due to contact of caustic or corrosive substances, an attempt may be
made to neutralize the effects by a chemical antidote, but the
physician is usually summoned too late to accomplish much in this
manner. Morphine should be given in full doses, hypodermatically.
Insufflations of morphine in powder, soothing inhalations, fragments of
ice in the mouth, cold compresses, and, where possible, oleaginous
drinks, are indicated to relieve topical distress. Rectal alimentation
should be resorted to where the difficulties of deglutition are at all
great. If symptoms of suffocation occur, tracheotomy must be performed.
The results of traumatic pharyngitis require treatment according to
their special indications.
Erysipelatous pharyngitis is to be treated by the administration, by
enema if necessary, of large doses of quinia, tincture of the chloride
of iron, brandy, and diffusible stimulants. Alimentation is to be kept
up by mouth or rectum, as may be necessary, with as much food as can be
given containing the most nutrition in the smallest bulk possible.
Locally, a strong solution of silver nitrate (sixty grains to the
ounce) should be so applied as to cover a margin of unaffected
structures. Sedative inhalations are of service. Extension to the
larynx demands scarification or tracheotomy.
When the diagnosis of common membranous sore throat can be made out
with certainty, there is nothing calling for special treatment, but the
treatment pursued in ordinary sore throat may be generally followed
with advantage. When fetor exists, as during the detachment of patches
of exudation, antiseptic and detergent sprays may be employed.
Solutions of borax, boric acid, carbolic acid, potassium chlorate,
potassium permanganate, etc. are appropriate. In some individuals,
especially strumous and tuberculous subjects, there is a constitutional
proclivity to chronicity or to the recurrence of the peculiar
manifestations. More active measures will be required in these cases.
Locally, frequent application of the dilute acids (_i.e._ every day or
two) affords the most satisfactory results. Internally, iron and
cinchona preparations should be administered. Opium in small doses has
a special application--not as a narcotic, but as a gentle stimulant or
nervous tonic. Nux vomica or arsenic may be employed for a similar
purpose. The diet should be highly nutritious and easily assimilable.
Unnecessary exposure should be avoided, and supporting measures
generally, hygienic, as well as medicinal, should be persisted in.
Membranous pharyngitis sometimes exhibits a tendency to phagedæna. The
treatment for gangrenous sore throat is then indicated. It may invite
an attack of diphtheria or the diagnosis may be in doubt. In that case
the prudent course is to treat it as diphtheria, but to avoid the
recommendation for diphtheria of some indifferent remedy, during the
exhibition of which a case of membranous sore throat has recovered.
When extension to the larynx occurs threatening suffocation,
tracheotomy to avert death should be performed, as in croup or
diphtheria.
The sore throats of the exanthemata, of typhoid fever, etc., are to be
treated on the general principles applicable to catarrhal or
phlegmonous pharyngitis. Oedema or tumefaction, as in malignant
scarlatina, of a sufficient extent to obstruct respiration, is to be
relieved by scarification, and when this is inefficient resort must be
had to tracheotomy. The sore {400} throats caused by drugs are to be
treated first by removal of the cause, and afterward according to the
special indications.
Tuberculous Pharyngitis.
DEFINITION.--An acute ulcerative pharyngitis due to infiltration with
miliary and granular tubercle and the consequent destructive
metamorphosis.
SYNONYMS.--Acute tuberculous sore throat, Acute tuberculous
pharyngitis, Tuberculosis of the pharynx, Phthisis of the pharynx.
HISTORY.--Only of late years has tuberculosis of the pharynx been
distinctly recognized as a tuberculous disease. The tubercular sore
throat or pharyngitis described by Green of New York, and other authors
following him, is an affection of entirely different character, and not
tuberculosis at all. The chronic tuberculous sore throat of advanced
tuberculosis is likewise a different affection clinically, though of
the same histological character.
To the late Isambert[2] of Paris belongs the credit of definitively
recognizing the specificity of acute tuberculous sore throat or
pharyngitis, and to him likewise the credit of indicating its
differentiation from syphilitic sore throat, with which it had long
been confounded. To B. Fraenkel of Berlin[3] is likewise due the credit
of an accurate comprehension and elucidation of the clinical and
histological pathology of this disease.
[Footnote 2: _Annales des Maladies de l'Oreille, du Larynx, etc._, vol.
xi., 1875, p. 162; _Conférences cliniques sur les Maladies du Larynx et
des premières Voices_, Paris, 1877, p. 219.]
[Footnote 3: _Berlin. klin. Woch._, Nov., 1876; _London Med. Record_,
Jan. 15, Feb. 15, 1877.]
ETIOLOGY.--Acute tuberculous pharyngitis is quite a rare disease. Its
predisposing causes, in all probability, are identical with those of
acute tuberculosis. Its exciting cause, in some cases at least, is some
unusual exposure to cold and wet. It is not certain that the throat is
affected before the lungs; but if this be the case, it is certain that
the lungs become affected soon afterward. The disease occurs in young
children, Isambert having recorded a case at four and a half years of
age, but it is much more frequent in adolescents and young adults. It
is impossible, as yet, to assign the reason why the pharynx rather than
other structures undergoes tubercularization in these exceptional cases
of pharyngitis. Syphilis sometimes coexists in the adult certainly, and
it may be questioned whether hereditary taint may not be an important
factor in determining tuberculosis in a region so frequently ravaged by
syphilis.
PATHOLOGY AND MORBID ANATOMY.--The local disease is essentially an
ulcerative pharyngitis or pharyngo-laryngitis, as may be, extremely
rapid in its progress, and terminating fatally within a few weeks, or a
few months at farthest. The ulcerative process usually begins on the
palatine folds or else on the lateral wall of the pharynx, thence
extending to the palatine folds, soft palate, uvula, and hard palate in
one direction, and toward the posterior wall of the pharynx in the
other. The uvula sometimes becomes thickened into a club-shaped,
gelatinous-looking mass, somewhat characteristic. Previous to
ulceration the mucous membrane is subjected to abundant infiltration
with miliary and granular tubercle just beneath the epithelial layer.
Macroscopically, these infiltrated portions of {401} tissue present as
irregular chagrinated groups of patches, generally confluent, which
when abundant or prominent are liable to be confounded with syphilitic
patches. Just beneath the surface the collections of tubercle project
as little semi-transparent grayish nodules, in size and form recalling
the appearance of vermicelli-seeds or fish-eggs. They steadily increase
in volume and in number, lose their translucency, and finally undergo
disintegration into lenticular ulcers with caseous bottoms and
undermined hyperæmic edges. The ulcers extend steadily in periphery and
in depth, and coalesce by necrosis of intervening mucous membrane.
Polypoid excrescences springing from the beds of the ulcers have been
described (Fraenkel). Collateral tumefaction takes place in some
instances, due, it is stated (Isambert), to infiltration of the tissues
by a gelatinous material, possibly a mucoid degeneration of the
connective tissue. The usual tendency of the disease, however, is to
incite atrophic metamorphosis of the adjacent tissues not undergoing
actual tubercularization. In many instances extension to the upper
portion of the larynx takes place; in some, extension to the vault of
the pharynx. Extension to the oesophagus, as has been remarked by
Mackenzie, and to the posterior nasal outlets, has not been noticed.
Enlargement of the cervical lymphatic glands is quite common.
Microscopic examination of the tissues of the pharynx has revealed
profuse infiltration with round cells--most frequently in the mucous
membrane and submucous connective tissue only, occasionally in the
muscular fibres likewise. The muscles sometimes undergo the fatty
degeneration, and the mucous glands both fatty and colloid
degeneration.
SYMPTOMATOLOGY.--The chief and characteristic subjective symptom is
extreme pain in swallowing (odynphagia)--pain much more intense than in
other morbid processes in the same locality, and inexplicable by the
extent of the visible disease merely. This pain often extends toward
the ears. Cough, adynamic fever, rapid emaciation, and so on are
present, as in acute tuberculosis generally.
DIAGNOSIS.--It cannot be stated that the diagnosis is easy. The two
distinguishing characteristics are the exquisite pain in swallowing and
the absence of pus from the surface of the ulcers. The aspect of the
ulcers differs, furthermore, from that of syphilitic ulcers by the lack
of opalescence and of inflammatory areolæ. The gray nodules in the
affected mucous membrane are different from what is observed in any
other disease. These points, with the history of the attack, the family
history, and the probable evidence of tuberculosis in the lungs, will
usually serve to discriminate the disease from syphilis, for which it
is most likely to be mistaken. In cases of doubt ophthalmoscopic
examination of the choroid and iris may reveal tubercle. The bacillus
tuberculosis has been found in the detritus from the ulcers (Guttman,
Gurovitch). The fact must not be ignored that syphilitic and
tuberculous pharyngitis may exist together. Febrile symptoms, typhoidal
in type, in a case of supposed syphilitic sore throat will most likely
be indicative of tuberculosis.
PROGNOSIS.--The disease is rapidly fatal, apparently inevitably so. An
exceptional case has been recorded, however (Cadier[4]), living {402}
several years after the diagnosis had been made by Isambert and many
others.
[Footnote 4: _Annales des Maladies de l'Oreille, du Larynx, etc._,
July, 1883, p. 136.]
Death takes place by asthenia in from six weeks to six months;
occasionally within a fortnight from the apparent onset.
TREATMENT.--The little that can be accomplished in the way of treatment
is limited to improving the diet and hygienic surroundings, with the
administration of such constitutional remedial agents as are given in
acute tuberculosis, and palliative treatment of the local suffering.
For the latter purpose insufflations of iodoform and morphine are to be
recommended, two or three grains of the former with one-fourth to
one-half grain of the latter, once a day or oftener. Such insufflations
should be preceded by douches or sprays of sodium borate or
bicarbonate, to rid the parts of mucus and detritus. A drop or two of
carbolic acid, of eucalyptol, or of a solution of thymol may be
advantageously added for purposes of disinfection. Solution of hydrogen
peroxide (2 per cent. or weaker) is a very valuable agent for use in
spray or douche. It may be rendered more agreeable by the addition of a
few drops of some balsamic.
When swallowing is impracticable, nourishment by enema is indicated,
with forced feeding by means of a catheter passed through the larger of
the two nasal passages into the oesophagus.
Chronic Pharyngitis.
DEFINITION.--A chronic inflammation of the mucous membrane of the
pharynx, whether implicating the glandular structures or not, and
commonly associated with similar chronic inflammation of contiguous
structures.
SYNONYMS.--Chronic sore throat, Chronic angina.
Chronic pharyngitis presents in two varieties: 1, simple chronic
pharyngitis (chronic catarrhal pharyngitis, chronic catarrhal sore
throat), in which the disease does not affect, or affects but slightly,
the glandular structures of the mucous membrane; and 2, follicular
pharyngitis (granular pharyngitis, clergyman's sore throat), in which
groups of the follicular glands of the mucous membrane are enlarged,
and sometimes inflamed.
ETIOLOGY.--The predisposing causes of chronic catarrhal pharyngitis are
those enumerated under the head of the acute form of the affection, and
the exciting causes are repeated attacks of the acute malady.
The predisposing causes of chronic follicular pharyngitis are
overcrowding, and sedentary occupations; and the exciting causes are
chiefly improper use of the voice and exposure to local irritations,
mechanical and chemical, including too free use of condiments, tobacco,
and alcohol, gormandizing, and the alternations of hot food, cold
drinks, ices, and hot drinks at meals. It is not so often a direct
sequel of attacks of acute sore throat as a result of prolonged
catarrhal pharyngitis; and sometimes it appears to be chronic, so to
speak, from the outset.
Both forms of chronic pharyngitis are frequently associated with
chronic inflammations of the mucous membranes elsewhere, particularly
of the nasal passages and of the stomach, and, to a less extent, of the
genito-urinary apparatus; the entire train of phenomena, in some
instances, {403} being due to passive congestion dependent upon
impaired cardiac power. Similarly, it presents at times as one of the
accompaniments of exophthalmic goitre. It is often associated with
phthisis, and is sometimes found in phthisical subjects prior to the
detection of the pulmonary disease. It is sometimes coincident with
chronic cutaneous eruptions, and may depend on the same causes, whether
dietetic or nervous.
Uterine disturbances may give rise to chronic pharyngitis, probably by
reflex nervous influence, and so do other chronic and dispiriting
complaints. In like manner, depression of spirits and impairment of
bodily vigor from domestic, financial, and social chagrin provoke a
train of phenomena in which chronic pharyngitis may be a prominent
manifestation.
PATHOLOGY AND MORBID ANATOMY.--Simple chronic pharyngitis is a chronic
catarrhal inflammation of the mucous membrane and submucous connective
tissue of the pharynx, with irregular hyperplasia of all the
histological elements, chiefly affecting the epithelial layers and the
most superficial strata of the submucosa. The pharynx, the posterior
surface of the palate, and the pharyngo-palatine folds are the
structures most generally implicated, but the glosso-palatine folds,
the base of the tongue, and even the anterior surface of the palate,
are sometimes involved. At an advanced stage of the affection extension
may take place to the vault of the pharynx and the posterior nasal
outlets, and in occasional instances to the larynx.
The initial hyperæmia of diffuse congestion finally leads to permanent
dilatation of tracts of capillaries varying in area and mode of
distribution, sometimes recalling the territorial outlines upon a map.
The mucous membrane is bright red in color and irregularly thickened,
sometimes into prominent welts or folds. The palate is often relaxed.
Hypersecretion takes place over the entire diseased surface, and there
is considerable desquamation of turbid epithelium, which sometimes
accumulates in masses. Glands are dilated and hypertrophied here and
there, but not in every instance, or if so indiscernibly, at least, to
the naked eye.
In some cases enlarged follicles are very prominent in the
infra-tonsillar space, between the anterior and posterior palatine
folds, and along the lateral walls of the pharynx down toward the base
of the tongue. The circumvallate papillæ may also be enlarged, and the
fungiform papillæ are sometimes very prominent and deeply congested.
In the folliculous variety of the disease the hyperplasia affects
chiefly the mucous glands and follicles, isolated or in groups,
together with zones of connective tissue surrounding them and the
epithelial investment of the mucous membrane in their immediate
neighborhood. A number of small projections, from the size of pinheads
to that of peas, mostly somewhat hemispheroidal, sometimes ellipsoidal
or quite irregular in configuration, stud the pharynx irregularly. When
clustered they are more apt to occupy the lateral angles of the
pharynx. In this locality indeed the chains of glands and their
enveloping mucous membrane sometimes present in longitudinal ridges
which simulate additional or adventitious post-palatine folds. The
projections are usually opaque, deeper in color than the surrounding
congested mucous membrane, and velvety from loss of squamous
epithelium. Sometimes they are translucent, as if filled with colloid
material, probably retained and degenerated secretion. {404} Very often
their contents undergo caseous degeneration, and sometimes even
calcification--a variety designated tubercular by Green, Gibb, and
others, but far different histologically from true tuberculosis of the
pharyngeal glands, which does occur occasionally in phthisical
patients.
Delicate red lines of engorged capillaries usually surround the base of
these projections. There is great disposition to the accumulation of
viscid, discolored mucus on the surface of the mucous membrane. As the
disease progresses all the processes become more widely extended, until
finally nearly the entire pharyngeal and oral mucous membrane becomes
involved. The soft palate becomes relaxed and the uvula thickened and
elongated, sometimes to an extreme degree. Chronic folliculous
tonsillitis exists in many cases.
When either form of chronic pharyngitis continues for a long while
unchecked, there may result atrophy of the glandular structures and
epithelial elements generally, giving rise to pharyngitis sicca or
atrophic pharyngitis (so-called dry catarrh). There is then but scanty
secretion, and this dries rapidly upon the surface of the thin mucous
membrane, which becomes rough, inflexible, and glazed.
SYMPTOMATOLOGY.--Cough, expectoration, impairment of voice, dysphagia,
and uncomfortable sensations in the throat present in various degrees
according to the stage of the disease and the temperament of the
patient. Hemming and hawking to clear the throat often become habitual,
especially in cases associated with chronic internal rhinitis, being
provoked in many instances by secretory products which drop into the
pharynx or glide along its walls. It is sometimes important to
distinguish this habit from the cough of laryngeal or bronchial
irritation.
In cases associated with chronic gastritis the loss of appetite and
consequent emaciation accompanying the symptoms of pharyngitis
sometimes lead friends of the patient to a mistaken diagnosis of
consumption; and when, as is not infrequent, chronic bronchitis also
coexists, even the physician may be misled.
In many instances of chronic folliculous pharyngitis evidently of long
standing, and accidentally discovered at times to the surprise of the
patient, no history of the classical group of symptoms can be obtained.
DIAGNOSIS.--The diffuse congestion of the mucous membrane and the
absence of marked involvement of the follicles are, with the history of
the case, the main discriminative features in the diagnosis of chronic
catarrhal pharyngitis. The regular or irregular masses of tissue
projecting beyond the general surface of the mucous membrane are the
distinguishing characteristics of chronic folliculous pharyngitis. The
vascular network of dilated capillaries mapping the surface into
numerous irregular small areas of different sizes is not peculiar to
either variety.
PROGNOSIS.--The prognosis of chronic catarrhal pharyngitis is favorable
when no irremediable malady of body or mind exists. Much depends on the
practicability of improving the dietetic and hygienic environment of
the patient. The prognosis is likewise good in chronic folliculous
pharyngitis under favorable surroundings, so far as relief from
suffering is concerned; but the follicles, when long hypertrophied, so
rarely undergo absorption under any treatment that their destruction
becomes necessary--quite a different thing from their cure. The
enlarged follicles once destroyed, the collateral irritative
inflammation caused by {405} them usually subsides. Impairment of
voice, a result of the disease, may be remedied in young subjects, who
will learn to use the voice with the abdomen in distension; but much
improvement cannot be expected in old subjects and in those in whom the
disease has been produced by improper methods of declamation, which are
beyond correction.
TREATMENT.--In chronic catarrhal pharyngitis constitutional treatment
adapted to the diathetic condition is required in the first instance.
Alkaline laxatives are usually indicated by the irregularly coated
tongue and the tendency to costiveness. These may be advantageously
administered in half a pint of hot water one hour or so before meals,
with a view of washing the stomach free from accumulations of mucus,
epithelium, and retained products of digestion and decomposition, so
that its condition may be improved for the reception and digestion of
the ensuing meal. Topical medication of the throat is likewise
requisite. This should be of a soothing character. Mild astringents are
applicable, but strong astringents are often actually injurious. Silver
nitrate and cupric sulphate in stick or strong solution should not be
used; but sprays of dilute solutions (one or two grains to the ounce of
distilled water), twice or thrice a day, are often of service. Zinc
sulphate (five grains to the ounce) may be used in the same manner.
Zinc chloride (ten grains to the ounce), carefully applied to the
surface daily with a broad brush or soft cotton wad, is a useful
remedy. Tannin in ether sometimes answers admirably, a delicate film
being left for some time on the surface. Solutions of bismuth nitrate
or borate in glycerin applied locally often relieve uneasiness. A broad
flat brush is the best instrument for making these applications, placed
low in the pharynx so as to paint the entire posterior wall by a single
movement from below upward.
For home use, sprays, three or four times a day, of tar-water,
containing five or ten grains to the ounce, of sodium borate or
bicarbonate, or sodium, potassium, or ammonium chloride, or sodium,
potassium, or ammonium iodide, are soothing and efficacious, and much
superior to gargles. They are often preferred warm. Demulcent lozenges
(gelatin, acacia, althæa, glycyrrhiza) slowly dissolved in the mouth
often relieve topical discomfort.
Much more active treatment is required in chronic folliculous
pharyngitis. Judicious constitutional treatment is of great importance.
Topical medication is of equal importance. In recent cases of moderate
intensity the ordinary treatment for the catarrhal variety sometimes
suffices. In cases of long standing strong solutions of silver nitrate
(sixty to one hundred and twenty grains to the ounce), carefully
applied with the broad flat brush twice or thrice a week, are often of
great remedial effect. Iodine (one drachm to the ounce of glycerin),
alone or in combination with equal parts of carbolic acid, applied
daily, may be serviceable in cases unimproved by the silver nitrate.
Dilatation of the capillaries may sometimes be benefited by
applications of ergot (fluid extract) or ergotin (grs. x-xx to the
ounce). Enlarged follicles of long standing are rarely amenable to
astringent and alterant topical treatment. They require destruction.
The agent to be used is a matter of indifference as a rule, and,
according to the taste or resources of the practitioner, may be the
solid silver nitrate, caustic potash, London paste, zinc chloride,
{406} or the incandescent cautery, whether heated by fire, hot naphtha,
or electricity.
The sprays and lozenges already mentioned are useful in this variety of
pharyngitis also. They may be medicated with sedative ingredients
according to indications for the relief of pain and discomfort.