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.