Part 10

As a sequel of catarrhal pharyngitis. Symptoms; as in catarrhal form, with more swelling and tenderness, glandular swelling, dyspnœa, and difficulty in swallowing; local induration followed by fluctuation and pointing. Complications; asphyxia, laryngeal œdema, purulent or inhalation pneumonia, pharyngeal fistula, palsy of vagus, secondary abscesses, septicæmia. Lesions, local, general. Treatment; General and local, fomentation—hot or cold and antiseptic. Embrocations. Lancing. Tracheotomy.

As distinguished from catarrhal pharyngitis this is inflammation of the submucous tissue and adjacent lymph glands, tending to abscess.

It is especially common in solipeds and rather rare in other classes of domestic animals. As a specific infectious disease it has its type in strangles (infectious adenitis), also in cattle in the complicated infection of purulent tubercle, but apart from such it is often the result of the penetration of the pus microbes from a catarrhal pharynx into the lymph plexuses and lymph glands. Traumatism may play an important part in causation as when vegetable barbs, awns, chaff or seeds, or strong hairs or bristles enter the open mouths of the mucous follicles, or the tonsillar cavities. Similarly trouble may arise from scratches by tough, fibrous fodder, from pricks by pointed or cutting instruments, by fractures of the hyoid, or by bruises by probangs, or tooth rasps. An overgrowth of the last molar, and a resulting wound and ulcer of the soft palate, and the presence of local deposits like those of glanders and actinomycosis, are other occasions of the entrance of the pus organisms. It will be recognized that this affection is not necessarily due to a difference in the infecting organism, but rather of the tissue involved, the microbes gaining the submucous tissues and expending their violence on these instead of confining their ravages to the surface layers of the mucosa. For this reason the deeper or phlegmonous affection may supervene on a catarrhal inflammation which may have already persisted for several days.

Symptoms. Beside the general phenomena of catarrhal pharyngitis, this form of the malady is characterized by a greater swelling and tenderness of the throat, extending from ear to ear, and from the trachea forward in the intermaxillary space; by nodular and painful swellings of the pharyngeal lymph glands, by the greater difficulty of deglutition, the muscular tissue being involved; by wheezing breathing amounting at times to violent roaring and threatened asphyxia. Perspiration on the throat, the ear, the side of the head or neck, of the fore arm, or of the dorsal region is not uncommon, and has been attributed to the compression of the vagus, or of the superior cervical ganglion of the sympathetic by the swelling. Fever usually runs higher than in simple catarrhal pharyngitis, which may be partly accounted for by the implication of the deeper and important structures but also in no small degree by the entrance into the circulation of the ptomaines and toxins, which in the catarrhal affection escape largely from the inflamed surface.

The resulting abscess is usually in or near a gland or group of lymph glands. The part passes through the usual succession of changes, of soft pitting swelling; firm, tense, painful condition in which the exuded lymph has coagulated; and softening and fluctuation which progresses from the centre toward the circumference. The abscess points variously according to its seat. If in the intermaxillary space it opens externally. If sub-parotidean or peripharyngeal it may burst inwardly into the pharynx or outwardly through the skin. If supra-pharyngeal (retro-pharyngeal), it may be so thickly encapsulated in unyielding walls that it may remain long indolent and inactive becoming a cold or chronic abscess. When an abscess opens into the pharynx, there is a sudden and copious flow of pus by the nose, and it may be by the mouth and a simultaneous subsidence of the inflammation.

Among the complications of the affection are asphyxia, œdema glottidis; abscess of the guttural pouch; rupture of an abscess into the larynx, and the descent of pus into the lungs; the entrance of saliva and alimentary matters into the lungs; gangrenous pneumonia; pharyngeal fistula; pressure on the vagus and paralysis of the pharynx or larynx; secondary abscesses; septicæmia.

Lesions. Besides the general inflammatory lesions some rather remarkable ones have been observed. Fractured hyoid, dissection of the mucous from the muscular coat, by aliments, for nearly the whole length of the œsophagus (Brückmüller), purulent infiltration of the supra-pharyngeal muscles (Wakefield), ulceration of the pharyngeal or guttural sac mucosa, or even gangrene, purulent effusion in the tonsils, around the hypoglossal nerve, the lingual branch of the fifth, or the vagus, embolic inflammations, suppurations or gangrene of the bronchia, and implication of the lung tissue and pleura. Catarrhal enteritis and fatty liver and kidney are common.

Treatment. Beside the general measures advised for catarrhal pharyngitis, this type demands especially measures to moderate the intensity of the suffering, and when abscess appears inevitable to hasten its maturation. The first demand is met by hot fomentations persistently applied to the throat. This may be done by spongio-piline, or simply by well washed wool or cotton bound upon the throat and wet at frequent intervals with water rather hotter than the hand can bear. The addition of a little carbolic acid will secure at once some local anæsthesia and a measure of antisepsis. In warm weather the substitution of cold water has been resorted to with apparently good effect. If adopted it should be frequently removed so as to keep up the constant action of cold and moisture. These have been especially recommended in dogs injured by a tight or ill-fitting collar.

When suppuration appears imminent as shown by the dense, hard, circumscribed phlegmon, stimulating embrocations may be used to hasten its progress. Camphorated spirit is suitable for carnivora and sheep. It may be combined with tincture of cantharides for horses. For cattle and swine, oil of turpentine may be added, the three being used in equal proportions. A liniment of ammonia and oil may be used more or less frequently and energetically according to the relative thickness and insensibility of the skin of the animal affected.

When matter has formed and fluctuates, it should be at once evacuated and the cavity treated by antiseptic dressings. In this way secondary abscesses, septic infections, molecular ulcerations and other injurious sequelæ may be largely obviated.

In case of threatened asphyxia the dernier resort of tracheotomy is always available, and this often acts very favorably in improving the æration of the blood, in restoring the flagging vital functions which depend on hæmatosis, and in removing the friction and irritation consequent on the passage of air through the narrowed and tender passages.

SUPRA-PHARYNGEAL (RETRO-PHARYNGEAL) ABSCESS.

A sequel of phlegmonous pharyngitis. Symptoms; masked by its depth; pharyngeal wheezing or roaring with little local swelling; difficult swallowing; resisting tissues tend to chronicity. Results; pharyngeal fistula, burrowing along œsophagus, rupture into chest or blood-vessels, lymphadenitis, compression of vagus, or jugulars, permanent infected cavity with small orifice. Diagnosis from pus in guttural pouches. Treatment; external opening; antisepsis.

This is a natural result of phlegmonous pharyngitis, but it is possessed of so great importance alike in its chronicity and its results that it seems to deserve a special article. Like its initial morbid condition it is especially common in the soliped, and like that may be traceable to strangles, influenza, and local traumatism.

The symptoms are at first those of phlegmonous pharyngitis, and, if the local swelling, induration and tenderness are less marked than in other cases, it is due to the location of the inflammatory lesion deeply between the pharynx and the atlas and occiput. Indeed the moderate aspect of the external swelling, conjoined with the noisy wheezing or violent roaring, may be taken as important diagnostic indications. The supra-pharyngeal region is so closely confined on its lateral aspects, by the union of the fascia of the sternomaxillaris and mastoido-humeral muscles, that the swelling is confined in the early stages just as the pus is later. As this resistant fascia prevents any relief by lateral expansion, the engorged tissues press downward on the softer and less resistant upper wall of the pharynx and seriously impair both respiration and deglutition. Similarly when pus has formed, these lateral fibrous barriers, reënforced by organized lymph, stand in the way of the advance of the pus toward the skin, and lead it to dissect its way downward toward the pharynx. Even here the thickening of the tissues by the organized products of the lymph will often interpose a serious bar, and the pus remains pent up indefinitely, a source of wheezing, roaring and impaired deglutition, and a constant threat of secondary abscess or septic infection. Even the dense fibroid tissues may soften and degenerate and the pus may make its way spontaneously to the pharynx, or less frequently through the skin of the parotid, or intermaxillary region, or into the œsophagus or larynx. A fistula of the pharynx opening externally and allowing the escape of alimentary matters has been often noticed. These are especially liable to follow puncture of the abscess.

Among the less common sequelæ are fistula of the œsophagus; purulent pneumonia in connection with the purulent dissection of the œsophagean walls and rupture into the chest (Fichet, Schneider); ulceration of the blood vessels in the cow (Jonge); adenitis and lymphangitis of the neck, and the thoracic glands, followed by pericarditis and pleurisy (Cadeac); multiple embolic abscesses of internal organs (Dieckerhoff); compression and degeneration of the vagus nerve, with consequent respiratory and digestive troubles (Baudon); and compression and obstruction of the jugulars with passive congestion of the brain and vertigo. (Delamotte, Debrade). Even when the abscess opens into the pharynx the orifice is usually small, the pus escapes imperfectly, and food materials enter and the fistula may thus persist for a length of time. The same imperfect discharge is liable to take place with an external orifice and the pent up pus becomes inspissated, caseated and even calcified.

Diagnosis. Supra-pharyngeal abscess is to be distinguished from pus in the guttural pouches, by the lack of coincidence of the discharge with the dependence of the head in grazing, eating roots or drinking from a bucket; by the absence of the intermission when the head is elevated; and by the fact that the discharge is less frequently limited to the one nostril. The hearing too is less likely to be affected.

Treatment. As soon as the presence of pus can be recognized it should be evacuated. This is often attempted through the roof of the pharynx, but with such an opening there is always danger from the entrance and decomposition of alimentary matters. If fluctuation can be felt externally, it is better to be opened through the skin. The integument may be incised with a lancet, and the tissues further penetrated by manipulations with the finger nail, a grooved sound or the point of closed scissors. In this way the vessels and nerves are pushed aside and the dangers of hemorrhage, fistula and paralysis avoided. The cavity must be irrigated with an antiseptic solution (carbolic acid 3:100; or acetate of aluminum 1:20).

PSEUDOMEMBRANOUS (CROUPOUS) PHARYNGITIS.

False membranes not due to a common microbian cause. Accessory causes in solipeds; caustics, smoke infection. Lesions: Congestion, necrosis; croupous exudate, extending to patches on bowels and bronchia; kidney infarctions; blood altered. Symptoms: fever, dyspnœa, mucous rattle in throat, swelling, painful, difficult deglutition, yellow or cyanotic mucosæ, pinched face, weakness, prostration. Duration. Diagnosis. Treatment, as for catarrhal pharyngitis with antiseptics by inhalation and electuary. Iron.

Pharyngites attended by the formation of false membranes are met with in all the domestic animals and may be grouped together as a special class. The collection of these in one group, however, must not be taken to imply that all of these, as met with in the different animals have the same pathology, and are due to one invariable cause. Above all it must not be inferred that they are identical with the malignant diphtheria of the human being. The bacillus diphtheriæ hominis isolated by Klebs in 1883, and proved pathogenic by Löffler in 1884, has not been successfully inoculated upon any of the larger domestic animals, and has not been found in any of the casual pseudomembranous pharyngitis of these animals. The common feature of the group is to be found in the formation of the false membrane, and the fact that a given disease is placed in the group must not be held to apply to any special character, of microbian origin, nor communicability by infection.

PSEUDOMEMBRANOUS PHARYNGITIS IN SOLIPEDS.

Cases of pharnygitis with false membranes have been seen in horses by Delafond, Targue, Rey, Bouley, Riss, Sonin, Robertson, Dieckerhoff and Schneidemühl.

They have been attributed to various causes, as caustic alkalies and acids, the smoke of a burning building (Bouley, Rey, Riss), to an infection which operated on dogs and horses (Robertson), to bacteria and other irritants.

Lesions. The mucous membrane of the mouth, pharynx and even the nares presents active inflammation with branching redness, petechiæ, circumscribed foci of necroses, and false membranes of a grayish, yellowish, reddish, greenish or blackish color. These are formed of a pellicle consisting mainly of fibrine and epithelium, pus globules and numerous cocci, and ovoid bacteria. The false membranes have been found on other parts of the intestinal canal (colon, cæcum); and broncho-pneumonia and pulmonary dropsy have been concomitants. The effect of the toxic products is seen in hæmorrhagic inflammation and infarctions of the kidneys, and in a black color of the somewhat diffluent blood.

Symptoms. Besides the usual phenomena of pharyngitis, there is intense hyperthermia (105°–106°), hurried breathing threatening suffocation, painful cough roused by the slightest pressure on the swollen throat and often causing the discharge from the nose of shreds of false membrane. Auscultation of the pharynx gives a loud gurgling sound. Deglutition is very difficult and painful, liquids and even solids being rejected through the nose. The face is pinched and anxious and the mouth is often held open and the tongue pendant. Weakness and prostration are marked symptoms from the first, and the walk may be unsteady and swaying. The visible mucous membranes are congested and usually have a more or less deep tinge of yellow. The disease makes rapid progress and may prove fatal under six days. When it takes a favorable turn, recovery and convalescence may be equally prompt.

Unless the expectoration of false membrane is detected, such cases are difficult of diagnosis, though a fair inference may be deduced from the extreme severity of the symptoms, and the unusual degree of prostration which is present. When a pharyngeal speculum, passing through the nose, can be availed of, it may become possible to reach a more definite conclusion.

Treatment. Beside the measures advised for catarrhal pharyngitis (poultice, counter-irritants, laxatives, antithermics, alkalies, etc.), the main reliance must be placed on antiseptics. Persistent inhalations of warm water vapor with carbolic acid, creolin, tar, lysol, camphor or sulphurous acid are in order: also a mixture of one or other of these agents or of boric acid, bisulphite of soda, or salicylic acid in honey or molasses to be frequently smeared on the teeth. One of the best agents is the saturated solution of chlorate of potash in tincture of muriate of iron, of which a drachm may be added to three ounces of water and given every hour or two. Calomel may be injected through the nose during inspiration, by means of an insufflator, care being taken not to exceed the physiological dose.