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The term subcrepitant rhonchus has been so long and so extensively employed, that the attempt to displace it may seem a bold and doubtful experiment; but I scarcely know a medical expression which has tended to produce more danger in practice. The term conveys to the mind the idea of a sound analogous to that usually designated crepitant rhonchus, but which I propose to call crepitation ; and has, in consequence, led to injurious depletion. If asked to specify the greatest abuse of auscultation with which I am conversant, I should instance the leeching and antimonializing of children in certain pectoral affections, of which the subcrepitant rhonchus is a prominent symptom. Under the cover of a pedantic numerism, the cure of pneumonia without depletion has, on the continent especially, been assumed to be common; because this so-called subcrepitant rhonchus, although really differing in character of sound as well as in cause, has been mistaken for the rhonchus characteristic of pneumonia. A reference to the table will show the marked difference between these sounds.
As respects diagnosis and treatment, I cannot but think that great importance may be attached to the co-existence of certain sounds with expiration as well as with inspiration; since with certain qualifications particularly in reference to vibratory rhonchi ; the presence of a morbid sound, during expiration, may be considered to afford evidence of the presence of secretion within the cells or tubes. This view is supported by the concurrence of clicking from softened tubercle with both respiratory actions, as contrasted with the inspiratory crackle of the first stage of phthisis. The same peculiarity distinguishes the small bubbling (submucous rhonchus) from true crepitation (crepitant rhonchus), which resembles the noise produced by rubbing a lock of hair between the fingers, and conveys to the mind an idea (probably in harmony with the fact) of the abrupt forcing open of cells, rendered less yielding by glutinous deposition in their walls. If the cause commonly assigned for “crepitant rhonchus," namely, air passing through secretion, were correct,—the air in repassing should produce a rhonchus during expiration also. The presence of viscid secretion within the pulmonary cells in cases of pneumonia may be acknowledged, without conceding that this secretion is concerned in the production of crepitation ; indeed, its tenacity may be a reason why bubbles are not produced, the calibre of the capillary tubes to a certain extent remaining free. When, on the resolution of pneumonia, the secretion becomes less viscid, and occasionally more copious, the rhonchus changes its character, and the sound which has been designated the “ redux crepitant rhonchus," having more of a bubbling character, and more or less audible during expiration, is produced. The sound sometimes termed “continuous subcrepitant rhonchus,” existing only during inspiration, and accompanying pulmonary congestion, such as attends some forms of fever, I should regard as a subcrepitation, not as a rhonchus.
As respects the treatment of inflammatory affections of the lungs, it may not be inappropriate to mention that, in proportion as sounds are confined to inspiration they afford reason for depletion, but that, in proportion as the rhonchi become bubbling, they indicate secretion, and suggest a discontinuance of antiphlogistic treatment.
Some authors, otherwise instructive, have complicated the subject of auscultation by looseness of expression, as well as by over refinement. Dr. Stokes, for example, in a work generally admirable for breadth of view and clearness of style, has sanctioned the use of that ambiguous term, “muco-crepitant rhonchus ;" respecting which it has been well observed that, if twelve physicians were asked the meaning, it is doubtful whether any two of them would agree. It is a sufficient proof of the vague manner in which auscultatory terms are employed that, when an author uses the word crepitation, we are often at a loss to determine whether he intends dry crepitation (crackle), moist crepitation (clicking), subcrepitant rhonchus (small bubbling rhonchus), or the true crepitation (“crepitant rhonchus ") of pneumonia.
The advantage of introducing terms so diverse as those suggested in the present plan is obvious. If we speak of crackle, the first stage of phthisis is indicated; if of clicking, the stage of softening; if of crepitation, pneumonia is detected ; if of bubbling or small bubbling rhonchus, secretion more or less copious is known to be present in the different orders of the bronchial tubes.
The distinctions thus proposed may be open to incidental objections; and doubtless the phenomena observed in practice are not likely exactly to correspond with systematic arrangements; but the beginner requires broad distinctions, and his own studious care will familiarise him with the requisite modifications. It should be remembered that the loudest sounds are not the most important, although catarrhal affections of the larger tubes may seem, to the novice more alarming than the fine crepitation of pneumonia, or the delicate crackle or clicking of phthisis. Skoda has expressed an opinion that dry crepitation (crackle), and moist crepitation (clicking), are bronchial sounds, and have no necessary relation to consumption. I cannot concur in this conclusion ; although aware that varieties of subcrepitation may be mistaken for them, if we overlook the modifications produced in bronchial sounds by deep inspiration, or cough. If a doubtful sound is removed by cough or superseded by vibration sounds, on deep inspiration, we may with little exception conclude that it is not crackle, or clicking.
Let me venture to urge the desirableness of avoiding the mongrel combination of different languages, too common in medical descriptions, and of adhering, whenever practicable, to our own mother tongue. The avoidance, as far as possible, of foreign expressions is important to simplicity, to accuracy, and, one is almost tempted to add, to patriotism. And, although, in this particular department of physical science, the use of French words has a special ground, it is yet better to sacrifice this consideration ; since, whenever our own language is deficient in descriptive terms, Greek words, or Latin words of Greek derivation, have the superiority in expressiveness, and in their accordance with our own. Of this truth, the word “ terminus,” for the extremity of a railway line, may furnish an example. For the purpose of designating certain unnatural sounds, not easily expressed by any of our English words, the word “ rhonchus” is perhaps the most appropriate, from its compass and significancy ; but there are advantages in restricting its application to sounds produced by air
permeating tubes or cells, modified by the condition of those tubes or cells, or of the fluid through which it passes.
It may be objected that the introduction of new terms would tend to increase the perplexity which we desire to avoid ; but this difficulty may be in a great measure obviated if, in using words not generally adopted, the best understood of the synonymous expressions most in vogue are placed in parentheses; for example, crepitation (crepitant rhonchus), bubbling rhonchus (mucous rhonchus). · In conclusion, it should be observed that the most accurate description of sounds, and the greatest aptitude in their detection, must never be considered sufficient without a careful investigation of collateral symptoms. A disposition to expect conclusive evidence from unassisted auscultatory signs has frequently entailed disappointment, and induced unreasonable disparagement of this branch of the medical art. A change of sound doubtless implies a change of condition ; but, as various pathological conditions may sometimes induce a similar sound, other indications must be sought, in order to determine which of these conditions is present. Notwithstanding the definiteness of information regarding local affections which auscultation may often supply, no prudent practitioner would determine his plan of treatment, without taking into account such circumstances as the degree of rapidity or labour in respiration, the character of the expectoration, and the amount of constitutional disturbance. The inadequacy of any single indication as a guide applies however still more to symptoms arising from sympathies, than to those depending on