ON THE CONNECTION 01' nub utfjcr Jiseases; Abstract of a Paper read before the New York Medical Journal Association, Jan. 7th, 1870. BY L. VELSBERG, M. D., Clinical Professor of Diseases of the Throat in the University of New York. FBOM '"THE MEDICAL GAZETTE," JAN. 22d, 1870. JJorh: TURNER & MIGNARD, PUBLISHERS, 109 NASSAU ST. 1870. ON THE CONNECTION OF ©pat anb otlp Jiseasts, Abstract of a Paper read before the New York Medical Journal Association, Jan. 7th, 1870. BY L. ELSBERG, M. D., Clinical Professor of Diseases of the Throat in the University of New York. Jlttu $ork: TURNER * M1GNARD, PUBLISHERS, 109 NASSAU 8'1 1870. ON THE (Konntdioii of ®ljroaf anti other diseases. Mr. President and Gentlemen :- Some of iny observations as to the connection of angina (using this word, for convenience, as synony- mous with the general expression-throat affection) and other diseases, are not particularly novel, but all of them are quite striking. I do not believe the subject is sufficiently appreciated by the profession in general, though I doubt not there are some pres- ent, who are acquainted with many of the points I shall bring forward. I am aware that every one of us who devotes himself with ardor to any particular branch of study or practice, is apt to attach to it an undue import- ance in its relation to others; but with the fear of falling into this error constantly before me, rejecting all evidence that could with reason be found fault with, doubting in each new instance until no longer able to resist conviction,-the facts I am about to present to you have been impressed upon me by scores upon scores of cases.. 4 ON THE CONNECTION OK The connection of throat diseases with various other derangements of health, was first pointed out to me by Horace Green, who had observed and knew a great deal more than he has left on record in any of his published books, in regard to throat affections, and what in antithesis to Abernethy's investigations he termed " the local origin of con- stitutional diseases." That acute inflammatory conditions of the naso- pharyngo-laryngeal mucous membrane can produce febrile disturbances, has, of course, been known from time immemorial. Rigor and chilliness, and pains in the limbs, followed by hot skin, irritable or excited pulse, furred tongue, loss of appetite, nausea or even vomiting, severe headache, and prostration, can be read of in the text-books as accompanying severe cases of coryza, tonsillitis, pharyngitis and laryngitis. Progressive emaciation, great mental depression, and general debility, not infrequently depend suspectedly or unsuspectedly upon some throat disease of more or less long standing. 'fhe popular idea that throat disease may, espe- cially in persons pre-disposed, lead to pulmonary con sumption-often denied by physicians-is based on facts. Cases also occur in which all the rational symp- toms of phthisis, cough, dyspnoea, emaciation, night- sweats, hectic fever, prostration, purulent expecto- ration, etc.,-are present, and which even terminate fatally, while the lungs have remained unaffected; but in many cases the lungs become gradually secondarily involved, though it is not to be denied THROAT AND OTHER DISEASES. 5 that sometimes the disease has commenced in the lungs, and involves the throat secondarily; which, ever is attacked first, disease of both conjoined is frequently met with. Prof. Bennet, of Edinburgh, already in his work " The Pathology and Treatment of Pulmonary Tuberculosis; and on the local medi- cation of pharyngeal and laryngeal diseases, page 142, states: " 1st, That not infrequently diseases, entirely seated in the larynx or pharynx are mistaken for pulmonary tuberculosis. "2nd, That even when tuberculosis exists, many of the urgent symptoms are not so much owing to disease in the lung, as to the pharyngeal and laryn- geal complications. "3rd, That a local treatment may not only remove or alleviate these complications, but that, in con- junction with general remedies, it tends in a marked manner to induce arrestment of the pulmonary disease." The throat is invaded by cancer; and it becomes easily diseased in what are called scrofulous subjects. The throat manifestations of syphilis are so varied and so frequent of occurrence, that they constitute a special and quite important chapter in the history of venereal. Diphtheria though undoubtedly, when developed, a blood-disease, contagious, occurring epidemically, etc., may well be regarded as frequently effecting an entrance into the system locally, in this respect somewhat similar to syphilis. Its connection with 6 ON THE CONNECTION OF the throat is of course well known, and I believe that the lymphatic glands there, often if not absorb something from the pseudo-membranous intiltration in the fauces and the tonsils, and thus •cause the general toxication. In gout, too, the throat sometimes partakes Though this happens but seldom, it is strange that very few physicians are aware of it, since Watson already in his celebrated " Lectures on Practice," calls attention to " gout in the throat " the ex- ample that he relates being the case of an eminent physician of his acquaintance. There is a connection also between renal and throat disease, which has not yet been sufficiently studied. Dr. Chas. Fauvel. of Paris, has published an excellent essay (Compte-rendu du Congres Medico-Chirurgical de tRouen,) in 1863, on "Al- buminuric Aphonia." " There is a curious relationship between the throat and the arterial blood vessels, in their under- going certain transformations of structure which appear to be somewhat analogouswith one another." Reference is mainly had here to atheromatous con- version, with degeneration into calcification, by no means always necessarily,and only, accompanying ad- vanced age, but on the contrary observed in middle age, and even much earlier. Dr. Gibb, of London, who has studied this subject very thoroughly, and was the first to call attention to it, in his work on Diseases of the Throat and Windpipe," designates this interesting new throat malady, as " saccharine THROAT AND OTHER DISEASES. 7 throat " a term for a good reason (as you will pres- ently see) yet notwithstanding not happily chosen, and for which I have long substituted in my lectures that of " atheromatous throat." Although only two well marked cases ofthis important disease have come under my own care, I am not inclined to believe that it is a very rare disease, but it is one which natu- rally would not easily present itself to the specialist, unless through the intervention of the family physi- cian. Both the following cases came to me without such intervention. Mrs. B. K., :et. 51 years, born in Germany, but having resided in this country about thirty years, consulted me on February 16th, 1865. She is the mother of a former patient of mine, a young lady who had had chronic follicular inflammation of the pharyngo-laryngeal mucous membrane for years, but is now entirely well. Mrs. K. is the mother of three daughters and four sons now living, in addition to whom, three children have died from various causes within the past few years. Her husband died eight years ago from typhoid fever. Her own throat has troubled her more or less, almost as long as she can remember, either feeling distressingly dry, or there being too much phlegm ; all her chil- dren were frequently attacked with sore throat. She has always been a hard working woman from childhood, has led a rather temperate life, but seen a great deal of trouble, drinks now and has for some years, a glass or so of lager-beer daily, which she thinks absolutely necessary to keep her strength 8 ON THE CONNECTION Or up. She always feels bloated, and really looks so: she has the appearance of a much older woman than she is; "arcus senilis" well marked, conjunctivae look fatty. She has now a cough which has lasted about seven months, and her voice has been husky nearly as long; both voice and cough are getting worse. She has all the time a nasty sweet taste in her mouth, which overcomes the taste of her food, and often nauseates her. The phlegm now is thick and gelatinous, and irritates her to clear the throat frequently. Examination showed tongue furred; pharynx covered with a greasy looking mucus, coming in part from the posterior nares; the membrane con- gested, thickened, and relaxed, studded with enlarged follicles; tonsils atrophied; the breath was of a peculiar, sickish, somewhat sweetish flavoi-; the laryngoscope showed the mucous membrane congested, and relaxed as far as the eye could reach, the vocal cords had a yellowish aspect, with several whitish patches, and also streaked with fine red vessels. The pulse weak, general health and strength poor, complains of some dyspepsia, bowels rather regular, micturition normal, and repeated subsequent chemical examinations showed no trace of sugar in the urine. I omit the other details of the case. Her diet was regulated; medicinal quan- tities of whiskey substituted • for lager-beer, and under local and general treatment of three or four months duration, she apparently entirely recovered. THROAT AND OTHER DISEASES. 9 The other case fell under my observation about a year ago. It was that of a middle-aged, rather stout man, a mechanic, with symptoms subjective and objective, similar to the preceding, but in whose urine, I found sugar from time to time. Treatment at first seemed to improve him, but he was very irregular in his attendance at my office, and soon staid away altogether. I was told that he died a couple of months ago, of apoplexy. In these cases, diabetes is not necessarily present; the quantity of urine voided is usually normal, and sugar either absent altogether, or present only occa- sionally and in small quantity. The sweet taste of the secretion is invariable, and on this account, Gibb gave the name saccharine throat to the disease. It depends, as Gibb says, on atheromatous degenera- tion or the conversion of the saccharine element, (hepatine or amyloid substance,) into fat and its com- pounds, which either become deposited in various parts of the body, producing polysarcia, or else cause a fatty disintegration of the tissues, associated with an atheromatous ulceration of the lining mem- brane of the cerebral and other blood-vessels; atheromatous degeneration of the vocal cords and calcification, (sometimes erroneously called ossifica- tion,) of the laryngeal cartilages, these becoming brittle and infiltrated with carbonate of lime, (not phosphate,) mixed with minute particles of fat, oil, and Hakes of cholesterine. In connection with typhus, typhoid and other fe- vers, chlorosis, and general anemia from any cause, va - 10 ON THE CONNECTION OF rious throat affections occur; and the prodromic stage or collection of initial symptoms of most of the acute diseases, and the exacerbation of chronic ones, is nothing more nor less than an angina. The symp- toms are the same, as have already been mentioned; headache, drowsiness, lassitude, wandering pains, loss of appetite, coldness, perhaps thirst, dry skin, irritable pulse, general debility, and on inspection, the con- gested, relaxed, inflamed condition of the throat cannot be mistaken. These initial symptoms either -subside, (i. e., the patient gets well,) or become de- veloped into a severe disease, perhaps small-pox or measles, or scarlatina; perhaps laryngitis, croup, bronchitis, or pneumonia; perhaps typhoid fever, or acute rheumatism, or intermittent fever, or dysen- tery, etc. Whatever the predisposing cause may be, certainly very often one of the exciting causes is the angina; and a similar assertion is true of chronic diseases. The old dyspepsia, or disease of the liver, kidney, bladder, uterus, ovary, heart, or other organ, has left a st weak spot " as it is popularly very cor- rectly and significantly termed, a least resisting part, and when disease comes with the angina as one of the initial causes, the part possessing the least power of resistance gives way most easily, and is involved in •the morbid process, either slightly and temporarily ■or perhaps severely and dangerously. In epidemics, this may often be noticed; with proper care, the throat affection is not easily overlooked generally. Cholera infantum, though it may be produced from over or improper feeding, or some cause acting THROAT AND OTHER DISEASES. 11 directly upon the alimentary tract, is not always so produced,but sometimes is radiated from the mucous membrane of the upper portion of the respiratory tract; and this leads me to say that on reflecting upon the subject of the connection of throat disease with other diseases, perhaps one of the first thoughts that would occur to anyone, relates to the great range the mucous membrane of the throat offers for ex- tension of disease by continuity. As the face con- tains in the nose and mouth the commencements of the respiratory and digestive apparatus, the throat contains their continuations. The membrane which lines the nasal fossa is continuous with that of the sphenoidal, ethmoidal,frontal and maxillary sinuses, through the lachrymal duct with the conjunctiva of the eye, along the Eustachian tubes with the mastoid cells and tympanum, through the posterior nares to the pharnyx and mouth, with the cesopha- gus and alimentary tract on the one hand, and on the other, with the larynx, trachea, bronchi, and their ramifications, to the air-cells of the lungs. Diseases of the throat, especially catarrh, are fre- quently observed to extend up or down to other portions of this extensive lining membrane. I shall not take up in extemo each of the parts named, for I take for granted, that the connection between some of the diseases of these organs and angina is generally understood; yet some of the points of this connection deserve to be specified. That deafness and various morbid sensations, as noises and bearing down weight in the head, are 12 ON THE CONNECTION OF very often connected with throat trouble, more- often than even educated aurists until recently be- lieved, may be dismissed with the mere statement. Of the interesting subject of "ear-cough" I have spo- ken in another place. The association of symptoms, called by Europeans, especially Germans, " gastric fever," is essentially an angina. Of course, gastritis, alcohol, and over-loaded or otherwise directly dis- ordered stomach may induce a fever, and this might indeed be termed " gastric fever," but the stomach has usually nothing to do with what is often so- called; indeed, Americans generally, with a nearer approach to pathological and etiological correctness,, but with great nosological indefiniteness, call the same symptoms "a cold," or "a general cold." Again, not a week passes, but some new patient tells me that the throat trouble that he complains of is caused by dyspepsia; and I find that a great number of physicians still believe that indigestion is not only a frequent, but the common exciting cause of chronic pharyngeal or laryngeal disease. As to by far the larger number of cases, holding such an opinion, is (to use a homely metaphorical expression,) putting the cart before the horse. The truth in this respect, was pointed out already by Horace Green, as long ago as in 1846. After slating that the gastric disorder is more frequently conse- quent and dependent upon than antecedent to the throat disease, he continues, in his " Treatise on Dis- eases of the Air Passages," pp. 176 and 177: " This will not appear surprising when we reflect upon THROAT AND OTHER DISEASES. 13 -the amount of vitiated secretion, which in disease of the follicles of the fauces and pharynx, must find its way into the stomach, conveyed there by the food and drink of the individual. Not unfrequently has it occurred to me, in the treatment of disease of the throat, to meet with cases of indigestion, com- plicated with these disorders, which, having proved obstinate under all the ordinary modes of treatment, have yielded readily to appropriate medication after the removal of the primary follicular disease." Bad breath, erosions on the tongue, and aphthous ulcers in the mouth are almost always ascribed to disordered stomach, but here, too, occasionally the primary disease is in the throat. Dr. Ferdinand Wydler, of Aarau, has recently published a pamphlet, entitled, " Die Migraine ist eine Angina; der acute Magencatarrh eine Neurosef (Hemi- crania is an angina, acute gastric catarrh is a neuro- sis) in which he calls attention to the connection of a number of diseases with throat disease. I quote from him the following, (pp. 19-22), on the subject of cardialgia or gastrodynia : " I do not say that 1 have seen all possible forms of gastralgia. That kind which Romberg has so well described, with the violent constricting pain in the pit of the stomach, sensation of faintness, sinking, and even annihilation, the pain radiating to the back, the sternum, and chest, with or without vomiting, with or without eructation, belongs assuredly to the class of cardial- gias connected with an angina. In certain cases, the differential diagnosis between gastrodynia and 14 ON THE CONNECTION OF chronic gastric ulcer is difficult to make ; generally, it is true, pressure aggravates the pain in the latter disease, and rather relieves it in the former; and this is true of pressure from without and from within, (by food); still there are persons who cer- tainly have gastralgia, who cannot bear pressure in the epigastrium on account of the great increase of pain. Usually, though not invariably, the tongue in gastralgia is clean, the appetite good, all sorts of anomalies of taste may be present or not, the attacks come with empty stomach. It occurs more in the female than male sex. Many authors have observed it typically about the menstrual periods; all admit its causes sometimes unknown. I desire to bring forward the fact of its occurrence, particu- larly when angina, gastric fever, and influenza abound; the accompanying one-sided headache and prostration first called my attention to the true na- ture of the disease, some cases of intercurring deli- rium and hysterical convulsions showed its relation- ship to hemicrania, and for some time now, I have always found the angina in cases of acute severe cardialgia. There are chronic cases in which the pain appears independently and locally several times a day, though not violently; here the fresh angina may have disappeared, just as in chronic trigeminus-neuroses. Just as the textbooks state. I have observed gastralgia particularly in persons lia- ble to attacks of hemicrania and neuralgia, and sometimes the same patients may have, during the menstrual period, alternatingly, once nervous head THROAT AND OTHER DISEASES. 15 ache, and the next time, gastrodynia." Ferrand (Union Medicate, 1868) also observed the alterna- tion of hemicrania and gastric pain, and concludes justly that the one does not depend upon the other, but that both come from the same cause. I regard gastralgia one symptom of the series of nervous angina; hemicrania or gastric fever occur- ring occasionally by itself, occasionally together with the other symptoms. The etiological factors ordinarily cited, as dysmennorrhoea, anaemia, chronic gastric catarrh, liver and kidney diseases, etc., may be present or absent,-a certain nervous element and tendency to hemicrania always exist. As an example how nice the question between ulcer and gastrodynia sometimes is, I relate the following case: The very intelligent father of a lady who had been under my care on account of hemicrania and gastrodynia, but also on account of chronic gastric, hepatic and uterine disease, came to me one day and said his daughter's sickness this time was surely not nervous, no gastralgia, but hitherto unrecognized chronic gastric ulcer, as proved by persistent vomi- ting of blood, and bloody stools since the day before. On seeing her I became, however, convinced that the diagnosis "gastralgia" was correct; first, be- cause of the whole neurotic appearance of the disease; secondly, the accompanying headache, and the quality and quantity of the blood. The vomited blood was light red, mixed with the matter vomited, in streaks, and also in roundish, coin-shaped clots,. 16 ON THE CONNECTION OF altogether little, with considerable retching, and spontaneous pain in the epigastrium, increased on pressure. Inspection of the pharynx showed fresh, dark red, anginal discoloration, and I knew from previous observations, how often apparent vomiting of blood from the stomach accompanied this symptom. The reported bloody stool amounted to but a few tea- spoonfuls of bright red blood, spread out in the chamber, that had been passed with much tenesmus. This, of course, came from the region of the sphinc- ter, hardly higher up, and in my opinion, the con- strictors at the beginning and end of the alimentary tract, by their mechanical action, (retching, and tenesmus,) had brought about the haemorrhage from friction and laceration of the fine superficial blood vessels. Aly diagnosis was evidently correct, a few doses of quinine and camphor chased all morbid symptoms away, and the patient on the next day ate beefsteak and ham with great gusto, and with- out any trouble from the stomach. There is perhaps no one symptom of disease which more disproportionately to its other direct effects alarms the patient than spitting of blood. The notion has been prevalent even among medical men, that haemorrhage is the incipient step to con- sumption, its efficient cause in fact, as the ancients had it: hamoptoe tabes." Pathologists now gener- ally more justly regard haemoptysis as a symptom, not so much in itself alarming, unless indeed the haemorrhage be exceedingly profuse, as the previously existing morbid condition; but the idea of its great 17 THROAT AND OTHER DISEASES. danger, so firmly fixed in the public mind, is ex- tended often to even the smallest speck of blood dis- covered as being spit out. Technically, the expres- sion " spitting of blood " is restricted to haemorrhage from the lungs, or from the lower air passages, but practically and popularly its more literal interpre- tation is adhered to, yet the actual danger of the technical haemoptysis is dreaded in every discharge of blood from the mouth. This spitting of blood is frequently connected with throat disease; its true origin is sometimes difficult to trace, the subjective and all rational symptoms are frequently deceptive, and only the most careful inspection, aided by appro- priate instrumental appliances, may enable the truth to be ascertained. The blood in these cases is usually owing to ruptures of the capillaries of the mucous membrane, especially when congested, but occasionally without being abnormally injected, of parts much exposed to motion and friction during coughing, retching, etc. Various neuralgias of the fifth pair of nerves are directly connected with irritations of the second branch of that pair, part of which is distributed to the throat. It is more particularly the affection which causes so very much suffering, which so often puzzles the physician in an attempt at exact diagnosis and in resisting his remedial measures, which is called nervous headache, and sometimes also sick headache, to which, in this respect, I want to call attention. This is well described in " Wood's Practice." (vol. ii., p. 681.) 18 ON THE CONNECTION OE " It is exceedingly irregular in its modes of attack, duration and recurrence, as well as in the character of the pain. Some- times coming on suddenly in a state of apparently sound health, it prostrates at once the mental as well as physical energies of the patient, and after a longer or shorter period, leaves him as abruptly as it approached, and with all his powers restored. In other instances, it comes on slowly, heralded, perhaps, by unaccountable depression of spirits, or acerbity of temper, and gradually increases for hours, perhaps for days, before it attains its acme and declines. In one patient, an attack is experienced at long intervals ; in another, the pain returns frequently and cpiite irregularly; in a third, it is scarcely ever absent entirely for long periods of time, at least the individual never feels himself secure against it at any moment. Sometimes it interrupts and prevents sleep, but more frequently the patient, though tormented during the day, will go to sleep at the usual hour, and upon awaking find that the pain has left him for a time. More fre- quently than any other variety of headache, this assumes the regular periodical form. In most instances, probably, the pain is in the front of the head, over one or both eyes; but it is occasionally felt in the occiput, and is often diffused without a definite seat. Not unfrequently it occurs in the form of hemicrania. It may be dull and grumbling, or heavy and throbbing, or sharp and lancinating, like neuralgia. After continuing a certain length of time, it not unfrequently pro- vokes vomiting; but differs from sick headache in the circum- stance, that the matter discharged from the stomach may be quite destitute of acid, bile, or any acrid property. Its duration is entirely uncertain. One attack seldom continues long; but the patient is liable to frequent returns of it, in many instances for months and years, and in some even for life. It is purely functional and leaves no traces in the brain after death. The headache itself never proves fatal; but it may, in the end, so far wear out the strength as to render the system less able to support the assaults of other diseases, and may thus contribute to shorten life." But Dr.Wood had no idea how often this assem- blage of symptoms is connected with a morbid con- dition of the throat. I have already indicated that Dr. Wydler, in a special pamphlet on the subject, goes so far as to call hemicrania an angina; and I ought to be able to speak of it graphically, having THROAT AND OTHER DISEASES. 19 not only observed it repeatedly and repeatedly in others, but being myself a sufferer. Let me but get cold, or cold and wet feet, or become chilled through, especially after much mental exertion or loss of sleep, and I catch it. The pain is usually one sided, just in the depth of the eye, and more often on my right than left side; breathing through the nose is frequently somewhat interfered with, and then the obstructed nostril always corresponds to the side affected. The angina is never absent, and is usually also only one sided. When it is not, both sides of the head are affected. In fact, this nervous head- ache " may be confined to one small spot, in which case it is sometimes called clavus, as if it might pro- ceed from a nail driven into the head; it may occupy a particular region of the cranium, as the frontal immediately over one or both eyes, the temporal, the parietal, or the occipital; it may embrace one side of the head as in hemicrania, or it may be diffused, and of indefinite extent;" and the angina, always present, is frequently correspondingly seated over a small or large extent on one side or both, in the nasal passages, in-(the}pharyngo-nasatyspace, in the fauces, etc. It is, perhaps, hardly necessary for me to add, to avoid misunderstanding, that I do not mean to imply that all cases of angina are accompanied with headache, nor that all cases of headache are accom- panied with angina,-but in sensitive constitutions (persons with nervous systems comparatively easily impressed,generally termed nervous), the connection 20 ON THE CONNECTION OF between the two is too striking not to be noticed frequently by every physician, after once having his attention called to it. There are other neuralgias in various parts of the body also connected with angina, such as tooth and face ache, and even cases of that anxiety, dyspnoea, sense of suffocation, with violent pain about the sternum, extending toward the arms, to which the name " angina-pectoris " has been given. Next comes the sympathy which is observed be- tween mucous membranes of the body not continu ous, and it is here especially the genital organs of the female, that I desire to call attention to. Follicu- lar disease, catarrh, or graver morbid processes of the rectal mucous membrane are occasionally found conjoined with corresponding throat diseases, both with and without affecting the intervening mucous membrane, and the urethral and vesical lining mem- brane of both males and females frequently sympa- thizes with the faucial; but analogous affections of the throat and of the vaginal and uterine mucous membrane so often coexist, that I have come to assert that hardly ever does a woman suffer for any length of time from disease of one of these regions, without becoming affected also in the other. This, even if admitted, might be supposed to be coincidental; especially asboth throat and uterine diseases are very common in this country, are caused by similar kinds of exposures, and are what is called "fashion- able " just now, being in reality, better understood and more thoroughly investigated than formerly; THROAT AND OTHER DISEASES. 21 but some closer, though not clearly explicable rela- tionship seems to exist between them, for it fre- quently happens-and that this is veritably a fact can be confirmed by Prof. Budd, together with whom T have tested it in many cases-that the throat or uterine affection resists all treatment direc- ted to it exclusively, or after being made well, recurs, unless the other is also treated. The equally inexplicable sympathy between the tonsils and the ovaries, pointed out already by Dr. Prosser James, in the London Medical Times and Gazette, September 1859, and the connection between retroflexion of the uterus and respiratory neuroses, a case of which is related by Dr. R. Chroback, in the Wiener Medizin- ische Presse, Nos. 1 and 2, 1869, must also'here be mentioned. Then the analogy, anatomical, physiological and pathological, between mucous membrane and skin, and the transition of one to the other, must not be lost sight of. Erysipelas, etc., must here be thought of. Indeed, there is a whole class of anginas called exanthematous throat diseases. Scarlatina, measles and small-pox, especially, make their mark in the throat as well as on the skin. l5he connection of " drug diseases " with the throat should also have a place here. The ravages in the mouth and throat, of mercurialism are well known, though happily no longer frequently seen. In lead palsy the throat is not unfrequently in- volved ; and also specially in the toxical effects of many other drugs. 22 ON THE CONNECTION OF I suppose I should speak here also of the relation- ship of the aiu.se of tobacco and throat disease. Horace Green says, (op. cit. p. 183) " As an exciting cause, the use of tobacco, in my experience, has proved a powerful agent in the production of follicu- lar diseases of the throat. Acting as a stimulant, directly and constantly, upon the mucous follicles of the fauces and throat; and greatly increasing, as it does, the secretion of these glands, its employ- ment, as we should conclude, a priori, must have a direct tendency to develop the disease, especially if a predisposition to the affection exists." Not only has the use of tobacco in all its forms, proved in my experience an exciting cause of laryngeal disease; but where its employment has been per- sisted in during the treatment of any case, I have found it impossible to restore such to perfect health." In addition to all this, diseases of neighboring organs re-act upon the throat; as aneurismal tumors, heart disease, etc., etc. d'hat hysteria in some of its protean forms does not omit to attack the throat, hardly needs mention; hysterical aphonia being so often diagnosed by physicians (more often, I might add, than it ought). Nervous cough is really often met with. But there is one point more on which I want to dwell a moment before I close; and that is, who are the persons in whom the connection of throat with other diseases is most pronounced ? They are the excitable, in one word, " nervous " people who constitute the majority of almost every physician' s THROAT AXD OTHER DISEASES. 23 patients. Nervousness is doubtless the child of civilization and mental culture, of refinements in clothing, food, dwelling-places, of want of proper physical and muscular exercise. It has its good as well as its bad sides. Half of all educated, refined people belong to this class. The highest that is reached in intellectual, scientific, social, political, and industrial relations, is accomplished by them. They are tough enough, and hardy in health, though easily giving way to morbid influences, in fact to im- pressions of every kind. They abound in this coun- try and this city. It has often been said that Americans as a nation live too fast, and in our me- tropolis this characteristic has reached its climax. Prof. Metcalfe has proposed for the neurasthenia which so often results from an exaggeration of this characteristic, the name " Morbus New-Yorki." The ever-busy hurried manner in which New Yorkers rush through their existence, tends to develop and perpetuate " nervousness " more and more. Even if their longevity be the same in years as other peoples', they crowd more action, whether good, bad, or indifferent, whether useful or useless, into their lifetime. Now, as in the constitution of but few persons, the different organs are so equally balanced,- and in the competitive struggle for the objects of existence, the different functions so evenly balanced, -that they are developed and used, wear out and decay evenly : inequalities of resistance to impres- sions must arise. And by the same law, the elucida- 24 ON THE CONNECTION OK lion of which we owe to Darwin and the modern school of naturalists, by which those characteristics that tend to facilitate the " struggle for life " are transmitted to posterity and by continued adapted- ness to surrounding circumstances are strengthened and made permanent, the quality of mind and body to which the name " nervousness " has been given, has now become hereditary, has been perpetuated among us, with both its good part and its evil. To preserve the good and remove the evil lies with ourselves. Let us bring about an equilibrium be- tween brain and muscle, not exercising the former less but the latter more, and both for the attainment of the highest ends of which humanity is capable. The points to which 1 wanted particularly to call attention by the foregoing paper, and on which I desire to elicit discussion are: 1, the possible local origin of diptheria; 2, atheromatous throat; 3, the nervous headache connected with angina; and 4, the connection between throat and uterine disease. The most Widely Circulated and Ably Conducted Medical Paper in America. THE MEDICAL GAZETTE, A WEEKLY REVIEW OF THE MEDICAL SCIENCES, Has now entered upon its Fourth Volume, ami is firmly established in profes- sional favor in every Stale in file Union. 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