Part 63

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.

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 {407} 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.

{408} 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.

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DISEASES OF THE OESOPHAGUS.

BY J. SOLIS COHEN, M.D.

Oesophagitis.

DEFINITION.--Inflammation of the oesophagus.

SYNONYMS.--Inflammatory dysphagia, Inflammation of the gullet.

Oesophagitis may be acute or chronic. Either form may be idiopathic, deuteropathic, or traumatic.

Acute Oesophagitis.

DEFINITION.--Acute inflammation of the gullet.

SYNONYM.--Oesophagitis acuta.