
      the heart, but of every species of sound produced by the motion of a
      the thoracic viscera. With this conviction, I forthwith commenced at
      at the Hospital Necker a series of observations, which has been cont
     the present time. The result has been, that I have been enabled to di
     d to discover a set of new signs of diseases of the chest, for the mo
     perhaps, to render the diagnosis of the diseases of the lungs, heart 
     er the diagnosis of the diseases of the lungs, heart and pleura, as d
     rcumstantial, as the indications furnished to the surgeon by the intr
     nger or sound, in the complaints wherein these are used.
     .
     ruction.- The general result has been that bodies of a mode-rate dens
     onsequently for my purpose. This result is perhaps contrary to a law 
     aps contrary to a law of physics - it has, nevertheless, appeared to 
      I use at present, and which has appeared to me preferable to all oth
     inder of wood, perforated in its centre longitudinally, by a bore thr
     es in diameter, and formed so as to come apart in the middle, for the
     One extremity of the cylinder is hollowed out into the form of a funn
      piece of wood so constructed as to fit it exactly, with the exceptio
     ion of the central bore which is continued through it, so as to rende
     h is continued through it, so as to render the instrument in all case
      funnel-shaped plug infixed,- is used in exploring the signs obtained
     - is used in exploring the signs obtained through the medium of the v
      or with the stopper removed, is for examining the sounds communicate
     ved, is for examining the sounds communicated by respiration. This in
     e simply the Cylinder, sometimes the Stethoscope.

      notice the particular positions of the patient, and also of the phys
     t,- that, namely, which contains the stopper or plug,- ought to be sl
     e slightly concave to insure its greater stability in application; an
     n application; and when there is much emaciation, it is sometimes nec
     ssary to insert between the ribs a piece of lint or cotton, or a leaf
     aper, on which the instrument is to be placed, as, otherwise, the res
     cylinder. The same precaution is necessary in the examination of the 
     tion of the circulation in cases where the sternum, at its lower extr
     rnum, at its lower extremity, is drawn backwards, as frequently happe
     y easily acquired, so that it is sufficient to have heard them once t
     ch are those which denote ulcers in the lungs, hypertrophia of the he
     ing in a great degree, fistulous communication between the bronchia a

     ion of the respiratory apparatus is an encrypted imprint of interior 
     affects on the body and operates as a cultural, environmental and gen
     etic assemblage that articulates itself through sound.

     this new method must not make us forget that of Auenbrugger; on the c
     he contrary, the latter acquires quite a fresh degree of value throug
     yment of the former, and becomes applicable in many cases, wherein it
     erein its solitary employment is either useless or hurtful. It is by 
     s combination of the two methods that we obtain certain indications o
     istence of liquid extravasations in the cavity of the pleura. The sam
     plication, such, for example, as the Hippocratic succussion, the mens
      of which methods, often useless in themselves, become of great value
     e when combined with the results procured through the medium of the s
     would beg to observe, that it is only in an hospital that we can acqu
     , the practice and habit of this new art of observation; inasmuch as 
      art of observation; inasmuch as it is necessary to have occasionally
     ion after death, the diagnostics established by means of the cylinder
     ment and in our own observations and that we may be convinced, by ocu
     emonstration, of the correctness of the indications obtained, It will
      or three subjects, to enable us to recognise it with certainty; and 
     with certainty; and the diseases of the lungs and heart are so common
      the knowledge necessary for his guidance in this important class of 
     guidance in this important class of affections. There are three class
     tion of this instrument, viz. as regards the Voice - the Respiration 
     h I shall here briefly notice as observable in the healthy subject; r
     ect; referring for the varieties of these, as modified by disease, an
     d for the diagnostic indications afforded by them, to the individual 
      on a comparison of observations at the bedside with the appearance o
     e viscera  - the internal organs situated in the trunk of the body - 
     rrelated with structural changes to symptoms of the ‘variable disorde
     ptoms of the ‘variable disorders of vital functions.’ In these circum

     ’ In these circumstances, it was inevitable that clinical signs, such
     n in health speaks or sings, his voice excites in the whole parietes 
     ax a sort of vibration, which is easily perceived on applying the han
     to the chest. This phenomenon is no longer observable when, through d
      chest by an effused fluid. This sign is of inferior value, since a g
     value, since a great many causes occasion varieties in the intensity 
      destroy it; For instance, it is little sensible in fat persons, in t
     sons, in those whose integuments are  considerably flaccid, and in th
     of the chest completely destroys it, even when the lungs are quite so
     destroys it, even when the lungs are quite sound, In any case it is o
     ack. From these and other causes we can derive little practical benef
     ew of further investigating this phenomenon, I soon found, as indeed 
     his phenomenon, I soon found, as indeed might have been expected, tha
     the peculiar vibration much less distinctly than the bare hand. I als
     ation varied in different points of the thorax. The places where it i
      these points, the voice appears stronger and nearer to us; in the ot
     he inferior and  posterior parts of the thorax, it seems weaker and m
      applying the cylinder, with its funnel-shaped  cavity open, to the b
     ntrance of the air into, and its expulsion from, the air cells of the
     ts expulsion from, the air cells of the lungs. This murmur may be com
     at produced by a pair of bellows whose valve makes no noise, or, stil
     deep and placid sleep, who makes now and then a profound inspiration.
     nd inspiration. We perceive this sound almost equally distinct in eve
     ore particularly in those points where the lungs, in their dilatation
     d superior edge of the trapezius muscle, exhibit the phenomenon in it
     in its greatest intensity. It is equally perceptible on the larynx, o

      through the whole tract of this canal to the bottom of the sternum; 
     chia, the respiratory murmur has a peculiar character, which evidentl
     acter, which evidently indicates the transmission of the air through 
     pace than the air cells. In this position, also, often seems as if th
     e patient, in inspiring, inhales air through the tube of the stethosc
     the state of respiration by this method, we must not rely on the resu
     the results of the first moments of examination. The sort of buzzing 
     on of the heart,- are all causes which may at first prevent us from c
     es which may at first prevent us from correctly appreciating, or even
     t, therefore, allow some seconds to pass before we attempt, to form a
     fore, allow some seconds to pass before we attempt, to form an opinio
      of considerable thickness, does not sensibly diminish the sound of r
     we must be careful that there is no friction between this and the ins
     here is no friction between this and the instrument, as this circumst
     tance, especially if the clothes are of silk, or of a fine hard stuff
     y exciting a sensation analogous to that produced by respiration. fat
     the peculiar sound. The sound is more distinct in proportion as the r
     proportion as the respiration is more frequent. A very deep inspirati
      made very slowly will sometimes be scarcely audible, while an imperf
     piration, such, for instance, as hardly at all elevates the chest,- p
     oduce a very loud sound. On this account, when examining a patient, m
     e performed rather quickly, This is, however, a very unnecessary prec
     sary precaution in most diseases of the chest, as the frequent presen
      of dyspnoea necessarily renders the respiration quick. The same is t
     e respiration quick. The same is true of fever, and the agitation cau

     attling of sputum in the throats of moribund (dying) patients.
     differentiated from crepitations because they resemble the noise of i
     y of the stethoscope declined as inventions like the x-ray and the ra
     gave much more accurate pictures of structural abnormalities in the l
     alities in the lung, lung sounds continued to be discussed in ninetee
     nth century language until 1970s when a 1957 paper, proposing that ad
     ds be classified into two groups - wheezing [continuous sounds ] and 
     ckling [interrupted sounds], was adopted.

     became interested in lung sounds whilst doing some research on a Vict
     g my research, I happened across a article by the Acoustical Society 
     ee on the exact source of sounds arising from within the lungs.  Subs
     te from, in the U.K. anyway, its obvious shortcomings as an underfund
     lic service, and their own leaps of faith in stethoscopic diagnosis.
     gy from which sound arrangements are produced. Like other mechanisms 
     hen in good condition, the lungs produce only a repetitive ‘whooshing
     ited number of additional sounds that can be identified.  These range
     urgling of the ‘death rattle’ as the lungs slowly fill with fluid.
     irectory in clinical terms. It's possible to infer some kinds of demo

     infer some kinds of demographics from the information or returning to
     tography. The sound arrangements are a cartophony. A sonic map that a
      of the diagnostic both in terms of that leap of faith I mentioned ea
     arlier and the strange questions posed by people who had converted an
      and recording of visitors. This process, normally associated with vi
      normally associated with visits to a local GP or medical institution
     t in order to encourage visitors to submit to examination. The inclus
     healthcare professional provides both the skills necessary to perform
     sary to perform the examinations and a certain legitimacy but also pr
     ain legitimacy but also provokes a number of issues from the conformi
     al environment, the problematics of locating illness in a given patie
     ss in a given patient insofar as legal issues prevent any disclosure 
     sure of possible health problems and the expectations of the patient 
     expect a clinical response. This readiness to suspend the aesthetic c
     linical response. This readiness to suspend the aesthetic content of 
     k in favour of physical analysis suggests an investment in the benefi
     ce of the medical institution as a whole. A view not entirely consona
     view of the health service. This fallout between belief in the medica
     n the medical profession and its institutionalisation is underpinned 
     linical; something that provides the clinical with a freedom not enjo

     t was fundamentally invisible is suddenly offered to the brightness o
     mple, so immediate that it seems to be the natural consequence of a m
     ghly developed experience. It is as if for the first time for thousan
     for the first time for thousands of years, doctors, free at last of t
      as a scientific instrument, its function is to allow the physician t
     n to ‘see’ the interior workings of parts of the body.  This fusion o
      albeit a conceptual eye, infers that the instrument provides empiric
     l evidence that the physician is able to think through and act upon. 

     perception, the stethoscope does not amplify or clarify the signals e
     t amplify or clarify the signals emanating from the chest cavities. I
      physician; a necessary space as the practice of auscultation is not 
      the practice of auscultation is not an exact science: 

      a lung sound just like the ones you were told you should be able to 
     medical school. But most doctors I think would admit that it’s rarely
     rs I think would admit that it’s rarely that clear cut; there’s often
     ap of faith between the crackles and whooshes in your ear and a confi
     l valve. Even one of my teachers at medical school, who was an outsta
     chers at medical school, who was an outstanding clinician, called his
     guessing tubes’ and it really is mostly guesswork if you’re on a nois
     s the x-ray, the stethoscope, as a primary instrument of detecting pa
     etecting pathological conditions within the pulmonary and cardiac are
     ecame obsolete. In light of this and more recent technological develo
     e, and the spectrogram, why does the stethoscope remain a primary too
      primary tool in the physician’s arsenal?

"When a rapidly flowing stream of gas containing vortices strikes a narrow wedge, the vortices become regularly spaced and their hissing noise changes into an ‘edge tone’ of well-defined pitch. In wind instruments of the flue type, where a pipe is tightly attached to such a system, the gas within the pipe is set into resonant oscillation, provided that the frequency of the edge tone and the natural frequency of the gas column are similar. The frequency of the resulting note depends on the length of the pipe and the velocity of sound in the gas. Although it has been suggested that edge tones arising from the carinae of bronchial bifurcations may excite resonant oscillations in the adjoining airways, there is no evidence that musical lung sounds are generated by this mechanism."

Paul Forgacs

 

The main text was generated with a custom written shell tool using the search term 's ' - the textual equivalent of the end of a short duration of white noise.

Selected Bibliography

Duffin, J. To See with A Better Eye, Princeton University Press, 1998

Forgacs, P. Lung Sounds, Bailliere Tindall, 1976

Foucault, M. The Birth of the Clinic, Routledge, 1997

Laennec, R.T.H. A Treatise on the Diseases of the Chest, English edition, 1821

Serres, M. Genesis, University of Michigan Press, 1995

Sterne, J. The Aubible Past, Duke University Press, 2003