mucous membrane covering the gland, and does not extend along the
lacunæ which dip inward from the surface and divaricate toward the
interior of the organ. It is termed catarrhal tonsillitis, and, as has
been intimated, is almost always associated with catarrhal sore throat.
It is attributed to hyperæmia, with passive engorgement of the vessels,
following retrocession of blood from the cutaneous surface after undue
exposure to cold and moisture. A severer form of the malady involves
the lacunæ in addition--several or all of them. This should be termed
lacunar tonsillitis, as suggested by Wagner. Primarily, at least, it
does not involve the follicles of the tonsils which open into the
lacunæ, and is therefore incorrectly denominated follicular
tonsillitis, although it is most generally so described. The lacunæ are
involutions of the mucous membrane, and in health furnish a slightly
turbid mucoid secretion which serves to lubricate the parts and, as is
generally believed, to facilitate deglutition. When the lacunæ are
inflamed these products become pent up in them to a certain extent,
accumulate, and project in part at their orifices in turbid creamy or
curdy masses, plastered over the parts when thin in consistence, or
tightly imbedded when thick or desiccated. These masses are usually
white, but sometimes, owing to various admixtures, they are more or
less yellowish or gray or brown. They consist of epithelium chiefly,
with more or less pus and accumulation of cells similar to those of
which the follicles are composed--whether from follicles which have
become distended by proliferation of their constituents, and have then
burst, is not known. This epithelium has often undergone fatty
degeneration in part. Cholesterin is an occasional constituent, and
swarms of micrococci and bacteria abound when the masses are not
recent, especially if the inflammation is occurring in a tonsil long
the seat of chronic disease of the lacunæ.
The tonsil itself is moderately swollen and its mucous membrane
hyperæmic. If the parenchyma of the tonsil be involved likewise, as
often occurs, the swelling will be much greater, so that the gland will
project a considerable distance beyond the margins of the palatine
folds. When a hypertrophied tonsil is the seat of the inflammation the
tumefaction will be much greater than when the inflamed tonsil has been
normal.
Acute inflammation of the palatine folds often coexists, especially of
the anterior fold. The soft palate may also be engaged in the morbid
process, which may involve the uvula likewise. Pharyngitis is an
occasional accompaniment, and stomatitis quite a rare one.
Lacunar tonsillitis sometimes subsides by spontaneous evacuation of the
pent-up contents of secretion and desquamation, the parts returning to
their normal condition. More frequently a desiccation of some of these
products ensues, with permanent chronic inflammation. Decomposition
then often takes place, fouling the breath by the escape of the gases.
Butyric acid has been recognized as one of the most prominent of these
fetid {385} gases. Calcareous change occurs in these contents of the
lacunæ in some instances. Lacunar or follicular tonsillitis is often
associated with severe inflammation of the peritonsillar connective
tissue and the contiguous palatine fold, with serous or cellular
infiltration into these structures almost always terminating in
suppuration. This form of tonsillitis is very frequent, and is often
confounded with parenchymatous tonsillitis or with tonsillar abscess.
In these cases the abscess is in the peritonsillar tissue or in the
posterior leaflet of the anterior palatine fold. It bursts above the
tonsil at the angle between the two folds in the greater number of
cases. In some instances the suppurative inflammation affects the
anterior surface of the posterior palatine fold, sometimes contiguously
to the antero-tonsillar abscess, sometimes independently, constituting
a retro-tonsillar abscess. The follicles in the posterior palatine fold
are sometimes involved, the thickened anterior surface of this
structure becoming studded with small projections the size of ordinary
pinheads or larger, distended with whitish-yellow contents.
In another class of cases of tonsillitis the inflammatory process may
be chiefly parenchymatous, for rarely is it wholly so. That is to say,
it may involve the glandular structure of the organ wholly or in main
part. The disease is then an adenitis, an inflammation of
gland-tissue--tonsillitis per se. It is associated with superficial
inflammation of the surrounding mucous membrane, secondarily if not
primarily, and often with inflammation of the lacunæ. In many instances
the parenchymatous inflammation is a direct extension of the lacunar
inflammation.
Parenchymatous tonsillitis may subside by resolution, or, as is quite
frequent, terminate by suppuration. A number of small abscesses may be
formed, which usually become confluent and rarely remain discrete.
Sometimes a single large abscess is formed. The confluent abscess may
discharge by several points. It is always associated with a severe
inflammation of the palatine folds and palate, especially the anterior
fold; sometimes of the adjoining half of the soft palate and the uvula;
sometimes of the entire velum and uvula. Sometimes these parts become
oedematous; sometimes suppuration ensues. Severe pharyngitis is not
uncommon. Glossitis, involving the posterior portion of the tongue
especially or exclusively, is an occasional accompaniment of
parenchymatous tonsillitis. (See GLOSSITIS.) Occasionally oedema takes
place in the epiglottis and upper margin of the larynx.
The character of the secretions varies. Sometimes these are semifluid;
sometimes soft, caseous, or pultaceous; sometimes fibrinous and
arranged in pseudo-membranes; sometimes hemorrhagic; sometimes moist
and viscid, sometimes very dry; often adherent, and always containing
cryptogams (leptothrix, Oïdium albicans, bacteria, and micrococci).
Collections of caseous products accumulate not only in the crypts of
the tonsils and in their overlying mucous membrane, but likewise in the
follicles of the palatine folds below the tonsil, and thence toward the
base of the tongue.
The submaxillary glands often undergo engorgement, and become so tender
that external manipulation is painful, and sometimes they undergo
suppuration. The tumefaction due to the swollen glands and infiltrated
connective tissue around it is frequently incorrectly referred to the
tonsil itself, rather than to the accompanying inflamed palate, with
the {386} lymphatics of which these glands are in more direct
anatomical connection. The tonsil is at a considerable distance from
the inflamed glands, and cannot be felt from the exterior except under
unusual circumstances.
Herpetic tonsillitis is a rare form of inflammation of the tonsil, or
rather of its investing mucous membrane, characterized by the eruption
of herpetic vesicles on its surface. The vesicles soon undergo rupture,
and the resulting ulcers coalesce and become covered with a fibrinous
exudation. The disease is usually associated with similar vesicles upon
the palatine folds and upon the soft palate, and exceptionally with
vesicles on the pharynx. (See Herpetic Pharyngitis.) It is by some
fortuitous circumstance only that it is observed in the vesicular
stage. It is confined to one side of the throat in most instances, but
may be bilateral also.
Mycosis tonsillaris has been described by a few observers. B.
Fraenkel[4] has recorded three cases, E. Fraenkel[5] one, and Bayer[6]
two. In these cases the disease was not confined to the tonsils, but
implicated the calciform papillæ of the tongue also, and one of Bayer's
cases some pharyngeal follicles in addition. E. Fraenkel's case was in
a male, and occupied but the right tonsil and base of tongue. The white
masses in this case were formed of spores and filaments (Bacillus
fasciculatus, Sadebeck), which are described as penetrating some
millimeters into the gland-tissue. These masses were tenacious, and
were reproduced rapidly after removal. In Bayer's cases, both females,
the same microphyte was recognized. In a female patient observed at the
Philadelphia Polyclinic[7] this affection followed rheumatic
tonsillitis, diphtheria being prevalent near her residence, which was
in a very unsalubrious locality. The deposit, confined to the left
tonsil, was so firmly adherent to the mucous membrane that the
implicated portion had to be torn away to get rid of the growth, which
was twice reproduced. The fungus was in its mycelial state, a few
spores and conidiferous filaments being recognized microscopically.
[Footnote 4: _Berlin. klin. Woch._, 1873, S. 94; _ibid._, 1880, No.
18.]
[Footnote 5: _Zeitschrift für klin. Med._, iv., 1882.]
[Footnote 6: _Rev. mens. de Laryngologie, etc._, Nov., 1882, p. 329.]
[Footnote 7: S. Solis-Cohen, _The Polyclinic_, March, 1884, p. 133.]
Quite recently, and since the above was written, the results of an
elaborate study of this affection by Theodor Hering of Warsaw have been
published in a paper entitled "Pharynxmycosis leptothricia,"[8] read
before the Society of German Naturalists and Physicians. The author
collates fourteen cases, six of which were observed by himself. He
claims that the microphyte is simply the Leptothrix buccalis.
[Footnote 8: _Zeitschrift für klinische Medicin_, Bd. vii. H. 4, 1884.]
The local subjective symptoms as collated by Hering vary from the
merest sense of discomfort in chronic cases to intense pain, difficulty
in speech and in deglutition, and various grades of cough in acute
ones. In some cases they are altogether wanting. Constitutional
disturbance may be entirely absent or may be presented in various
febrile or sub-febrile manifestations.
DIAGNOSIS.--The history of the attack, the appearances described, and
the symptoms narrated should ordinarily suffice for a correct
diagnosis. Still, mistakes do occur. An unsuspected tumor of the tonsil
observed for the first time during an ordinary sore throat might be
taken for an inflamed tonsil, but the progress of the case would soon
lead to its due {387} recognition. While tonsillitis is infrequent
after the fourth decennium, it occasionally occurs late in life, and
has been observed even in the ninth decennium; and reserve is proper as
to the cause of enlarged tonsils in the sore throats of those advanced
in life.
The deposit in follicular or lacunar tonsillitis or angina is pulpy and
not membraniform. It can be wiped from the surface with a fragment of
sponge, and does not tear from the surface in strips, as is the case
with the pseudo-membrane of diphtheria or of common membranous sore
throat. There is no abrasion of the mucous membrane beneath the
deposit. The patches are more prominent, usually more circumscribed,
and dip down into the lacunæ, or rather project from the crypts upon
the surface of the tonsil. In its physical aspect the deposit more
closely resembles that observed in the sore throats accompanying
cachectic conditions, as in chronic tuberculosis, advanced syphilis,
some forms of scarlatina, typhus and typhoid fever, extreme old age
(agine pultacée, Fr.; cachectic angina); but the existence of previous
constitutional disease and actual debility should prevent the mistake
in diagnosis. In susceptible subjects the oncoming of an attack of
rheumatic tonsillitis may often be inferred, previous to the
manifestation of local symptoms, from the existence of otherwise
inexplicable odynphagia, the pain being especially intense upon
attempts to swallow saliva. Sometimes laryngoscopic inspection at this
early stage of the disease will reveal vivid redness of the mucous
membrane in the neighborhood of the crico-arytenoid articulations.[9]
The value of this early diagnosis lies in the opportunity it affords to
try abortive treatment.
[Footnote 9: S. Solis Cohen, _The Medical News_, Aug. 11, 1883, p.
146.]
PROGNOSIS.--The prognosis of catarrhal tonsillitis is almost invariably
favorable, except under very obviously unfavorable conditions, the
inflammatory process subsiding spontaneously within a few days. It is
favorable, as a rule, in phlegmonous tonsillitis subsiding within ten
or twelve days in most instances, even though all the stages be
completed to suppuration and discharge of the abscess. Sometimes two or
three weeks are consumed in the process. A certain amount of reserve is
requisite, nevertheless, in severe cases, in view of the possible
complications which may prevent recovery. If both tonsils are affected
to such an extent as to interfere seriously with respiration, death by
suffocation may ensue should the obstruction be not relieved by
excision of portions of the swollen glands or an artificial opening be
not made into the air-passage. Suppuration may perforate the internal
carotid or the external maxillary artery and produce sudden fatal
hemorrhage. The remembrance of such occurrences should screen a surgeon
from the imputation of carelessness should he be unfortunate enough to
incise an abscess under similar conditions. Some cases are on record of
fatal hemorrhage but a short period before a proposed operation could
have been performed.
Suffocation has ensued from discharge of the abscess into the
air-passage, usually during sleep; but it has occurred even during the
moment of speaking (Stokes).[10] Such results are accidental and
exceptional.
[Footnote 10: _Med. Times and Gaz._, Aug. 29, 1874, p. 251.]
Recurrences are frequent, especially in scrofulous subjects, and such
recurrences are apt to result in permanent hypertrophy and induration.
TREATMENT.--Mild cases of tonsillitis require no treatment except to
{388} keep the patient protected from exposure to abrupt changes of
temperature. The course of the affection both in mild cases and in
severe ones may often be materially shortened by prompt resort to the
use of guaiacum, both internally and topically. A gargle containing an
ounce each of ammoniated tincture of guaiacum and compound tincture of
cinchona to the pint, with the addition of three ounces of clarified
honey, and saturated with potassium chlorate (twenty grains to the
ounce), may be used, a drachm at a time, every two hours, hour, or half
hour, according to the urgency of the symptoms, and may likewise be
administered internally in drachm doses for an adult every two or more
hours. The beneficial effects will often be manifested within less than
twelve hours. Pellets of ice held in the mouth from time to time often
relieve pain and repress inflammation. Sodium bicarbonate locally, in
powder, affords great relief in some instances. In the presence of
marked pyrexia tincture of aconite may be given in drop doses every
hour until an impression has been made upon the heart, when its
continuance at intervals of four or more hours will be a matter for
consideration.
Guaiacum and aconite may be given with equal benefit in any form
preferred by the prescriber. At the same time saline laxatives may be
required from time to time. Regulation of the diet is often necessary.
When the tonsils are very much swollen, gargling of all kinds becomes
too painful, and therefore sprays of sedative and emollient mixtures
are to be substituted, or steam from water impregnated with volatile
substances, as benzoin, paregoric, hops, chamomile, and sage. When the
cervical glands are swollen, continuous hot and moist applications
externally afford great relief. If the suffering from the inflamed
tonsil be intense, scarification should be practised and the bleeding
be encouraged by warm water. When suppuration exists, the abscess
should be promptly evacuated by incision at the most prominent
accessible point.
Special symptoms require appropriate management on general principles.
The pain in swallowing can often be diminished by pulling on the lobe
of the ear at the moment of deglutition (Grewcock).[11] In debilitated
subjects, or during epidemics of diphtheria, quinia, iron, and
supporting measures are indicated.
[Footnote 11: _Lancet_, Nov., 1882, N.Y. reprint, p. 399.]
The rheumatic cases are best treated with sodium salicylate, ten to
fifteen grains every hour or two until relieved. Instituted in the
formative stage above alluded to, this treatment frequently seems to be
veritably abortive, especially when preceded by a full dose of an
alkaline purgative--say one ounce of Rochelle salts. Oil of gaultheria
may be used in small doses as an agreeable flavor to the mixture, or in
doses of ten to twenty minims, well diluted, as an adjuvant to the
salicylate, or even as a substitute for it. After subsidence of the
acute symptoms cinchonidine salicylate may be continued for a few days
in appropriate doses.
Herpetic tonsillitis requires the ordinary treatment for erythematous
tonsillitis, with additional topical treatment by sprays of alkaline
solutions, such as sodium borate or bicarbonate, five grains to the
ounce, or lime-water. Internally, small doses of mercuric chloride will
be of service, the dose varying, according to the age and size of the
patient, from one-forty-eighth to one-sixteenth of a grain every two
hours, until the stomach shows signs of irritation therefrom. In cases
of doubt as to {389} diagnosis from diphtheria the treatment for
diphtheria will be indicated as the safer measure. Here, again, the
mercuric chloride is sometimes equally valuable.
Mycosis of the tonsil does not seem amenable to medicinal treatment.
Thorough removal of the fungus with forceps or sharp spoons is
required, even though mucous membrane be detached with it. When this is
impracticable, ablation of the tonsil may be necessary. Raw or cut
surfaces left by any of these manipulations should be subjected to
thorough cauterization, electric cauterization being the most feasible
method.
{390}
DISEASES OF THE PHARYNX.
BY J. SOLIS COHEN, M.D.
Acute Pharyngitis.
DEFINITION.--An acute inflammation of the mucous membrane of the
pharynx, whether implicating the glandular structures or not, and
usually associated with inflammation of contiguous structures.[1] Acute
pharyngitis may be catarrhal or erythematous, phlegmonous or
suppurative, ulcerative, herpetic or membranous, gangrenous, and
erysipelatous.
[Footnote 1: In deference to the plan suggested by the editor of this
work, separate articles have been prepared under the heads of
Pharyngitis and Tonsillitis respectively. The two processes, however,
are so frequently associated that they should be studied together, the
more that both of them are likewise associated with extensions of the
inflammatory process to the palate, palatine folds, base of the tongue,
and other contiguous structures. The writer has always preferred to
describe these diseases under the head of sore throat, which does not
presuppose any limitation to individual anatomical structures.]
SYNONYMS.--Sore throat; Angina.
ETIOLOGY.--Acute pharyngitis may be idiopathic, deuteropathic,
traumatic, toxic, or parasitic. The predisposing cause may be
diathetic, as scrofula, rheumatism, gout, and syphilis; it may be a
depression of the vital powers from any cause, such as continued
exposure to foul air or impure water, improper diet or sedentary
occupations. There exists in some individuals a predisposition to
"catching cold," independent of any cachexia. Pharyngitis may occur at
any age, but is more frequent in the young. One attack increases
subsequent liability to the disease.
The exciting cause is usually exposure to cold and damp. Hence the
disease is more frequent at the seasons when these conditions prevail
or when sudden changes of temperature are taking place. Sudden chilling
of the body when overheated may occasion it in warm weather; for
instance, a plunge into the ocean while covered with perspiration. The
ulcerative variety, when not due to syphilis or tuberculosis, is
usually of septic origin, and is apt to occur in the debilitated
especially. The gangrenous form, which is rare, results from profound
blood-poisoning. The herpetic or membranous variety may be due to
disturbance of the trophic nervous system, and has been attributed to
mental emotion (Feron), to uterine disturbances (Bertholle), to the
contact of irritating substances and to miasmatic or fetid exhalations
(Peter). It prevails principally during epidemics of diphtheria or of
scarlet fever, and may be of cryptogamic origin. The cryptogam of
thrush is sometimes developed on the mucous membrane of the pharynx,
either primitively or as an extension of the disease from the oral
cavity. Certain conditions of the {391} atmosphere give rise at times
to so-called epidemic pharyngitis. Paludal or malarial pharyngitis may
arise from the same causes as malarial fevers. Pharyngitis occurs in
the various exanthemata as an essential part of the morbid process, and
is always more or less prevalent during epidemics of measles or scarlet
fever. It occurs not rarely in typhoid fever, and is an occasional
complication of pneumonia, rheumatism, herpes, pemphigus, and other
acute affections. It is one of the complications of facial erysipelas,
but erysipelatous pharyngitis may occur primarily. Pharyngitis may be
excited by the inhalation of deleterious solid, fluid, and gaseous
substances in the atmosphere which act mechanically or chemically on
the mucous membrane. Many drugs administered in poisonous or even in
medicinal doses may give rise to an attack of inflammation of the
pharynx; among them may be cited preparations of mercury, antimony,
iodine, arsenic, copper, lead, zinc, silver, stramonium, belladonna,
and most of the Solanaceæ. Traumatic pharyngitis results from
deglutition of boiling water or of acrid or caustic substances; from
inhalation of hot air, of steam, or of flame, and is most usually
associated with traumatic oesophagitis or with laryngitis.
PATHOLOGY AND MORBID ANATOMY.--Acute pharyngitis, as most commonly
encountered, is a simple erythematous inflammation of the mucous
membrane; the palate and tonsils being likewise involved. In most
instances there is simply an active hyperæmia which may subside in a
day or two. When more intense than this the mucous membrane of the
palate, tonsils, and pharynx becomes congested and swollen, uniformly
or in circumscribed areas. In some instances the submucous tissue of
the pharynx is greatly relaxed, and the mucous membrane lies upon the
substructure in thick folds. In others there is more or less oedema.
The mucous follicles, especially those of the posterior palatine folds,
are frequently swollen. There is an abnormal though not excessive
secretion of viscid mucus, clear or turbid. The uvula is often swollen
or distended with serum, and its mucous membrane is relaxed. Sometimes
it appears as though pasted to one of the folds of the palate by viscid
secretion. The posterior palatine folds may be distended with serum,
and their arched appearance thus become obliterated. Resolution occurs
gradually in some instances, quickly in others.
Phlegmonous pharyngitis exhibits a still higher grade of inflammation.
It involves the submucous structures as well as the mucous membrane,
including at times the fibrous sheaths of the muscles. It may, in
addition, involve the palate, the tonsils, the base of the tongue, and
contiguous structures. Suppuration is common, usually circumscribed,
but not infrequently diffuse in patients of enfeebled constitution.
One variety of the disease is essentially a deep-seated pharyngitis;
and this form almost always progresses to suppuration (suppurative
pharyngitis). The process becomes then, not infrequently, a diffuse
suppurative inflammation of the subpharyngeal connective tissue,
extending sometimes downward along the oesophagus, into which the pus
may be discharged by spontaneous rupture, with a result of permanent
stricture from irregular cicatrization. Sometimes the suppurative
process extends anteriorly beneath the cervical fascia, and the pus may
gravitate so as to occlude the air-passages, partly or completely, by
direct pressure; or in other instances the entrance of {392} the larynx
may become blocked by the tumefaction of the pharynx. When phlegmonous
pharyngitis is of traumatic origin, there will be more or less
destruction of the mucous membrane according to the nature of the
injury, whether accidental or designed, whether due to burn, scald,
inhalation of hot air or steam, or to deglutition of alkaline, acid, or
other corrosive substances. In these cases the morbid process is rarely
confined to the pharynx, but the larynx, the oesophagus, and even the
stomach, are liable to be involved. If regurgitation of hot air or of
caustic fluids takes place through the nasal passages, the injury will
of course involve those regions.
Ulcerative pharyngitis is a low form of inflammation present in sore
throat, probably dependent upon septicæmia. The tonsils are somewhat
congested and swollen, and one or more white superficial ulcers form on
their surface, or on the palate, or on the pharynx. These ulcers are
generally round or oval, and vary greatly in size. When two or more
ulcers exist, they exhibit no tendency to confluence. Healing takes
place rapidly, usually without leaving any traces of the lesion.