Bellevue Hospital, New York

AUSTIN FLINT
1882 Boston Medical and Surgical Journal  
You will remember that in my lecture on Bright's disease last week I presented one patient who was passing an unusually large amount of urine. After the lecture I learned that this was due to a great extent to the diuretic remedies that he was taking, although without the aid of these the quantity was very considerable. You will thus see that a different treatment has been pursued here from that which was adopted by the physician whom I met in consultation in a case of Bright's disease, and
more » ... 's disease, and who, you will remember, had actually been endeavoring to diminish the quantity of urine which his patient was passing. To-day I will show you first a case of tuberculous laryngitis by way of contrast to the one of syphilitic laryngitis which I had the pleasure of recently presenting before the class. Afterward I have a case of advanced phthisis to bring before you, in which the physical signs of cavity and solidification of the lung can be studied with great advantage, and finally, I will introduce a patient suffering from abdominal dropsy dependent upon cirrhosis of the liver, upon whom the operation of paracentesis will be performed in your presence. TUBERCULOUS LARYNGITIS. Here, then, is our first patient. When, in reply to my questions, he tells me that he lost his voice about two months since, atid that this occurred not suddenly, but gradually, you perceive at once that he has aphonia, and you notice that the attempt to speak is attended with a visible effort. The latter point distinguishes it from paralytic aphonia, in which there is no effort in speaking, and the fact that the trouble has come on gradually distinguishes it from nervous aphonia, in which the voice is often lost quite suddenly, and as suddenly recovered. The aphonia here, however, has the saine general characteristics as that due to syphilis, which you saw in the other patient. The diagnosis between the two affections is to bo made from the past history and the concomitant features of the case. In the former patient there was a distinct history of syphilis, while repeated examinations of the chest failed to detect any disease in the lungs. In the present case, on the other hand, there is well-marked tuberculous disease of the lungs, aud the past history shows that the pulmonary trouble commenced before that in the larynx. Long ago the precedence, in point of time, of the tuberculous deposit in the larynx was established as the rule, although this sequence has recently been doubted in certain quarters. Personally I believe that, with possibly a very rare exception, this is always the case, and it may be that in some instances where the larynx appears to be affected first the tuberculous deposit in the lungs is so small that it may altogether escape detection until after the laryngeal affection has been recognized. In this patient there is no difficulty whatever in determining the presence of disease in the lungs, aud also the fact that it 1 Specially reported for the Journal. has existed for a considerable time, while the trouble iu the larynx, as you have heard, is quite recent. A glance at this man's pallid and emaciated face shows that he is suffering from some grave, wasting disease, and an examination of the chest at once reveals dullness on percussion, feeble respiratory murmur, and more or less broncho-vesicular respiration at the summit of the right lung. In this case at least the pulmonary disease preceded the laryngeal. The young man has bad a cough for over six months, and says lie has emaciated for more than three months, while it is only two months since the loss of voice, which has gradually become complete, commenced. In regard to tuberculous laryngitis, there is one point of practical importance to which I will call your attention before dismissing the patient. It is this, that the laryngitis, unless it should interfere with alimentation, does not render the prognosis of the pulmonary tuberculosis more unfavorable than if it were not present, so that, as a rule, the patient stands just as good a chance of recovery, or of the disease being held in abeyance, whether thi3 complication is present or not. I have arrived at this conclusion after quite an extensive experience, and therefore I give it to you with considerable confidence. ADVANCED PHTniSIS WITH WELL-MASKED PHYSICAL SIGNS. Our next patient is a female, well on in life, who is suffering from advanced phthisis, there being a cavity at the summit of the left lung, and around this the evidences of solidification. I will not take up your time by reading the history of the case, which would offer but little of interest, but I propose at once to describe the physical signs, which are characteristic of the condition mentioned, and which are remarkably well shown here. The patient is rather feeble, but though now in bed she is not confined to the bed all the time, but sits up a portion of every day. If you direct your eyes to the chest from above downward, and compare the two sides, you will find it very evident that there is a shrinkage of the lung on the left side, and a corresponding sinking in of the chest wall. When the patient makes forced respiration you perceive that the left side is comparatively motionless. We have thus the evidence of diminished volume and diminished expansion of the left lung at the apex. From the lack of mobility we may also infer the existence of old pleuritic adhesions. So much for inspection. When we practice percussion at a certain part of the left apex, which I now indicate, we get amphoric tympanitis, and on auscultation at this spot there is found to be cavernous respiration. Just below this point we get well-marked bronchial respiration, and it will therefore, perhaps, be well for me to enumerate the characters which distinguish these two signs. In studying physical diagnosis I may remark, in passing, it is very important that the learner should first get a clear and definite appreciation of the different signs before he attempts to verify them in the subject. It was a no less distinguished diaguostician than Skoda who declared that there was no appreciable difference between cavernous and bronchial respiration, and to this day all the German authorities adhere to the same opinion. I hardly know how to account for the latter fact unless it is that their reverence for the weight of authority forbids them to dispute such a dictum. Notwithstanding this, however, it is certainly
doi:10.1056/nejm188209071071001 fatcat:h5whrufph5acphylmbep66vuwi