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under treatment. We believe that it is only in a moderate proportion of cases of chronic throat ailments, signalized by frequent “ bemming," dryness and tickling, hoarseness and loss of voice, that the glands of the mucous membrane are conspicuously or pre-eminently affected.
The title of angine glanduleuse, or glandular angina, first employed by Chomel, and adopted in the present work, while it would restrict the principal part of the local disease to the glands, is otherwise not free from objection. The word angina signifies suffocation, and is derived from the Greek word ayyw, I strangle or hang, and by the Greek and Roman physicians it is applied to those diseases in which a tendency to suffocation is a marked feature. Now, it will not be asserted that in glandulous angina there is any material tendency that way. Glandular angina would be a very appropriate title-did we require a new one-for inflammation of the parotid and other salivary glands, and for enlargement of the lymphatic glands of the upper part of the neck, often dependent upon the absorption of poisonous secretions in the fauces, and which we have ourselves known to cause death by suffocation.
Chomel's doctrine of the almost invariable dependence of glandulous angina upon the herpetic diathesis, has been fully adopted by the author of the work before us. The introduction is devoted to the discussion of diatheses in general, and of the herpetic diathesis in particular. According to our author, most acute diseases are the results of accidental transient causes, while chronic maladies originate in an inherent disposition of the organism itself, or from the long-continued operation of external influences. The name of diathesis is given to those pathological conditions, to those morbid constitutional states which reveal themselves by multiplied, successive, or simultaneous manifestations.
The diatheses play an important part in the production of chronic diseases.
According to Dr. de Mussy, the diagnosis of diathetical affections, which do not present well-defined topical characters appreciable to the senses, is to be made out by reference to their duration. If diseases last longer than is usual with them, they are to be regarded as diathetical. With him unusual chronicity is almost always held to be pathognomonic of diathesis. This may be generally true, yet disease may be unusually prolonged by the operation of unknown external causes, or certain obstacles to cure in the body itself, altogether independent of diathesis.
Dr. de Mussy makes some judicious observations on the treatment of diathetical diseases. He says
“When a person is under the influence of a diatbetical affection, to devote exclusively to the local disease the whole of our therapeutic efforts, is in many cases fruitless, and sometimes a source of danger, if the manifestation which it is desired to repress does not compromise life, and if the diathetical action may develope itself in another organ, the functions of which cannot be disturbed without peril.” (p. 16.)
He maintains that the physician should abstain from all topical medication when the disease is of long standing, when it entails little or no inconvenience, when there is reason to fear the substitution of graver disorders, and when the patient is old, has little elasticity, or few resources.
The author recognises two important causes in the production of diathetical manifestations. The first is debility of the organism ; the second is a local irritation. In this matter he only reiterates the opinion of the medical world.
The author dwells upon the fact, well known to practical physicians, that affections of the mucous membranes frequently alternate with diseases of the skin.
“We often see herpetic affections, pulmonary catarrhs, and obstinate diarrhea succeed and replace each other in so remarkable a manner, that it is difficult not to admit a connexion between these different manifestations." (p. 27.)
“ When we see this balancing of morbid conditions, occupying different seats, when the internal malady which has replaced the external affection exceeds in its duration the ordinary limits of an accidental disease, we can admit, without carrying the results of inductive reasoning too far, that behind these different manifestations there is concealed or disguised, to speak in the picturesque language of ancient medicine, one morbific cause, one pathological condition of the organism-in a word, a diathesis-the origin and substratum of these different disorders.” (p. 27.)
The author enumerates the causes of the herpetic diathesis in the following paragraph:
« After hereditary taint, errors of regimen, residence in an impure atmo. sphere, an exciting diet, or the habitual use of certain unwholesome articles of food, exciting or prolonged emotions of the mind, long-continued watchings, neglect of hygienic rules suitable for the maintenance of the functions of the skin, direct chemical or mechanical irritations applied to this organ, excitement of the functions by heat of the atmosphere; all those conditions which can weaken the vital energy or disturb the harmony of the functions, such as pu. berty or the cessation of menstruation, pregnancy, fatigue of body and mind, are the causes which appear to intervene the most frequently in the development of herpetic manifestations.” (p. 33.)
According to Dr. de Mussy, herpetic manifestations once developed have a great tendency to persist and reproduce themselves; and if the tendency be strongly pronounced, it is not unfrequently observed that their disappearance, either spontaneous or procured by topical applications, is succeeded by affections of the internal organs. We see, he adds, glandulous angina following herpetic affections, which it seems to replace; "the skin is a blood instrument,” he informs us, “a vast vascular network, an immense secreting or absorbing surface.” (p. 38.) No one, we conceive, will be disposed to doubt the correctness of Dr. de Mussy's views respecting the causes of the so-called herpetic mani. festations. His views on diathesis, and on the tendency which suppressed or repelled skin diseases have to induce disturbance of the 39-xx.
internal organs, would be extremely useful had they not long since been inculcated. The truisms which he communicates-elegantly, we admitwould not be less appropriate, we are disposed to think, in the discussion of almost every other disease to which the human body is subject. We are inclined to admit no closer connexion between herpetic affections and the so-called glandular sore throat, than exists between this affection and many other external and internal diseases. In support of this opinion we would simply state that, during an inquiry made recently at one of the hospitals in London, we have met with many examples of the disease in persons perfectly free from all disease of the skin, and that out of numerous examples, in only one or two was there the least manifestation of a herpetic character. On the other hand, we observed that persons suffering from pityriasis, eczema, and acne, to a striking extent, and therefore selected for examination, presented the uvula, the tonsils, and pharynx in a state of the most perfect health.
That herpetic eruptions may appear upon the soft parts in the interior of the mouth, we readily admit. We have occasionally seen vesicles on those parts. Within the last few days we have seen a very fine vesicle on the uvula of a great smoker of tobacco. But this indicates no peculiar attraction on the part of the herpetic diathesis for the interior of the month. How many diseases are found in that locality ! do we not find syphilis, the exanthemata, and many skin affections there!
It was only yesterday we saw psoriasis well developed upon the tongue of an elderly lady, whose entire trunk and arms are covered with this squamous disease. Erysipelas is known to have its manifestation in the throat; and an enormous carbuncle on the nape of the neck, we have lately seen in combination with nearly all the symptoms which Dr. de Mussy would hold to mark the course of glandulous angina.
Following Dr. de Mussy, the characteristic of glandulous angina, as the title would perhaps indicate, is a morbid development of the glandules of the vehum palati, uvula, of the pharynx, and larynx. The author informs us that the structures generally described as follicles, are in reality glands arranged in clusters the only parts in which follicles are found being the posterior and lateral parts of the tongue. Into these follicles, according to our author, the excretory ducts of the glands open.
"l'pon the posterior portion of the palatine vault, and upon the inferior aspect of the velum palati, the glandules in clusters form many continuous beds. Ou a level with the little depressions described by Albinus, and whieh, when they exist, are found in the vicinity of the palato-maxillary articulation, these glands, instead of being gathered together, separate and soon disappear. They show in great fore in that part of the pharynx which is situated between the atlas and axis behind, the basilar process above, the superior face of the velum palati inferiorly, the posterior opening of the nasal fosse region which has been described by M. Sapper under the name of posterior
in front, & carity of the nasal fossa. They are found in great numbers at the superior part of the pharynx, and arrange themselves in groups around the months of the Eustachian tubes. They become more rare as we approach the esophagus. .... Some of these glandules are found lodged in the little holes of the fibro-cartilage of the epiglottis. . ... They are very numerous in the larynx, more particularly under the mucous membrane of the ventricles.” (p. 14.)
We have recently examined these parts, and have seen no reason to doubt the accuracy of the descriptions of Dr. de Mussy.
Amongst the circumstances which favour the development of glandulous angina, Dr. de Mussy ranks sex. Men are more subject than women to this disease : sixty-six men suffered, while only twelve women were affected. This great preponderance of the male sex does not correspond with our experience. Of twenty-two patients examined only during the last ten days, we found that thirteen were females and only nine were males. The influence of profession has been dwelt upon by some writers; and though the point is noticed by Dr. de Mussy, we do not perceive that he has added any facts to our stock of knowledge. Dr. Green had remarked that clergymen were special sufferers, and M. Chomel has indicated that barristers, readers, and singers, are frequently affected.
Dr. de Mussy is of opinion that of all the occasional causes of glandulous angina, the practice of smoking tobacco is one of the most indisputable. It produces an irritation of the mucous membrane of the glandules. He believes that, in order to effect a cure, it is necessary to renounce the practice. The practice of snuff-taking he likewise believes to be injurious. One of his most remarkable cases occurred in an old man who took snuff to an immoderate extent. Mr. Solly no doubt can produce similar testimony. There can be no question whatever of the tendency of tobacco smoke, or of tobacco in the shape of snuff, to create irritation of the mucous membrane and of the glands situated beneath it. Yet we are strongly inclined to believe that the evils they actually produce are greatly over-rated. A man suffering from material irritation of the lining membrane of the nasal fossæ and of the pharynx, is not likely to persist long in the immoderate use of tobacco. At all events, we see hundreds who daily smoke and snuff, and of these only a very small proportion suffer from glandulous or any other angina. We would say in passing, that while we deprecate the practice of smoking, we cannot admire that lax science which makes untenable assertions, even in furtherance of a good cause. We know many persons afflicted with phthisis-and comparatively few so situated are altogether free from some lesion of the laryngo-pharyngeal membrane—who not only smoke tobacco, but derive benefit from its use. Several of our patients smoke stramonium, and are soothed by it. Dr. de Mussy takes no notice of many acknowledged irritating agents. He is all but silent on the injury caused by excess in the use of spirituous liquors. The peculiar action of some medicines on the membrane under consideration is omitted. Croton oil and belladonna, and, in many persons at least, the iodide of potassium, exercise a most irritating influence; yet when treating of the causes of the disease, these agents are unnoticed. We have known a state of intense irritation
produced in the laryngo-pharyngeal membrane by a strong enema of extract of belladonna, and the same state of things has occurred, together with severe coryza and swelling of the eyelids, from a moderate use of iodide of potassium. It would be interesting to know the result of the almost universal and hourly practice of chewing tobacco prevalent amongst British sailors. No one who has been in an English sea-port will accuse them of aphonia.
The disease which Dr. de Mussy describes he acknowledges to be essentially chronic, yet it sometimes assumes an acute character. In the acute form the progress is quicker, and it occurs in attacks marked by long intermissions. Febrile symptoms are associated with the local disorder, fits of coughing causing a sense of suffocation and oppression at the sternum, and tickling at the fauces annoy the patient, who is in the frequent habit of making short and violent expulsive efforts from the larynx, producing a sound like that of the word “hem." This socalled English verb is of very frequent occurrence in the work before us, and is perhaps more familiar in the mouth of Dr. de Mussy than in that of any Englishman with whom we have met. By the way, he labours under a singular impression in respect to an allied word “hawking," which he characterizes as “ picturesque."
Some examples of the acute form of the disease are given, but they contain nothing of material interest, while they occupy considerable space.
The author now proceeds to the consideration of the main subject - the symptoms and progress of glandulous angina. His descriptions are good, and we shall therefore give a few extracts.
"Precursory phenomena.-Glandulous angina, from its first appearance, seems sometimes to announce itself by frequent attacks of croup-like cough, coinciding with herpetic manifestations. Later, there is a disposition to transient hoarseness, which is repeated many times each year, chiefly in the variable seasons. This alteration of the voice, as I have already said, is often preceded by repeated coryzas, which leave in the posterior part of the nasal fossæ a habit of excessive secretion, of a thick yellow or greenish colour, which the patient is compelled to bring from the throat into the mouth.” (p. 46.)
First Stage "In general, the malady manifests itself after puberty. Sometimes its invasion is sudden; it occurs after immoderate exercise of the voice, or after sudden cooling. The patient experiences froin time to time a sensation of embarrassment, of pricking, of tickling, of smarting in the throat, of closure of the larynx. . . . . Some patients complain at times of a little pain in swallowing. . . . . The expectoration is scanty; in the morning the patient from time to time, especially after efforts of 'hemming' or coughing, emits some viscous masses, sometimes opaque, more frequently transparent or slightly opaline, grey when the patient has inspired the smoke of fire-places or of artificial lights, strewn with white points very like diluted starch, as has been remarked by M. Chomel.” (p. 47.)
We have found expectoration of this character to be composed of large mucous cells with dark granules.
Second Stage "The voice is habitually harsh, rough, hoarse, often lower than its natural