Sore throat; its nature, varieties, and treatment, including the connection between affections of the throat and other diseases
James, Prosser, 1836-1918
*S^Sjy?" sw*wfsvx*fc<w! : "I givtihefe Baoh for the founding of cl College intkizColonf'' Gift of Dr. D. Bryson Delavan 1924 TRANSFERRED TO YALE MEDICAL LIBRARY <\b Plate 1 6. SORE THROAT, ITS NATURE, VARIETIES, AND TREATMENT ; INCLUDING THE CONNECTION BETWEEN AFFECTIONS OF THB THROAT AND OTHER DISEASES. BY PROSSER JAMES, M.D., M.R.C.R, LECTURER ON MATERIA MEDICA AND THERAPEUTICS AT THE LONDON HOSPITAL; PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THE THROAT; LATE PHYSICIAN TO THE NORTH LONDON CONSUMPTION HOSPITAL. THIRD EDITION, ILLUSTRATED WITH COLOURED PLATES. LONDON : J. 6* A. CHURCHILL, NEW BURLINGTON STREET. 1878. ^ PREFACE This little work originally appeared at the close of i860, and, in accordance with publishing custom, bore on its title page the date of the approaching year. It was the first, and, for about three years, continued to be the only English book on the Laryngoscope — an instrument, the value of which was recognised throughout. At the end of 1865 an illustrated edition was issued, in which five lithographic plates exhibited as many methods of employing the laryngoscope. These plates were copied from photographs, with which it was originally intended to illustrate the work; but the photo-printing was attended with so many delays, that while passing the previous winter on the Continent, I had them transferred to stone by a foreign process. Those lithographic illustrations have served the purpose for which they were first designed, and, therefore, are not now reproduced. Instead of them I have added to this edition two much more costly coloured plates, on which are depicted twelve examples of laryngeal diseases, drawn and painted from life by the aid of the laryngoscope. They are selected from cases occurring in my own practice, and some of them are of special interest, not only as illustra- IV PREFACE. tions of diseases which can only be certainly detected and efficiently treated by the aid of the laryngoscope, but as additional demonstrations of the accuracy of my former observations, respecting cases of recovery from morbid conditions usually considered incurable. In some " Clinical Illustrations of Diseases of the Throat and Lungs," contributed to The Medical Press in 1872, I recorded two examples of recovery from ad- vanced laryngeal phthisis, having previously brought some before the British Medical Association. A picture of one of these appears in my " Lessons on Laryngoscopy and Rhinoscopy," and another will be found in the present volume. These and other satisfactory instances of recovery from advanced consumption, impel me to repeat my asser- tion that neither laryngeal nor pulmonary phthisis should be abandoned as hopeless. The delay in the appearance of this edition has been quite unavoidable. Seven years since, in compliance with the wishes of pupils and friends, I expressed a determina- tion to revise the book. A little later an eminent foreign professor favoured me with a visit, during which he pre- ferred a similar request, urging that for several years he had used it as the text-book in his class. Stimulated by this, I readily undertook to set about the revision, but a series of acute rheumatic attacks interposed to prevent the execution of my purpose. At length, on resuming practice after the rest enforced by a season of severe suffering, one of my first cares has been to redeem my promise by preparing a new edition. In doing so it has been a gratification to find how little I have had to retract from the teaching laid down so long ago. Some of the doctrines then thought novel have been widely adopted, the remedies I recommended are now regularly prescribed, those I discountenanced have been gradually abandoned, and the only statements I made PREFACE. V which provoked opposition have become generally ac- cepted. Considerable additions have, however, been made to the work, which is so far rewritten as to coincide with the further experience acquired in the years that have elapsed since the last edition, during which favourable opportu- nities for observation have been afforded me as physician to the Hospital for Diseases of the Throat, as well as other public charities, one of them a Hospital for Consumption. Still, I am by no means unconscious of the shortcomings of my work, though I venture to hope it will again be found useful to my professional brethren, and not alto- gether unworthy of the position their confidence has conferred upon me, and which it has always been my endeavour to deserve. No doubt the additions may be detected by their dif- ference in style, especially as in making them no circum- locution has been resorted to in order to avoid the use of the pronoun I. In extenuation of this I might plead that professorial labour seems naturally to produce a tendency to employ dogmatic modes of expression. But, indeed, I am ready to admit that, at this date, I feel entitled to make assertions, which twenty years ago it was natural to put in the more modest form of suggestions. Moreover, as the first English worker with the Laryngoscope, it seems to me as well thus to signify my acceptance of such responsibility as may attach to my teaching. PROSSER JAMES, M.D. 3 Dean Street, Park Lane. May, 1878. CONTENTS. CHAPTER I. NATURE AND VARIETIES OF SORE THROAT. PAGE The throat and the organs which enter into it : a passage for air and food : its parts, the soft palate, velum, uvula, pillars of fauces, arches, isthmus, tonsils, pharynx, larynx, trachea. — Mucous membrane, its construction and use. — Epithelium: its varieties.— Follicles and glands. — Secretion. — Congestion and inflammation of mucous membrane : its stages : its tendency to spread. — Catarrh — coryza, or rhinitis, influenza, angina, ton- sillitis, pharyngitis, laryngitis, tracheitis, bronchitis, &c. — Aphtha. — Thrush or millet. — Inflamed Sore Throat, — Acute. — Chronic. — Relaxed Sore Throat. — Consequences of inflammation : effusion, erosion, abscess, ulceration, &c. — Follicular Sore Throat. — Phlegmonous Sore Throat— Suppu- rative, parenchymatous, typhous. — Gangrenous Sore Throat. — Exudative Sore Throat — Nature of exudation — seen in various conditions. — Croup and Diphtheria — distinctions between. — Glands. — Cynanche parotidea. — Fungous Sore Throat.— Muguet and the oidium albicans. — Non-Inflamma- tory Aefections — Hyperemia, anaemia ; hyper- trophy, atrophy ; degeneration ; hyperesthesia, neu- ralgia, anaesthesia, paraesthesia ; paresis, paralysis, spasm ; external influences, pressure, wounds, injuries, entrance of foreign bodies, &c. — Specific Sore Throat — Tubercular, cancerous, syphilitic. — Exan- thematous Sore Throat. — Relations between the skin and mucous membrane— displayed in eruptive fevers — in vesicular diseases — in the haemorrhages — in pustular and other skin diseases, &c. ... ... I Vlll PREFACE. CHAPTER II. DIAGNOSIS OF SORE THROAT. PAGE Means of study. — The history.— General impression. — Ana- lysis of this in the several senses. — AUSCULTATION and Percussion. — Voice, cough, breathing. — Pal- pation.— Tenderness, hardness and softness, rough- ness and smoothness, &c. — Enlargements, change of form, new growths, &c. — Inspection. — Tongue de- pressors.— Mirrors. — Speculum. — Art OF LARYNGO- SCOPY.— Apparatus.— The image seen in the laryngo- scope. — Its several parts. — The changes seen in disease. — Changes of colour and form. — Alterations in movements.— Rhinoscopy.— Apparatus.— The image seen in the rhinoscope in health. — Changes in disease. — Anterior rhinoscopy. — CEsophagoscopy ... ... 42 CHAPTER III. TREATMENT OF SORE THROAT. General Therapeutics.— Bleeding.— Leeches.— Scarifi- tion. — Emetics. — Antimony.— Mercury.— Purgatives, &c. — Iodine and its compounds. — Chlorate of potass. — Chloride of sodium. — Nitrate of potass. — Guaiacum. Senega. — Aconite. — Throat Therapeutics.— Fo- mentations.—Inhalations. — Atomised sprays.— Fumi- gations. — Injections. — Sternutatories. — Gargles. — Nasal douches.— Pharyngeal douches. — Insufflations. —Lozenges.— Laryngoscopal Therapeutics.— Ap- plication to the larynx of liquids, solids, caustics. — Operations within the larynx.— Tracheotomy ... 69 PREFACE. IX CHAPTER IV. INFLAMED SORE THROAT. PAGE Catarrhal. — Phlegmonous. — Traumatic. — Erysipelatous. — Relaxed sore throat. —  Inflammation. — Hypertrophy. — Ulceration of follicles. — History. — Diagnosis. — Treatment ... ... ... 128 CHAPTER VII. APHTHOUS SORE THROAT. Its relations to stomatitis. — Aphtha, and other diseases of the mouth. — Stomacace. — Sloughing ulcer. — Gangrene of the mouth. — Noma ... ... ... ... 136 CHAPTER VIII. FUNGOUS SORE THROAT. Thrush. — Oidium albicans , in mouth and throat.— Attacks only squamous epithelium.— Treatment ... ... 141 X PREFACE. CHAPTER IX. INFLAMMATION WITH EXUDATION. PAGE The distinctions between croup and diphtheria. — Croup. — History. — Symptoms. — Varieties. — Laryngeal spasm and paralysis. — Treatment. — Antiphlogistics. — Emetics. — Counter-irritants. — Fomentations. — Cold. — — Tracheotomy. — Inhalations. — Topical applications. Hot vapour. — False croup and allied spasmodic affec- tions.— Diphtheria. — Character and symptoms. — Varieties. — Parasites. — Contagion. — Treatment. — Complications. — Sequelae ... ... ... ... 145 CHAPTER X. THE SOFT PALATE AND UVULA. Congestion. — Haemorrhage. — Anaemia. — Inflammation. — (Edema. — Ulceration. — Gangrene. — Atrophy. — Cica- trices.— Tumours. — Cancer. — Syphilis. — Nervous dis- eases.— Malformations. — The Uvula. — Inflammation. — (Edema. — Elongation and hypertrophy. — Uvula cough and consumption. — Ulceration. — Polypus. — Warts. — Paralysis and spasm ... ... ... 175 CHAPTER XL THE TONSILS. Inflammation. — Quinsy. — Ulceration. — Chronic inflamma- tion. — Lacunal inflammation. — Hypertrophy. — Atrophy. — Cysts. — Syphilis. — Cancer.— Sympathy BETWEEN THE OVARIES AND THE TONSILS ... 1 85 PREFACE. XI CHAPTER XII. THE PHARYNX. PAGE The membrane. — Pharyngitis, catarrhal and phlegmonous. — Abscess. — Chronic pharyngitis. — Follicular disease. — Ulceration. — Pharyngitis sicca. — Hypertrophy ... 203 CHAPTER XIII. THE LARYNX. Variations of colour. — Hyperaemia. — Congestion. — Anaemia. — Pigmentation. — Inflammation. — Acute catarrhal laryngitis. — (Edema. — Phlegmonous laryngitis. — Treat- ment of laryngitis. — Chronic inflammation. — Chronic laryngitis. — Varieties. — Consequences. — Treatment. — Perichondritis. — Growths in the larynx.— Benign. — Malignant. — Cancer. — Sarcoma. Extirpation of larynx. — Specific diseases. — Syphilis. — Glanders. — Lupus. — Leprosy. — Other lesions. — Wounds. — Injuries. — Foreign bodies ... 216 CHAPTER XIV. LARYNGEAL PHTHISIS. Relations to 'pulmonary consumption. — Course. — Laryngo- scopy appearances and general symptoms. — Not neces- sarily a fatal  Affections of motor nerves. — Forms of paralysis of vocal cords. — Laryngeal spasm. — Spasmodic cough. — Affec- tions of sensory nerves. — Hyperaesthesia. — Neuralgia. — Anaesthesia. — Paresthesia ... ... ... 255 CHAPTER XVI. THE TRACHEA AND BRONCHI. The tracheal image. — Congestion. — Inflammation and its consequences. — Stenosis — Causes and course. — Spasm. — Foreign bodies ... ... ... ... 267 CHAPTER XVII. THE EXANTHEMATA AND SORE THROAT. Small-pox. — Measles. — Scarlatina, the lesions in the throat and in ear.— Course. — Consequences. — Diag- nosis.— Treatment ... ... ... ... 274 CHAPTER XVIII. EXTERNAL SORE THROAT. Angina externa. — Enlarged glands. — Tumours of the neck. — Mumps. — Angina Ludovici. — Goitre or bronchocele. Exophthalmic goitre. — Thyroiditis. — Cysts and other tumours. — The thymus ... ... ... ... 285 SORE THROAT. CHAPTER I. NATURE AND VARIETIES OF SORE THROAT. THE word throat is used in several senses. Thus it serves first of all to designate the front of the neck, and this meaning is sometimes so far extended as to embrace the sides, and occasionally, though with less propriety, the whole circumference of this part of the body. With a little more precision the word is ap- plied to the windpipe and gullet, or one of them ; and again it is further restricted to the interior surface of either or both of those passages for air and food. It may be thought that these indefinite uses of the word are rather inaccurate; but classical authority may be cited in their favour, and they are firmly estab- lished in our language. The next meaning of the word throat is to discriminate those parts which lie beyond the mouth, but can be seen on looking through that cavity — the fauces, as we say technically — the B 2 SORE THROAT. "back of the throat," as our patients frequently phrase it. Since, on careful inspection, we can dis- cover parts of several organs, the whole of each of these may naturally be included in the term. In a secondary sense the English word throat also means a roadway, generally speaking, a narrow defile or gorge. The same latitude of meaning belongs to the Latin word fauces, which was used for a pass, or outlet, or narrow way. Corinthiis posita in angustiis atque in faucibus Grcecice. — Cic. But the primary meaning was that of the part of the body. Pliny said Swnminn gulcz fauces vocantur, extremum stomachics. As gula usually meant gullet, the pharynx might appear to be intended, but it is clear from other pas- sages that the word was not thus restricted. In fact, fauces corresponds very closely with our own word throat, which comes to us direct from the Saxon throte, and as it is found in several other of the Aryan languages, was probably derived from the Sanscrit tri and ut, meaning to pass through or go beyond. The Greek word pharynx (tjydpvyS), which we have adopted for a single organ, seems to have been used classically with almost equal latitude ; but for our secondary meaning of defile, or ravine, the kindred word (pdpayg was often employed, the two corresponding very closely with the Latin fauces, which, in fact, most likely came from the same root, <f>dp(D, cleave, cut, or divide, this verb being but a changed form of the Sanscrit phal, signifying a joint opening, or cleft. The throat is often described as the roadway from the mouth and nose to the stomach in one direction, and the lungs in the other. It would give a better ANATOMY OF THE THROAT. 3 idea, perhaps, to compare it to the junction of two curved roads which cross each other and then run a parallel course. One of these, the channel for food, goes from the mouth backwards into the throat, cross- ing the other at the summit of the larynx, where the epiglottis falls like a draw-bridge asf the food passes over into the pharynx; whence it is despatched along the gullet or oesophagus downwards to the stomach. The other road is for air, and may be said to start from the nose, taking its way along the posterior nares into the throat, where it bends rather abruptly forwards, and having crossed to the front of the food channel, continues its course downwards along the larynx, trachea, and bronchi, to the lungs. If further illustration were required we might com- pare the throat to a narrow defile through which both air and nutriment must find access to the body, where accordingly two roads coming from the exterior converge, and from which two other roads lead to the interior — to say nothing of smaller passages, such as that which leads to the ear, and thus brings that organ into intimate connection with the throat. From what has been stated it will be seen that the air has free access from the open mouth as well as through the nose. The respiratory passage is always open except during the act of swallowing, when, as we have seen, the epiglottis closes it below, so that nutri- ment can pass over. At this moment it is also neces- sary to shut off the upper part of the air-tube in order to prevent the aliments from entering the nose. This is accomplished by the soft palate, which here playing 4 SORE THROAT. the part of a swing-door or gate, closes the nares during deglutition, but immediately afterwards re- sumes its usual position, where, hanging like a loose curtain from the hard palate, and therefore appro- priately named velum pendulum palati, it separates the mouth from the throat more or less completely, according to the constantly varying degree to which it descends or is drawn up. The loose border of the velum is so shaped as to make it resemble a scolloped valance or looped-up cur- tain ; for this free edge in its course from one side to the other describes two arcs, separated from each other by a conical prolongation, which descending between the two is common to both, and is named the uvula. The two concave or retracted segments are called the arches of the fauces. From these the outer bounding folds are continued downwards — one on each side — as low as the floor of the mouth, so as to form a pair of columns or piers from which the arches may be said to spring, and which are named the pillars of the fauces. Thus the uvula appears as one imperfect division between the two arches which communicate below. When the velum is completely retracted, the central part is drawn up so much higher than the sides, that the two concave segments seem thrown into each other, so that wre have only a single arch spanning the distance from side to side, sup- ported on the two pillars, with the uvula looking like a mere ornament suspended from the keystone. Exa- mining the parts a little more closely, we see that there is a second pair of columns, one standing in front of the other ; they are distinguished as the ante- ORGANS OF THE THROAT. 5 rior and posterior pillars. At their summits both pairs converge, so that all four are lost in the base of the uvula ; but tracing them in the opposite direction, we observe that the distance between the anterior and posterior pillars increases as they descend, since the former are prolonged to the sides of the tongue, while the latter are directed backwards to the pharynx. Thus on each side there is enclosed a rather trian- gular space in which lies the tonsil — an oval body, on the surface of which several lacunae are visible. The constricted aperture between the mouth and throat, bounded by the parts just mentioned, is called by anatomists the isthmus of the fauces. In resorting to geography for a name, it would have been better to have borrowed the word straits ; for we have to do, not with a solid part, but with a channel, a mere empty space, bounded by the solid organs. This being so, it is obvious that a mere communication between two cavities can suffer no change, except as to its size and shape ; and even these are only altered indirectly, through changes in the boundaries. It is therefore with the organs which bound this channel — the shores of the straits (isthmus) — that we have to do in disease. Beyond the isthmus lies the cavity of the pharynx, of which the posterior wall, immediately in front of the vertebral column, faces the observer and bounds the view. How much of this wall can be seen, depends on the extent to which the velum is retracted and the tongue depressed. In some cases, inspection also re- veals the tip of the epiglottis, standing erect like a sen- tinel on guard at the opening into the larynx. But to b SORE THROAT. see this valve satisfactorily we must employ a mirror and suitable illumination. The skilful disposal of these enables us to look behind the velum, so as to examine its posterior surface and explore the pharyngeal cavity, including the roof or vault above, the passages into the nose, the ends of the Eustachian tubes leading to the ears, and in fact the entire surface of the walls of the pharynx, which is continuous below with the oeso- phagus. Posing the mirror so as to reflect the rays into the larynx, we may also illuminate the interior of the organ of voice, and watch the intensely interest- ing movements of its several parts, besides which, with a little dexterity, we may trace the trachea in its course, and sometimes see the bifurcation of the bronchial tubes. How all these ends are to be attained will be shown when we come to speak of Laryngoscopy and Rhinoscopy. If the reader will now be good enough to inspect some friend's throat, or his own by the aid of a mirror, he will have recalled to his mind a more vivid notion of the relations of the several parts we have men- tioned than the most careful detailed description could convey. Nothing more is necessary at this stage than to remind him, that the mucous membrane which covers • these parts is continuous, is, in fact, a portion of the great gastro-pulmonary tract, which, commencing at the lips, eyelids, and nostrils, passes back through the mouth, throat, alimentary canal, and air-passages, thus lining the inside of the body, just as the skin does the outside, the former being always moist, the latter comparatively dry. The continuity of these structures ought never to be lost sight of. MUCOUS MEMBRANE. J Their analogy is closer still ; in structure and function they are very similar, and indeed they appear to run into each other. A single glance at the lips suffices to show that it is not easy to tell where the external skin ends and the internal one begins. There is no distinct line of demarcation between the skin and mucous membrane ; they glide insensibly into each other ; in a word, they are continuous. In certain circumstances, when the conditions of the one get imposed upon the other, they become readily trans- formed into each other, and so go far to show that in essence they are but one, their difference depending on the conditions to which they are subjected. This is a beautiful instance of Nature's simplicity, and we may well admire her handiwork when we contemplate this exquisitely-fitting garment, woven without seam, adapted by a hundred variations to every office it has to fulfil, covering the body outside (skin), and lining it inside (mucous membrane), winding through every turn of the wondrous labyrinth, and enclosing in its folds the strange machinery of life. Reduced to its simplest form, mucous membrane may be described as consisting of a very fine lamina, mounted on a network of blood-vessels, and covered by epithelium. In the same rough manner it may be stated that the blood is brought to the part by the vessels, that some of its constituents ooze through, and, together with cast-off epithelium-scales, form the secretion. We must, however, be a little more definite. A mucous membrane consists of two distinct layers, the deeper corresponding with the true skin, cutis vera or corium^ and the superficial corresponding with 8 SORE THROAT. the scarf-skin, cuticle, or epidermis, and named epithe- lium. It should, however, be observed that this superficial layer is not merely protective, but dis- charges a more important function in relation to secretion. Beginning with the deepest layer — the fibro-vascular base — we find it composed of networks of blood-vessels and lymphatics supported and united by connective tissue, areolar and retiform. It is of various degrees of thickness, and arranged, sometimes in prominences, called papillae or villi ; at others in depressions, called crypts, follicles, or lacunae ; and, again, in involutions, called glands. The deepest layer of the corium is formed of bundles of non-striated muscular tissue running either longitudinally or circularly, and often in both these directions. This layer is sometimes, distinguished by the name muscularis mucosce, and lies immediately upon the areolar sub-mucous tissue to which mucous membranes are attached. The superficial boundary of the corium may mostly be made out as a distinct layer dividing it from the epithelium, and called the primary or basement mem- brane (inembrana propria) which is so delicate that it long defied all attempts to make out its structure, and was therefore called a simple, transparent, homo- geneous layer. But by treatment with nitrate of silver, it has been shown to consist of flattened epithelioid connective-tissue cells, more or less fused together by their edges. This basement membrane in some parts — e. g. the cavity of the tympanum and the nasal sinuses — is so fine, if indeed it exist, that it cannot be demonstrated. EPITHELIUM. 9 The epithelium is made up of nucleated cells arranged in one or more layers, adhering together by- some intercellular substance, which, as it exists in only minute quantity, cannot be demonstrated. From the variety which occurs in the shape of the cells, epithe- lium has received different names. Where the cells are simply spherical or globular-shaped bodies the epithelium is called spheroidal ; when they are flattened out into scales or plates, it is variously termed squamous, scaly, tesselated or pavement epi- thelium. Again, when the cells are lengthened out into a prismatic, or pyramidal form, and set upright on the surface, it is columnar or cylindrical epithelium. When the cells assume intermediate forms between those above mentioned, the fact is sometimes ex- pressed in the term transitional epithelium. Lastly, the cells may be furnished with minute hair-like fila- ments called cilia, which are in constant active move- ment in a definite direction, this movement continuing for some time after death. This variety, which is of great interest in relation to our subject, is termed cili- ated epithelium. Ciliated cells are usually of the columnar form, and their cilia are placed on the free bases. It is the epithelium which gives the smooth surface to mucous membrane, and to its cells belongs the more intricate part of the act of secretion. These cells, as they grow, appropriate to themselves their own proper nutriment. Having attained perfection, they exist for a short time, and then bursting or dis- solving, give themselves and their contents to form the secretion. Each individual cell thus goes through the stages of life — arrives at maturity and passes 10 i: THROAT. away — an exact picture of the economy of which it forms so small a portion. In the submucous tissue the blood-vessels divide into numerous branches. These penetrate the corium, and there form a network of capillaries in immediate contact with the basement membrane, advancing with it into the papilla?, and receding with it to surround the tubular or glandular recesses. Similarly, the lymphatics form networks which communicate with plexuses in the submucous tissue. The nerves of mucous membrane arc also freely distributed in the fibro-vascular layer into which it is comparatively easy to trace them, but they are also found to penetrate the basement membrane. In the palate they have even been traced between and among the epithelial cells, and the most recent researches seem to indicate that filaments penetrate the cell walls. Looking at mucous membrane as a secreting appa- ratus— had it simply covered the internal surface it would not have sufficed for the purposes of animal life, and consequently some contrivance was needed to augment its extent. That end is attained by making the surface irregular — sometimes this is done by protrusions, but much more frequently by recesses, as already mentioned. A simple ail de sac of mucous membrane forms a crypt, follicle, lacuna, or glandule. Such a blind pouch may be lengthened out and coiled up ; much more frequently it branches out or sub- divides in various ways. Thus glands— so far as we have here to do with them — may be defined as dispo- sitions of mucous membrane for the sake of providing a greater secreting surface. Their shape depends on FOLLICLES. GLANDS. SECRETION. II the connective tissue which supports the vessels and unites the branches. They are often enclosed in a fibrous envelope, and are always supplied with nerves and lymphatics. The same contrivance is adopted in other cases. The intestines are coiled on each other, and the capillaries wind and flex into a most amazing network, just as these elevations, depressions, and involutions pack into a small compass many thousand inches of the secreting membrane. The portion of the mucous membrane with which we are now concerned is studded with innumerable de- pressions, commonly called the follicles of the throat. In them secretion goes on actively ; possibly, too, its product may be somewhat, different from that of the plain surface. The tonsils may be ranked between these and more perfect glands. On their surface may be seen upwards of a dozen openings leading into recesses, from which in their turn other but smaller orifices lead into numerous follicles. These are lined by mucous membrane, and surrounding their walls are a number of closed capsules ; whether they discharge their contents by bursting is unde- cided. Very similar to these are a series of follicular recesses at the root of the tongue, forming a layer ex- tending from the papillae vallatse to the epiglottis, and from one tonsil to the other. The salivary glands are perfect secreting organs of their class, elaborating important fluids, and possessing ducts to convey them to their destination. The act of secretion is modified by many circum- stances to which living beings are subjected. From what has preceded, it will be anticipated that an 12 SORE THROAT. unusual flow of blood to a part will cause an extra amount of secretion, while a diminished supply of the vital fluid will give rise to an opposite effect. Yet the sequence is not so invariable that diminution or excess may always be thus easily accounted for. Other disturbing and counteracting agencies are often at work. The tone of the capillary system seems to have a wonderful effect, for in a relaxed state more fluid escapes than in health, giving rise to hyper- secretion or passive haemorrhage. An unusual quan- tity of the material secreted getting into the blood, has to be eliminated by an increased activity of the organ which usually secretes it. Again, the presiding nerves have considerable influence over the act, as pro /ed by stimulants to them augmenting the flow. Through the nervous system certain mental states find expression by an increased or decreased secre- tion. The effects of joy, grief, anxiety, or content- ment on the skin, kidneys, and bowels are familiar to all. In many instances emotion increases secretion, but sometimes a contrary effect is produced. There must be few who have not seen diarrhoea thus set up. It may in the same way be arrested. I have known the sudden death ofa relative completely arrest a dia- rhcea which had continued in spite of various reme- dies. The liability of the salivary glands to refuse to work from mental anxiety is probably the foundation of the Indian method of detecting a thief, in which the parties implicated are compelled to chew rice, and spit it out on a leaf. He who has not saliva enough to wet it is judged guilty. The preceding sketch of the anatomy and physi- CONGESTION AND INFLAMMATION. 1 3 ology of mucous membrane affords an advantageous standpoint for glancing at its pathology. CONGESTION AND INFLAMMATION OF THE MUCOUS MEMBRANE. In entering on the diseased state of the lining of the throat and air passages, the important part played by congestion and inflammation demands that these lesions occupy our attention first. Congestion is a word often used to imply a minor degree of inflam- mation. It is at other times, perhaps more properly, restricted to the state of hyperaemia or excess of blood in a part, producing increase of redness. If the hy- peraemia be arterial, it is termed active. If the hue be more venous, it is passive. As soon as perversion of secretion or other interference of function, and espe- cially increased cell development, occur, the congestion or hyperaemia has passed into inflammation. A com- mon cold or catarrh may serve for an example, and that kind called influenza is still more typical. The first impression frequently falls on the nose and eyes, very often it commences in the throat. Wherever it begins it displays a tendency to spread. The first in- dications that the membrane is inflamed arise from the preternatural condition in which it is placed. The afflux of blood is increased, and the nerves are dis- turbed ; tumidity, heat, and dryness, with impair- ment or loss of function, are thereby occasioned. Hence the prominent symptoms are obstruction of the nose, redness, a feeling of stuffiness, heat, itching, it may be even pain ; loss of smell, partial or entire, 14 SORE THROAT. &c. The redness, heat, and swelling depend on the congestion, just as in inflammation of other struc- tures. The pain is seldom intense, often only itching, as this tissue is not possessed of the same sensibility as others. Moreover, pressure from within is more easily yielded to than in tougher textures. We never observe that pain which charactererises parts highly congested and incapable of much distension, but we often meet with very great swelling. Then the itching or pain is often referred, not to the part irritated, but to its extremity, where the mem- brane joins the skin ; so itching of the nose is an everyday symptom of worms in the intestinal canal. This state — the dry stage — soon ends in a moist one, when the prominent phenomenon is increased secretion. The debilitated vessels suffer a great deal of fluid to escape, which departs more or less from the normal character of the secretion. We now have a running from the nose of a thin discharge, often so acrid that it excoriates the lip. After a while this becomes thicker, yellowish, or even greenish, and returns gradually to the healthy state. As a rule, these stages are to be observed in all inflammations of mucous membrane, which consist essentially of engorgement of the vessels, swelling of the tissues, abundant production of cells, and an increased flow of perverted secretion ; the variations which occur depend mostly on incidental circumstances, such as specific cause, constitution of the patient, severity or duration of the complaint, and, above all, on the position of the part attacked. Of such consequence is this last item in reference CATARRH AND INFLUENZA. 1 5 to the symptoms set up, the danger impending, and the treatment to be employed, that inflammation of mucous membrane receives different names accord- ing to the part attacked. In the lining of the nose it is coryza, or rhinitis or a cold in the head ; in the lining of the fauces it is sore throat, cynanche or angina (the Greek and Latin words, cynanche and angina being used in the same general sense as the English " sore throat") ; if it affects the pharynx only it is pharyngitis ; if the tonsils, tonsilitis, or cynanche tonsillaris ; further down the air-passages, laryngitis, tracheitis, and bronchitis successively. The frequent origin of the disease in cold, has given it the popular name of cold, and the scientific one of catarrh ; and inasmuch as simple congestion or inflammation, how- ever caused, presents the same phenomena, it is not uncommon to designate it as catarrhal, without reference to its cause. A " cold in the head " is the popular term for a coryza or rhinitis. A "slight cough" or a "stuffed chest" are terms often used when congestion of the trachea and larger bronchi exist. A more exclusively bronchial congestion is often called only " a cough," or " severe cough," or more properly bronchial catarrh. When the lesser bronchi are in- volved the term bronchitis is more frequently used. When the local disease is accompanied by fever, the case is often designated febrile catarrh or catarrhal fever, and by the public "a feverish cold" or "feverish cough." Since the great epidemics of influenza it has also become common to speak of catarrhal fever as influenza, and inaccurate as this may be, the word has obtained such a foothold in the 1 6 SORE THROAT. language that it is almost hopeless to attempt to dis- place it., and we are therefore frequently obliged to prefix the term epidemic to distinguish the influenza which should be known by the simple word. Thus we see how so many sore throats, coughs and colds, resolve themselves into congestion, or simple, often called catarrhal, inflammation of some part of the mucous membrane. The term catarrh is also ex- tended to all simple inflammation of mucous mem- brane, even that caused by mechanical injury ; thus entirely eliminating the idea of its causation by cold, or, as it was termed, catarrh. The tendency of this lesion to spread has already been alluded to. In influenza this is particularly observed. Com- mencing in the nose and eyes, it soon involves the throat, and even runs along the Eustachian tubes, giving rise there to distressing singing or noises in the ears or deafness. The soft palate and tonsils almost invariably suffer. Then it travels down the larynx, trachea, and bronchi, sometimes to their minutest ramifications. And although its chief force is thus expended on the respiratory tract, the diges- tive canal does not altogether escape. The pharynx is necessarily involved by its position in a disease so inclined to spread over the adjoining structure. From this it may spread along the continuous mem- brane of the oesophagus, and so find its way to the stomach, the disturbance of which is manifest in the symptoms to which it gives rise. Nevertheless, the violence of influenza is for the most part spent on the respiratory tract. When it commences in the throat, we may watch its extension in both directions, down- CATARRHAL INFLAMMATION. 1 7 wards to the lungs and upwards to the nose. Not- withstanding this tendency to spread, we often see inflammation confined to a small portion of mucous membrane. The throat is the highway to both the lungs and the stomach, its lining forms part of both the respiratory and the alimentary tract taken separately, and on this account is a frequent suf- ferer. It has been seen to be embraced by influenza, which for the most part exhibits a predilection for the respiratory portion, as do many other diseases, and it is equally obnoxious to affections which have a strong inclination to run along the alimentary canal, leaving the respiratory membrane free or nearly so. Of these aphtha is a familiar illustration. Usually commencing in and always attacking the mouth, thrush passes along the throat, the common highway to the lungs and stomach, choosing the oesophageal road, and by its not infrequent appearance at the other end it has given rise to the conjecture that it has travelled the whole length of the tube. Dissection shows, however, that its appearance at both termina- tions is not a proof of its extending throughout. The extremities are the most sensitive, they more readily take on diseased action than the intermediate portion, and seem to sympathise with each other. Hence we meet the disease in both these situations, where there is strong evidence that its extent is not so great as a careless observer might conjecture. In muguet the coating does not spread to the larynx, but it takes the road of the oesophagus, which tube has been seen completely filled with thrush deposit. It is not seen in the stomach. In those who suffer from this disease, C 1 8 SORE THROAT. infants, and persons dying of chronic disease, diarrhoea is commonly present, and some have thought it is due to this ; others think it only a symptom of the general derangement ; certainly any irritant will cause diarrhcea in weak patients, and many suffer from both symptoms. On the other hand, many infants with thrush have no diarrhcea. It is now time to consider inflammation of the mucous membrane confined to the throat. The patient complains of heat and soreness in the part, difficulty or pain in swallowing, and yet he cannot refrain from the attempt, for the unusual fulness imparts a sensa- tion of something to be got rid of by this process. The redness and swelling are very perceptible on looking into the fauces. The uvula is enlarged, its increase of size being most manifest by its elonga- tion, which may be so excessive as to tickle the base of the tongue, the epiglottis, or even to fall into the larynx. It will thus aggravate the desire to swallow, produce nausea, even vomiting, or give rise to a very annoying cough, or set up paroxysms of spasmodic cough or dyspnoea. The tonsils may be much swollen, their hot, hard, congested state being easily perceptible to the touch. When they are the chief sufferers, the attack is called cynanche tonsillaris. The pillars of the fauces are very prone to attack, and then deglutition is difficult and painful. The lining of the rest of the pharynx in the same way is con- stantly attacked, and the symptoms vary with the part most affected. Details must be deferred to the chapter on the pharynx. So too, when the larynx is inflamed, according as the changes affect the breathing INFLAMMATION. 1 9 or voice we have other symptoms, which will be referred to in the chapter on the larynx. When the moist stage -comes on, the secretion, which is not so abundant as in other parts, is hawked up with pain and difficulty, being rather thick and extremely tenacious. Difficult breathing will be present whenever the swelling or .accumulation of secretion impedes the passage of air. The above form of disease is often brought on by cold, and is that to which the term inflamed sore throat, or catarrhal angina, or cynanche, is most appli- cable. When it is severe, fever is set up, and even in subacute cases there is generally some constitutional disturbance. In connection with the exanthemata, very intense fever is present, and the inflammation extends to the deeper tissues. So when it puts on the worst form, typhoid symptoms supervene, and mortification may ensue, constituting malignant or putrid sore throat. In healthy constitutions catarrhal or inflamed sore throat rapidly resolves itself, or at most subsides into the chronic state. This, whether coming on gradually, or being the remnant of an acute attack, presents the same symptoms in a less degree, but is more obstinate. Congestion is no longer active ; soreness is not intense, often it is not complained of; swallowing may be easy, or only unpleasant ; a feeling of dryness or heat is present, and a continual hawking of tena- cious phlegm or a tickling cough harrasses the patient. The throat is no longer fiery red — often it is pale, but there is evidently a want of tone, the tonsils are perhaps large, the velum low down, the uvula a good deal elongated. The veins are sometimes seen of 20 SORE THROAT. abnormal size, coursing over the membrane, analagous to the condition called " blood-shot," in the conjunc- tiva. Such is the state called " relaxed sore throat." The condition of the parts will explain the symptoms ; thus, the enlarged tonsils and the swollen pillars are the cause of the obstruction to the food, the elongated uvula tickling the epiglottis, gives rise to the cough, the thick and tenacious secretion to the hawking, the combination of these to the desire to swailow, and so on. In other cases, more chronic still, instead of increased, we meet with permanently diminished secre- tion ; the membrane seems to be actually dryer than natural, sometimes glistening as if it had been varnished. In these cases there is general atrophy of the tissues. This has been called pharyngitis sicca. It might as well be termed dry sore throat. It is very obstinate, though not incurable. When the disease implicates the Eustachian tubes or tympanum, we have, on the one hand, deafness, on the other, ear-ache. So if the nasal membrane be implicated, obstruction of the nose is produced, or a coryza, according to the prevailing condition, while the intense headache or brow-ache so commonly seen in influenza, is perhaps produced by the extension of the inflammation to the frontal sinus. The consequences or terminations of inflammation in the throat do not differ from those of the same lesion elsewhere. Chronic induration or thickening is not uncommon in the velum and uvula, and is of great importance in the larynx. Effusion demands atten- tion, for infiltration of the uvula may cause an annoy- ance, the only difficulty of curing which consists in CONSEQUENCES OF INFLAMMATION. 21 ■discovering it ; while oedema of the glottis may rapidly suffocate the patient, or necessitate an immediate operation to save life. Abscess is mostly met with in the tonsils, constituting quinsy. Gangrene is to be dreaded in the severer forms, especially in connection with eruptive fevers. Ulceration is a common conse- quence when the constitution is originally unsound or has become contaminated. Thus in scrofulous, tuber- culous, and syphilitic patients it is most common. 