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.
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 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 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.
Membranous pharyngitis, or herpes of the pharynx, is one of the 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, 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.
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 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 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 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 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.
Traumatic pharyngitis must be treated on general principles. When 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 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 Isambert2 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 Berlin3 is likewise due the credit of an accurate comprehension and elucidation of the clinical and histological pathology of this disease.
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.
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 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 (Cadier4), living several years after the diagnosis had been made by Isambert and many others.
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, 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. 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 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, 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.
In cases resisting the plan of treatment suggested mercuric chloride may be successfully used, both internally (gr. 1/16 two or three times a day) and in spray, a drachm or less night and morning (one grain to four ounces). External counter-irritation by repeated blistering over the larynx and under the angles of the jaws is useful in some instances. During treatment the voice should be used as sparingly as practicable.
In chronic atrophic pharyngitis the treatment, constitutional and local, should be such as favors secretion from mucous membranes—internally, cubeb, pyrethrum, calamus, xanthoxylum, jaborandi, ammonium chloride; topically, sprays, four or more times a day, of hot water, glycerin and water, ammonium chloride. Patients sleeping with the mouth open should wear an apparatus, extemporized or made to order, to keep the lower jaw closed in sleep.
Syphilitic Pharyngitis.
DEFINITION.—A specific inflammation of the mucous membrane of the pharynx or of the mucous membrane and submucous tissues, the result of syphilis, and often associated with like disease in contiguous structures.
SYNONYMS.—Pharyngitis syphilitica, Pharyngitis specifica, Syphilitic sore throat, Syphilis of the pharynx.
ETIOLOGY.—Contamination by syphilitic virus is the sole cause, whether by direct inoculation or by systemic poisoning, hereditary or acquired. Direct inoculation proceeds from primary sores on the lips, tongue, cheek, and hard palate, themselves the result of actual contact with sores in other individuals. Initial sores have been seen upon the tonsils, palatine folds, pharynx, and even the epiglottis. Direct inoculation from secondary sores may be communicated by the tooth-brush, blow-pipe, pipe-stem, trumpet, mouth-piece of feeding-bottle, pap-boat, or similar article previously used by an infected individual. Uncleansed surgical instruments convey the disease in like manner.
PATHOLOGY AND MORBID ANATOMY.—Syphilitic pharyngitis—or, more strictly speaking, syphilitic sore throat—occurs in all varieties, primary, secondary, tertiary, and hereditary. Secondary manifestations are the most frequent, and primary sores the most infrequent. The primary sore is soft in some instances, and hard in others. Phagedænic ulceration may ensue. Secondary manifestations are usually bilateral, and often symmetric in configuration and distribution. They appear from a few weeks to a few months after infection, and are among the most frequent early manifestations of secondary syphilis. The inflammatory process begins in erythema, usually diffuse, often punctated, sometimes in patches. It extends from above downward more frequently than in the reverse direction, but may spread in any direction. The lesion commences upon the soft palate and tonsils more frequently than on the pharynx, but may commence in any portion of the oro-guttural cavity. Tumefaction ensues, with lividity of the surface. The epithelial cells become distended; the resulting opalescence, somewhat characteristic, eventually subsides into a central opacity, the true mucous patch or condyloma latum. Mucous patches vary in size from mere specks to large irregular surfaces, often the result of coalescences. They sometimes become red and granular and covered with purulent products. Microscopically (Cornil), they consist of thickened epithelium upon a base of proliferated lymphoid cells, which often infiltrate the deeper tissues extensively. They may disappear in the course of a few weeks by resolution and absorption. Sometimes suppuration occurs in small superficial abscesses which discharge upon the surface. Several abscesses discharging simultaneously in coalescence, an extensive ulcer may result, which, in repair, leaves a cicatricial trace of its site. Flat and circular bluish-white patches, due to thickening of epithelium, appear after the first year of constitutional syphilis, and may exist in association with the true mucous patch. They bleed readily on rough handling, but rarely undergo ulceration.
Tertiary manifestations may present within a few months after infection or not until many years. Gummatous infiltration of the connective tissue, diffused or circumscribed (syphiloma), follows diffuse or localized erythema, and then the gummata break down, discharge by ulceration, and leave deep-seated irregular ulcers with undermined edges and surrounded with inflammatory areolæ. These manifestations are much more frequent in the palate than in the pharynx, and the ulcerative process often destroys the uvula and large portions of the palate and palatine folds. When the pharynx and posterior surface of the palate are both ulcerated, cicatricial adhesions are sometimes inevitable, and thus serious stricture of the suprapalatine pharyngeal canal may ensue. The lesion may be quite limited in extent or may involve the entire pharynx. The ravages may become sufficiently extensive to involve the vertebra and the skull or to perforate the large blood-vessels. Cicatrization in the pharynx is vertical or stellate as the rule, and the peculiar pallid lustre of the cicatrices is quite characteristic of the syphilitic lesion. In many instances secondary and tertiary manifestations commingle. Ulceration is then more likely to extend superficially than in depth.
Hereditary manifestations pursue much the same course as tertiary manifestations. They usually occur before puberty, but are occasionally delayed until after maturity. Deferred tertiary and late hereditary manifestations sometimes present the characteristic ulceration of the commingled secondary and tertiary disease; and this form of ulceration is often incorrectly attributed to scrofulosis and to lupus.
SYMPTOMATOLOGY, COURSE, DURATION, COMPLICATIONS, AND SEQUELÆ.—The subjective symptoms of syphilitic pharyngitis are those of erythematous and ulcerative pharyngitis of like grade, except that there is very little pain. The course is chronic unless specific treatment be instituted, when prompt repair may be expected unless the general health has been much undermined. The duration is indefinite. The manifestations subside under treatment, and recur if it is not sufficiently prolonged. Complications occur with similar manifestations of syphilis in adjacent or contiguous or distant structures, as may be. The most frequent sequel in neglected cases is cicatricial stricture.
DIAGNOSIS.—Bilateral inflammation in symmetric distribution is very characteristic of syphilis. Irregular ulcers with undermined borders and surrounded by inflammatory areolæ are similarly characteristic. Acknowledged history of syphilis or the detection of syphilitic manifestations elsewhere serves to confirm the diagnosis. In cases of doubt a few days' treatment with specific remedies in large doses will almost invariably serve to clear up the diagnosis.
PROGNOSIS.—The prognosis as to life is good unless the ulcerations have become so extensive as to threaten perforation into blood-vessels or the patient has become greatly debilitated. The prognosis as to freedom from cicatricial adhesions and stricture is not good in the presence of lesions which have destroyed large territories of tissue, even under very careful management.
TREATMENT.—Specific medicines in positive doses constitute the most effectual treatment. Mercury is indicated in secondary lesions. Extensive ulcerative tertiary and hereditary lesions are peculiarly susceptible to large doses (30 to 90 or more grains daily) of potassium iodide, under the influence of which they often heal without any local applications whatever. As soon as a positive impression has been produced the dose may be diminished. The parts should be kept clean and comfortable by periodic douching with sprays of alkaline solutions, or, what is still more serviceable, with a ten-volume solution of hydrogen peroxide diluted with one or more parts of distilled water. The best local application to the edges of the pharyngeal syphilitic ulcers is the solid cupric sulphate. Chromic acid (1:8) is a serviceable local stimulant to indolent ulcers. Necrosed fragments of bone should be removed. Should any impediment to respiration take place during administration of the iodides, oedema of the larynx may be suspected, and should be looked for. Professional supervision is requisite for many months after the lesions have healed. Cicatricial sequelæ of stricture require surgical interference.