vous. In this case, there was, at the same time, considerable evidence, that incipient tubercles pervaded the lungs. On the whole, my impression is, that the condition of the tubes approximates that which produces the sonorous rale, yet to be considered and heard particularly in acute bronchitis. The peculiarity of the patient's constitution, in connexion with the diseased condition of the pulmonary parenchyma and of the membranes of the tubes, may cause a viscid and delicate secretion, which, by its dryness, takes on a fibrillous or ciliated form. If so, the peculiarity of the sound would, in strictness, rank it with the rales; but it is so slight a modification of the respiration as scarcely to merit a consideration with that important class of sounds. At any rate, the sound is worthy of the further consideration of pathologists.

Another variety of respiration is the interrupted or jerking. In this, the air seems to be measurably arrested in the tubes, for an instant, before it passes on to the vesicles. The quantity of the sound is essentially normal; and the respiration takes its name solely from the broken manner in which the air passes.

It arises from different causes. In a nervous sensitive patient, it is often produced by spasm, under the influence of excitement. In bronchitis, a thickening of the walls of the smaller tubes, by inflammation, may produce it. So, too, may simple congestion. But the most serious condition which ever gives rise to it, is a deposit of incipient tubercles. This, of course, limits the sound to that small portion of the lung in which the tuberculous disease is commencing. It is a symptom of but little importance, except as, in this last instance, it becomes a sign of phthisis.

Dr. Bowditch speaks of what he call mucous respiration, and says that, in it, "the respiratory murmur seems more moist than natural, almost enough so to produce a crackling rale." He says, "it may be heard, throughout both lungs, but is most distinct at the lower and posterior portions." According to him, the sound is indicative of chronic bronchitis; and a fit of coughing will sometimes so augment the secretion as to produce the mucous rale. Though he speaks of the existence of this sound as a discovery of his own, and says he is not aware, that "others have noticed it," yet, to my mind, it is perfectly clear, that he attempts

to describe what Dr. C. J. B. Williams calls the sub-mucous rhonchus. Dr. W., having spoken of the mucous and gurgling rhonchi, says, "when there is a little liquid in the smaller bronchi, the bubbling or crackling is more regular, although the sound is weaker, and is sometimes only a roughness added to the ordinary respiratory murmur. This is the sub-mucous rhonchus. It may result from slight degrees of bronchitis, and owes its importance only to its being permanently present, when such slight inflammation is constantly kept up by the irritation of adjacent tubercles in an incipient state." I am not aware of having myself noticed a peculiarity of this kind worthy of any separate description. It is perfectly conceivable, however, that the bronchial tubes may be a little moistened with a thin or mucous secretion, and yet the quantity of this secretion may not be sufficient fully to develope either the mucous or the subcrepitant rale. That the sound, when in exists, should in strictness, be classed with the rales, rather than as a simple sound of respiration, is, to my mind, clear. The peculiarity is evidently produced by a slight liquid obstruction, and not by the mere force of the air striking against the walls of the air-passages. Still, such nicities of classification are practically of but little importance; and the sound is so slight a change from the normal respiration, as hardly to entitle it, in description, to the dignity of a rale.

Beside these modifications of the respiration, still others may be named. Both the normal sounds may be increased, or they may be diminished, without any other change of character. A portion of the lungs may become so compressed or so diseased, as to be impervious to air, and incapable of performing the proper office. In that case, another portion will act with increased energy, and give a louder sound of respiration. Instances of this are observed in pleuritic effusions, and in pneumonitis. Even in bronchitis, there may be so much lesion of the bronchial tubes. as to obstruct the passage of air into one part, and thereby give an increase of sound in another part.

Again, the sound of respiration as it reaches the ear, may be less than is normal, in consequence of disease in the structure of the lungs or in parts adjacent. In emphysema, for instance, both the bronchial and the vesicular sounds are enfeebled. In bronchi

tis, too, this sometimes occurs. In phthisis, it is frequently observed in a portion of one lung; but, in this disease, there are usually, perhaps uniformly, other alterations of the respiratory sounds. In the second stage of pleuritis, in hydro-thorax, in empyema, or whenever the pleura contains a liquid of any kind, the respiration, as heard, is more or less feeble, partly by reason of the compression of the bronchi and vesicles, and partly because the interposed liquid interrupts the conduction of the sound to the ear.

SECTION IV,

RALES.

Rales are an important class of sounds, made, indeed, by the passing of air through air-passages, but yet in a manner somewhat different from that in which the simple diseased sounds of respiration are produced. The rales always suppose impediments or partial obstructions to the passage of the air; and it is the resistence met with which mainly gives the modification of sound.

The term rale has been transferred from the French to express an idea for which we have had no authorized English word. Even this, in the original, is far from giving the exact meaning. It merely signifies a wheezing, or a rattling in the throat. Some pathologists prefer the Latin term rhonchus, which signifies a snoring or snorting. The idea being a new one, of course, to express it, a new term must be adopted, or there must be an accommodation of an old one. Either expedient is well enough; and the term rale, or rhonchus, or even the simple English word rattle, will convey the idea, when once its application is defined and understood. I prefer the term which I have adopted, simply because it is a monosyllable and easily pronounced, while, orthographically, it forms its plural after the usual English manner.

The rales are properly divided into the dry, and the moist or humid. This distinction is founded on the nature of the impediments which produce the sounds. These impediments are either solid or liquid. The dry rales are three,-the sibilant the sonorous, and the crackling.

The sibilant rale is a musical or gently whistling sound. It may be sufficiently well imitated by whistling between the teeth, with the lips partly closed or slightly apart. It is produced by the passage of air through a small and rather circular aperture. This aperture is generally formed by a slight obstruction in one of the smaller tubes, though it may be made by a greater obstruction in a tube of larger size. The sound is extremely moveable, and equally irregular in the time of its reappearance. Heard, at one point, in one respiration, in the next, or not until some subsequent one, it may be heard at some point remote from the first. It exists, both in respiration and expiration; and from the situation of the smaller tubes from which it mostly arises, it is mostly heard over those portions of the thorax, especially the anterior, which are a little remote from the pulmonary roots. Under different circumstances, however, it is heard over almost every portion of the chest, anterior, posterior and lateral.

It is produced in asthma, in which the tubes are congested, and are constricted by the spasmodic contraction of their circular fibres. In this disease, particularly if severe, it is a protracted sound, heard in both inspiration and expiration. In bronchitis, the tubes may be so narrowed, by the swelling of their mucous and submucous coats, as to produce it. In the third stage of phthisis, it is quite frequently heard, in connexion with other diseased sounds, the tubes being constricted by the muco-purulent matter which passes into them. In the latter case, the sound is short, and is generally heard from different tubes during the same or successive respirations. It may be caused, in different diseases, by such an adherence of viscid mucous to the walls of the tubes as diminishes their calibre.

The sonorous rale might, with more special propriety, be called a rhonchus. It is more of a snoring sound, or like deep guttural breathing, than any of the other rales. Various similitudes have been adopted to describe it. It has been compared to the sound of a bassoon, and to that of a bass-viol;-to the cooing of a pigeon, to the hum of insects, to the sounds produced by a piece of paper fluttering in the wind, and to the grating of a cart-wheel upon snow in weather severely cold. But, whatever idea may

be formed of it, from these and like comparisons, it is sufficient to say, that it is a deep cavernous sound, so unlike any other produced in the thorax, that when once distinctly heard, in its marked form, it may ever afterwards be recognized. It, however, varies considerably in tone, according to the circumstances under which it is created. It is produced by such an obstruction as leaves a flattened aperture. It is a vibrating sound; and either the walls of the tubes generally, or the lips of the aperture, where the obstruction exists, must be the seat of the vibration. The latter is probably the true explanation. A partial "swelling of the sides of a tube, particularly at its bifurcation, a pellet of tough mucous in it, or external pressure on it," may give the proper aperture to produce the sound; but then there must be, in addition to the form, a vibrating surface. I am of the opinion, that a viscid secretion assuming a fibrillate or stringy character, is really the vibrating substance, though it may be that the substance of the tubes, when hardened by inflammation, is capable of vibrating. It is mainly produced in the larger bronchial tubes, though sometimes in those of medium size. In the latter case, the sound usually has a higher note than in the former; though it would seem that the size of the aperture, at the point of partial obstruction, is principally concerned in giving key to the sound. It is most heard both anteriorly and posteriorly, when the ear is placed in most immediate proximity to the larger bronchi. It is well spoken of as a fugitive sound, since it will frequently cease and return, so far as one tube or point is concerned, with almost every act of respiration. It is not, however, always so moveble; and when it is, it still may often be heard with every respiration, though, successively, from different points. It exists with both inspiration and expiration; but is quite as marked with the latter as with the former.

The sound is pathognomanic of bronchitis. In the acute form of the primary disease, it almost uniformly attends the progressive stage. In the chronic form it is not heard. In many cases of secondary bronchitis which attends other diseases, it is heard. If not connected, however, with any of the humid rales, it is indicative of but a mild affection.

I have only to add, that the sibilant and sonorous rales now