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.