these two accounts, then, first, because the infiltration of the integuments obstructs the sounds proceeding from the chest; and, secondly, because on pressure it gives rise to another sound, which may be easily confounded with one of intrathoracic origin; the serum of oedema should be carefully pressed out of the cellular membrane before auscultation is attempted.

5. Combined use of mediate, and immediate Auscultation.

From what has been already said, it will be evident that, on some occasions, and in some parts the ear, and on others the stethoscope, may be most advantageously employed. As, therefore, it will conduce to the efficiency of his investigations, it is desirable that the student should be practically conversant with both modes of auscultating. Let him on no account neglect the use of the stethoscope, because he finds that, under ordinary circumstances, he can hear better with the unguarded ear; as in practice cases will constantly occur to him in which he will be compelled to employ the cylinder, or to leave certain parts of the chest unexamined.

The plan of proceeding which will perhaps be found on the whole most useful, is in each case to practise both mediate and immediate auscultation. Thus, on the anterior part of the chest,

and particularly in the acromial, the axillary, and the infra-clavicular regions, the stethoscope may be used; while in the lateral regions, and all the posterior surface of the chest, excepting the space above the spine of the scapula, the ear will be found at least as effective, when unguarded, as when supplied with the solid conductor. If the patient be very fat, or the integuments be infiltrated with serum, mediate is preferable to immediate auscultation; as with the stethoscope more direct and local pressure can be made than with the ear, which, though not so far removed, in such cases comes not into such near acoustic relation with the solid parietes, as when the solid conductor intervenes between them.

In all examinations of the larynx and trachea, it is almost always necessary to employ the stethoscope. In all affections of the heart, excepting when great tenderness exists upon pressure, the stethoscope is to be preferred to the ear; while in the auscultation supplementary to succussion, to be afterwards noticed, and in the superfical examinations made through stays and petticoats, the ear, if it be evenly placed, and the patient's body be firmly pressed against it by the the hand placed upon the opposite side, will be ordinarily a more effective auscultatory instrument than the cylinder.

6. Auscultation of the Organs of Respiration. It is absolutely necessary, as has been before

stated, that the student be perfectly familiar with the sounds naturally existing in the chest, previously to his becoming acquainted with, or being capable of judging of, those which are abnormal; just as he must be conversant with the healthy appearance of organs, before he can fairly expect to become a morbid anatomist. tural sounds of the respiration and the voice, therefore, will be first noticed, and subsequently those which exist in disease.

1. Of the Natural Respiration.

The na

To enable the examiner to judge correctly of the healthy, or morbid condition of the respiration, ordinary inspiration is scarcely sufficient. It is desirable that the air should be more generally diffused through, and should more perfectly inflate, the pulmonary cells, than it does in common inspiration. In nice examinations, therefore, the patient should be desired to fill his chest by a succession of forced inspirations. The examiner will be thereby enabled to make his observations upon the sound, and duration of the expiration, as well as upon those of inspiration; the former of which, in ordinary breathing, is sometimes scarcely audible, and differs from the latter in some other important particulars, which will be afterwards referred to. To prevent con

fusion it may be well to confine attention, in the first instance, to the inspiration*.

If the ear be applied to the stethoscope, evenly placed upon the larynx, or trachea, and gentle pressure be made, the sound, caused by the ingress and egress of air during the act of respiration, will be observed to be hoarse and hollow; like that produced by blowing, with the lips considerably compressed, through a pipe of large calibre, as through the bore of the stethoscope;

* Simple as the process may appear, it is by no means an easy matter to make some persons take a really deep inspiration, in such a way as to enable the auscultator to judge of Their awkwardness is sometimes so

the condition of the lung.

great as really to have the appearance of design. First they raise the shoulders, without inspiring at all; then they inspire deeply; then they draw in the air through the compressed lips, or relaxed fauces, in such a manner as to give rise to noises, which overpower the sounds originating within the chest ; afterwards they protrude the abdominal muscles, and then perhaps go through the entire series of awkward efforts again. To tell them to take a deep breath, to heave a sigh, to fill the chest, to draw in the air, to raise the ribs while they breathe, and even to shew them how to do so, are of no avail. The more you talk, and the more they appear to try to effect the object you desire, the farther do they remove from that object; the more stupid in this respect do they seem to be. But they often involuntarily do exactly that which, after many and diversified attempts, they have been unable to effect. Thus, if told to cough, and to continue coughing for a short time, they will, from the mere exhaustion caused by the repeated short expirations, which constitute that act, spontaneously take such a soft, quiet, yet deep inspiration, as all previous efforts had failed in causing them to accomplish.

or that which is sometimes produced by a draught of air through the key-hole of a door. It is called tracheal respiration. When a similar sound is heard, as the result of disease, in other parts of the chest, the breathing is said to be tracheal.

If, instead of being placed upon the neck, the stethoscope be now put upon the upper bone of the sternum, below the sterno-clavicular articulation, or between the scapulæ upon either side, and the individual be desired to breathe deeply; a sound very much like, but not exactly similar to, the tracheal respiration will be heard by the auscultator. The sound may be generally, but, it must be acknowledged, by no means universally, observed in the state of health in the situations indicated. It is sometimes absent in all the localities, but sometimes, when inaudible on the front of the chest, may still be heard close to the spine, at a level with the centre of the scapula. It is not so loud, or so hollow, as the tracheal sound. It may be represented as its diminutive. It resembles the noise occasioned by blowing through a small reed, or a quill of moderate size. It arises from the rush of air through the larger bronchial tubes, and, wherever heard, is therefore · called bronchial respiration, or tubular breathing. If discovered in other situations than the upper part of the sternum, the inner side of the infraclavicular, or the interscapular regions, it may