infrequent phenomena of a not uncommon sore throat, which exhibits at
first a collection of small vesicles the size of millet-seeds or
larger, isolated here and there or clustered in groups on the palate
and uvula, less frequently on the tonsils. Herpes of the mouth and lips
sometimes coexists. These vesicles are surrounded by inflammatory
areolæ. Their contents are more or less turbid. In rare instances they
disappear without trace after a day or two. Usually they soon undergo
rupture, sometimes within a few hours, so that small ulcers are left,
which almost immediately become covered with a grayish-white exudation.
A number of patches will coalesce, forming limited sheets of false
membrane not unlike those of diphtheria. The disease is usually
confined to one side of the throat, the corresponding submaxillary or
cervical glands being affected moderately when at all involved. The
tonsil is swollen, and the mucous membrane of the palate and the
palatine folds is congested and often tumefied. There is an abnormal
secretion of viscid, ropy, turbid mucus. In a few days the ulcers heal
beneath the exudation, which becomes disintegrated and detached, the
inflammatory process subsiding by gradual resolution. Sometimes the
ulcers cicatrize without previous deposit of false membrane.
Occasionally there are at longer or shorter intervals successive crops
of vesicles, which may or may not undergo ulceration.
Gangrenous pharyngitis may supervene upon any form of pharyngitis, but
in the majority of instances its malignant character is inevitable from
the outset; so that some authors have even restricted the term
gangrenous to a form of sore throat characterized by primitive gangrene
of the pharyngeal mucous membrane originating independently of any
other malady. Whether an idiopathic disease, or whether it follows
scarlatina, measles, small-pox, dysentery, or enteric fever, it is
associated with that depraved condition of the system denominated
typhoid. At times it occurs in tuberculous phthisis. The initial
manifestations may be simply those of intense inflammation. The tongue
is covered with a dark creamy, pultaceous deposit consisting of
broken-down epithelium, pus-cells, bacteria, and molecular débris,
while similar masses are occasionally seen upon other mucous surfaces
of the mouth and throat. The tonsils, {393} palate, and pharynx are
livid and swollen, and sometimes oedematous. At an early period the
tonsils, the palatine folds, and the posterior wall of the pharynx
become covered with dark, ashy-colored ulcers with excavated edges.
Sometimes these spots are black from the first, and appear slightly
elevated. These soon slough out with more or less of the surrounding
tissues, and the ulcers left are covered with sanious, ichorous, fetid
secretion. In some instances a delicate pseudo-membrane has been found
in the bed of the ulcer after death (Mackenzie). The destructive
process rapidly extends--sometimes to the oesophagus in one direction
or to the nares in the other. The larynx is less frequently implicated;
should it be attacked, oedema is liable to occur. Occasionally the
process is limited to the tonsil, and there is no pharyngitis at all.
Erosion of the blood-vessels may give rise to fatal hemorrhage. In
those instances where the gangrene is circumscribed there are found,
post-mortem, depressed oval or circular patches from one-twentieth to
one-half an inch in diameter, varying in color from dark gray to
absolute black. The edges are of a brownish color and are
perpendicular. The bundles of muscular fibre are laid bare by
destruction of the mucous membrane and submucous connective tissue, but
as a rule escape implication of their substance. Similar patches have
been noted in the epiglottis and the upper part of the larynx as well
as in the mouth and pharynx--in some cases, indeed, in the trachea, the
lungs, the oesophagus, the stomach, and the intestines.
Erysipelatous pharyngitis is usually an extension of erysipelas from
the facial integument, which may take place by the lips and mucous
membrane of the mouth, by the nasal fossæ, by the Eustachian tube from
the tympanum and external ear, or by the nasal fossæ from the
conjunctiva and eyelids through the lachrymal duct. When the disease
begins in the pharynx the order of communication may be reversed. The
pathological processes are the same as in cutaneous erysipelas. The
mucous membrane of the pharynx will be diffusely red or purplish and
shiny. Sometimes little bullæ are formed and become ruptured, leaving a
patch of softened whitish-yellow tissue, which is sometimes torn from
the surface beneath by the act of coughing or of deglutition. The
inability to swallow is not due to swelling of the tissues, but to
actual paresis of the muscles, probably from interstitial infiltration,
but perhaps from implication of their substance. The cervical and
submaxillary glands are rarely involved. Erysipelatous pharyngitis
usually terminates by resolution, desquamation of the greater part of
the epithelium of the mucous membrane often taking place; but it may be
followed by abscess or by gangrene. Extension may take place to the
larynx, and oedema may follow.
Exanthematous pharyngitis accompanies some cases of cutaneous
exanthemata. The pharyngitis of small-pox is occasioned by an eruption
upon the mucous membrane similar to that which appears on the skin.
Often in advance of the cutaneous eruption it occupies the inside of
the cheeks, the palate, uvula, and pharynx; sometimes the larynx as
well. Maturation occurs more rapidly than upon the skin, and there is
more or less purulent infiltration of the submucous connective tissues.
Ulceration of the larynx or trachea may ensue so severe in character as
to cause fatal termination by the local lesion.
{394} In measles an eruption similar to the cutaneous manifestation
occupies the air-tract from nostril to bronchi rather than the
food-passages. The Eustachian tubes may be involved, and the
inflammation is sometimes propagated along the lachrymal duct. The
throat may be affected a day or two before the external integument.
Small red points the size of a millet-seed or larger appear on the
palate, the tonsils, the posterior palatine folds, and the wall of the
pharynx. These disappear in a few days, though sometimes in bad cases
fibrinous exudation may accumulate. In other instances abscess or
ulceration takes place, chiefly in the larynx.
The pharyngitis of scarlatina develops a day or two prior to the
cutaneous eruption, the mucous membrane of the palate, tonsils, and
pharynx being deeply congested, uniformly or in patches, with slight
papulous elevations here and there. In the course of a day or two an
opalescent or milky deposit, consisting chiefly of detached epithelium
and viscid mucus, is observed on the swollen palate and tonsils. In the
anginose variety the hue of the inflamed structures is more dusky.
There is a pseudo-membranous deposit of a dirty-white, ash, or even
yellow color. It is not limited to the tonsils, but accumulates rather
on the palate, palatine folds, and posterior wall of the pharynx. The
mucous membrane beneath the patches is often ulcerated, and sometimes
gangrenous. There is much greater tumefaction of all the parts than in
simple scarlatina, the enlargement of the cervical and submaxillary
glands and the infiltration of contiguous connective tissue being so
great in some instances as to prevent the mouth from being opened. A
viscid and turbid secretion accumulates in the mouth. The nasal
secretions sometimes desiccate into firm crusts. Suppuration may occur.
Sometimes otitis media results from extension along the Eustachian
tube, and sometimes suppuration of the membrana tympani, suppurative
external otitis, or disease of the internal ear with extension to the
cerebrum. In malignant cases all the processes are aggravated.
Ulceration or gangrene soon ensues, the pseudo-membranous deposit being
dark, almost black, from extravasated blood. Oedema of the uvula and
soft palate is liable to occur, and if the larynx be involved there may
be oedema of the epiglottis and ary-epiglottic folds.
SYMPTOMATOLOGY.--Simple pharyngitis very often gives rise to but little
discomfort. There is usually more or less heat and dryness in the
parts, especially at first. There is some dysphagia, principally from
pain in swallowing, but in part from actual debility in the muscles of
deglutition. Hoarseness is not usual, and cough is infrequent if there
be no elongation of the uvula. Speech may be embarrassed by difficulty
of articulation. There is usually some febrile movement, with
acceleration of pulse and respiration. Some cases exhibit more intense
inflammatory action, with a corresponding aggravation of the
constitutional symptoms. The skin becomes markedly heated, the
body-temperature rises to 101° F. or higher, the pulse reaching
100-120, in some instances 140, beats per minute, even in the adult.
In that variety known as rheumatic sore throat there will be in
addition pain and soreness in the neck, back, and limbs, often severe,
and increased by motion. There will be great accumulation of saliva in
the mouth because of the intense pain in swallowing it. Speech, and
even respiration, may become painful. These manifestations are
frequently {395} followed by the ordinary phenomena of acute articular
rheumatism, but they may subside in a few days, leaving only a general
feeling of muscular soreness or slight stiffness in one or more of the
joints. Sometimes a temporary torticollis follows.
In some cases of pharyngitis the cervical glands become swollen and
painful, but this is not common. In children the constitutional
disturbance is much greater than in adults. In malarial districts or in
subjects of malarial poisoning the manifestations may assume a periodic
character. Recovery takes place, as a rule, in from three to ten days.
In many instances the local phenomena are most prominently manifested
on one side of the throat. There will then exist great liability to
similar involvement of the other side after convalescence of a day or
two, and without care and avoidance of exposure the second attack may
be far more severe than the first.
The severe variety of pharyngitis denominated phlegmonous is often
ushered in with a decided chill, the phenomena of fever following
within twenty-four hours. The symptoms, both local and general, are of
much greater severity than in catarrhal pharyngitis, especially in
cases proceeding to suppuration.
Paralysis of the palate and other paralyses may follow either of the
forms of sore throat just described. Albuminuria sometimes results. In
extremely rare cases it is an accompaniment of the disease.
Superficial ulceration of the mucous membrane may occur in almost any
form of pharyngitis or of sore throat. Some authors have separated a
special form of ulcerative sore throat occurring in those enfeebled
from long exposure to unwholesome influences, such as nurses, hospital
attendants, etc., in whom the first symptom is pain in deglutition,
especially of saliva. The tongue is furred and the breath is offensive.
There is loss of appetite, with general lassitude, feebleness of
circulation, and more or less elevation of temperature. Intense
headache is often present. Under suitable treatment recovery is rapid.
The ulcerative sore throats of syphilis and of tuberculosis require
separate consideration.
Common membranous pharyngitis frequently gives rise to but slight
symptoms, differing very little from those of other forms of
pharyngitis; but there may be high fever of sthenic or of asthenic
type, very often preceded by general malaise, sometimes by a decided
chill. The pain in deglutition and the local heat and dryness are
sometimes much greater than in the more ordinary forms of pharyngitis.
The distress may extend into the ear, sometimes to the nasal passages,
in rare instances to the larynx. The disease lasts for a week or ten
days, usually terminating in recovery. In occasional instances, chiefly
in children, it terminates fatally by apnoea from extension of the
membrane into the larynx. Paralytic sequelæ are not rare.
The advent of gangrenous pharyngitis is sometimes indicated by sthenic
phenomena, but usually from the first it is marked by extreme
prostration, comparable in some instances to the collapse of cholera.
There is a low type of fever. The pulse is feeble and infrequent. The
skin, especially of the extremities, is cold and blue. The eye is
glassy, the countenance haggard. The pain, as a rule, is not severe,
sensation being benumbed. The disease is often accompanied by an
irregular erythematous cutaneous {396} eruption. The secretions and
excretions escape by the mouth and nose, and they are extremely fetid.
There is indeed a peculiar odor, which once encountered can scarcely be
mistaken. If the lungs become affected there will be copious
hæmoptysis. In some cases the tendency to hemorrhage is general, blood
oozing or gushing simultaneously from lungs, bowels, nose, and mouth,
and sometimes extravasating beneath the skin. Sphacelus ultimately
takes place at the points of ecchymosis. Diarrhoea, abundant and fetid,
due to invasion of the alimentary tract, often sets in before the
close, and may be regarded as a sure precursor of death. Death usually
takes place from syncope, intelligence often remaining unaffected to
the last. When these cases recover a horrible amount of deformity often
remains to mark the ravages of the disease. During cicatrization the
positions of contiguous parts become very much altered. The palate may
become adherent by its sides, and by more or less of its posterior
surface, to the pharynx, sometimes resulting in complete occlusion of
the nasal portion of the pharynx.
The constitutional symptoms of erysipelas of the pharynx are those that
attend the usual manifestations of external erysipelas, the febrile
phenomena, epigastric pain, nausea, and so on, being increased in
severity. There will be great pain and difficulty of deglutition. If
there be serious oedema, symptoms of suffocation will occur. Laryngitis
will be indicated by pain referred to the larynx. The duration of the
disease varies from forty-eight hours to a week, rarely longer. Death
may occur within two or three days from oedema of the larynx or from
other causes frequently indiscernible. Resolution usually takes place
in those cases which recover. Occasionally abscess occurs.
DIAGNOSIS.--The diagnosis rests upon the conditions already described
under the heads of Pathology and Symptomatology. Under ordinary
circumstances it presents no difficulty, but during the prevalence of
epidemics of scarlatina or diphtheria even the mildest sore throat
demands careful attention and frequent inspection until the exclusion
of the graver maladies may be positively determined. The greatest
difficulty will present in cases of common membranous sore throat, for
it is sometimes impossible to make the differentiation from diphtheria,
especially as the vesicular stage is rarely seen. Sometimes, it is
said, it is possible to detect one or more of the small ulcers left by
the rupture of the vesicles; sometimes small isolated spots of false
membrane will by their transparency indicate recent formation, and by
their circular shape the previous existence of a vesicle (Peter, cited
by Mackenzie). The coexistence of cutaneous herpes is corroborative of
the diagnosis, but by no means an infallible sign. It must not be
forgotten in this connection that membranous sore throat may predispose
to an attack of diphtheria. In gangrenous sore throat the grayish-black
patches may be mistaken for the pseudo-membranes of diphtheria, but
their color is dark from the outset, while in diphtheria they become
dark only as the disease progresses. They always represent actual death
of the tissues, which is not an essential lesion of diphtheria.
Swelling of the cervical glands is unusual. Finally, the characteristic
odor of gangrene is almost unmistakable.
PROGNOSIS.--The prognosis is favorable in catarrhal pharyngitis and in
the milder forms of the phlegmonous, non-specific, ulcerative, and
{397} common membranous varieties. It is unfavorable in intense
suppurative pharyngitis, though cases often get well. In gangrenous
pharyngitis the prognosis is extremely grave, but recovery is not
impossible. In traumatic pharyngitis the prognosis will of course
depend upon the nature and extent of the injury, being not unfavorable
if this be confined to the pharynx, though even in limited cases there
may be stenosis or other ill results from cicatrization. Erysipelatous
pharyngitis is of grave prognosis when the result of extension of the
disease from the face, but recovery is frequent when the pharyngeal
disease is primary.
TREATMENT.--The treatment of superficial pharyngitis is very simple.
Unless the case be so light that no special medicinal treatment seems
advisable, the patient should be confined to a bed or lounge to secure
rest, a light coverlid being thrown over the body to equalize the heat
of the surface. If a meal has recently been taken, a mild emetic is
often of service to empty the stomach and save the labors of digestion.
A gentle laxative or, if the patient be of costive habit, a saline
purge is indicated to facilitate the passage of matters already in the
intestinal canal. In cases of actual constipation a drastic cathartic
may be required. If there be considerable pain a small dose of morphine
may be advantageously combined with the aperient. If frequent pulse or
high temperature exist, especially in severe cases, tincture of
aconite, in doses of one or two drops every hour or two hours at first,
will be useful. As soon as any marked effect has been produced the
aconite may be discontinued or the intervals between administrations
lengthened. Locally, the free use of demulcent drinks, and of pellets
of ice when cold is agreeable, will relieve the pain in the throat and
sometimes repress excessive secretion. Cold compresses to the neck
anteriorly are often soothing, and sponging the entire surface of the
body with tepid water, acidulated or alcoholized, will allay the
intense heat of the skin. The diet should be light and nutritious. Very
often the emetic, rest, and regulation of diet will constitute the
entire treatment required.
When the local distress is very great, astringent lozenges (catechu,
krameria) may be allowed to dissolve in the mouth, or sprays of weak
solutions of alum or of carbolic acid may be propelled upon the mucous
membrane. Tannin, potassium chlorate, and cupric sulphate are often
used for this purpose. When the uvula is elongated or oedematous it is
often a constant source of irritation and discomfort. Scarification to
give vent to pent-up blood or puncture to allow the escape of effused
serum will afford prompt relief. Excision is never necessary.
In phlegmonous pharyngitis the treatment will necessarily be more
active. Here an early emetic is of great service. A saline laxative may
be administered every three or four hours for a day or two, each dose
containing a drop or two of the tincture of aconite, with the addition
of morphine if indicated by pain. Drop-doses of aconite at more
frequent intervals sometimes serve a better purpose. Inhalation of
steam, or of steam from water impregnated with hops, chamomile-flowers,
paregoric, compound tincture of benzoin, juice of conium, or the
aqueous extract of opium, belladonna, or conium, will afford great
relief, as will the frequent projection of sprays of warm water, simple
or slightly aromatized with cologne-water or with toilet vinegar. Warm
and moist applications externally are often very soothing. Gargling
entails too much pain to be of {398} service, but medicated sprays may
be used of aqueous solutions (twenty grains to the ounce) of tannin,
alum, zinc sulphate, or cupric sulphate, care being taken to guard
against the swallowing of any of these drugs. Powders of alum, tannin,
krameria, etc., diluted with liquorice, acacia, bismuth, lycopodium,
and the like, may be blown upon the parts, and are often efficient.
Sodium bicarbonate frequently affords relief. The topical application
of silver nitrate is rarely practicable and generally unnecessary.
When the inflammatory process is of a higher grade and not likely to
yield to purely medicinal treatment, leeching or venesection may be
employed, but should not be resorted to without urgent reason. The
recognition of abscess is an indication for its immediate discharge by
incision or aspiration. In suppurative cases quinia and iron should be
given in large doses. The general treatment is like that of simple sore
throat. When liquid food cannot be swallowed, nourishment by enema is
requisite. Efforts at deglutition should be spared as much as possible,
and with this view medicines which can be administered by inhalation,
by enema, or by hypodermatic injection are to be preferred.
In pharyngeal sore throat, whether catarrhal or phlegmonous, depending
on rheumatic or gouty diathesis, salicylic acid or the salicylates will
prove useful, either alone or in conjunction with other measures.
The treatment of ulcerative pharyngitis is practically the same as that
recommended for phlegmonous pharyngitis. Antiseptic gargles may be used
locally, but as a rule the pain is so great that inhalations of
soothing vapors, as before recommended, will answer a better purpose.
When the process is very acute fragments of ice will be most useful.
Ice to the head will afford relief to pain. A little good wine, with
quinia and iron, comprises the medicinal measure requisite.
Gangrenous pharyngitis calls for the most active and supporting
treatment. Eggs, milk, cream, nutritious soups (up to the limits of the
patient's capacity for swallowing, and by enema when necessary),
quinia, tincture of the chloride of iron, and alcohol in large doses,
are indicated. Local treatment is of high importance. Agents to destroy
diseased tissue promptly and prevent the extension of the gangrenous
process, such as bromine, strong nitric or hydrochloric acid, acid
solution of mercuric nitrate, or caustic potassa, are to be thoroughly
applied, in the hope of exposing a healthy surface beneath which will
heal by granulation. When this treatment is unsuccessful or too
hazardous, as in cases where the blood-vessels are probably involved,
we can only palliate the symptoms by applying weak solutions of acids
and astringents, to which opium may be added, relying on constitutional
measures for restraining the destructive process. Washes and sprays of
potassium chlorate, eucalyptol, thymol, hydrogen peroxide, etc., or the
agents employed in common sore throat, are often agreeable to the
patient, and may be useful in restraining fetor, but they have no
direct therapeutic influence on the progress of the disease. If the
ulceration is extending into the vicinity of the great vessels of the
neck, measures for compression should be at hand, in the use of which
the nurse should be instructed, and preparations be made to facilitate
ligation of the carotid artery in an emergency. Tracheotomy may be
necessitated by oedema of the larynx. The deformities resulting from
gangrenous sore throat in cases that recover usually require surgical
treatment.