Phlegmonous Pharyngitis.

Synonym.—Cynanche Maligna.

Definition.—A low grade of inflammation, involving the deeper tissues of the throat, attended by sepsis and ulceration.

Etiology.—The cause is not known, though all the symptoms point to poisoning of the blood, and no doubt it bears a close relation to the infectious material of kindred diseases. Depravation of the blood from any source, as well as poverty, with its attendant surroundings, predisposes to this lesion.

Symptoms.—Dr. Scudder gives such a plain, typical, and vivid picture of the symptoms that I will reproduce it here:

"For two or three days, sometimes for a week, it is noticed that the patient looks pallid, his skin waxy or pasty, and that there is a want of expression in the countenance. The breath is also bad, the tongue broad and pale and somewhat loaded.

"In some cases the disease is fully announced by a chill of longer or shorter duration. But in others there is such a gradual increase in the symptoms that it is difficult to separate the forming stage from the fully developed disease.

"When the physician is called, he finds evidences of a general and a severe local disease. The pulse is soft, easily compressed, and increased in frequency from ten to thirty beats per minute. The extremities are kept warm with difficulty, the skin is pallid or sallow, and presents a peculiar waxy appearance, looking many times as if it were edematous, and would pit on pressure. The face is pallid and expressionless, with a dark line under the eyes, which also are dull, with dilated pupils. The bowels are irregular, the feces clay-colored and papescent; the urine free, pale, and of low specific gravity. There is no appetite; indeed, from the condition of the mouth and throat, there is disgust for food.

"On examining the mouth and throat, we find the mucous membranes pallid, the tongue broad, pitting where it comes in contact with the teeth, and covered with a pasty, white coat. The mucous membrane of the throat is swollen and discolored; in some cases it is livid, in others of a dusky red, and in some few it presents a peculiar blanched appearance. The tissue seems relaxed and flaccid, and the circulation sluggish.

"In a couple of days small points of ulceration will be seen, sometimes superficial, at others with a tendency to extend in depth. These ulcers increase in size more or less rapidly, according to the severity of the disease, and the throat will present a markedly ragged and foul appearance. In very severe cases the ulcers pass through the mucous membrane and invade the cellular tissue, so that in fatal cases the structures are destroyed to a greater extent than we would deem compatible with life, for some hours before death ensues.

"A distinctive symptom of malignant sore throat is the change in the tone of the voice; it is not so much hoarse as hollow and sepulchral; as a musician would say, 'It has lost its timbre.'

Diagnosis.—"This disease is readily recognized by the fetid breath, the abundant secretion from the throat and mouth, and by the peculiar relaxed condition of the structures. Add to this the general cachexia, which is peculiar to this and, to some extent, to cancrum oris, and we have a grouping of symptoms that can not be mistaken.

Prognosis.—"Though the disease is a very unpleasant one, and attended with much depravation of the fluids and solids, the prognosis is not unfavorable. A large majority of cases will recover, probably as much as ninety or ninety-five per cent.

Treatment.—"The treatment of cynanche maligna will be both constitutional and local. We want to antagonize the septic influence, improve the circulation of the blood, increase the tone of the system, and place the stomach in condition to receive and appropriate food, and re-establish secretion.

"Aconite and belladonna may be given in small doses, to improve the circulation. Under their influence we find the pulse becoming stronger and more full. the capillary circulation better, and the temperature of the body more uniform.

"Of the antiseptics I prefer sodium sulphite in the majority of cases, giving it, in the usual doses, every three hours. In some cases potassium chlorate may be used instead, or alternated with the sulphite; triturated with gum arabic and sugar, as named for diphtheria, will probably be the best form for administration. The baptisia in infusion is an excellent antiseptic, and may be associated with either of them."

Echinacea, in full doses, will be among our best agents.

"In addition to this, I prescribe quinine in stimulant doses, sometimes alone, at others in combination with hydrastin. The dose will be about two grains, three or four times a day. Tincture of muriate of iron can also be used with advantage in some cases. It may be especially named as an important remedy in those cases which manifest an erysipelatous tendency.

"The local means will vary in different cases. In the milder ones a decoction of baptisia, used as a gargle, will be sufficient., In others we may alternate this with a gargle of potassium chlorate, and in others the sodium sulphite will answer a good purpose. In those, cases where the tissues are relaxed and the ulceration progresses rapidly, potassium permanganate will be the most powerful, as well as the most certain local remedy we can use. We would make the solution of the strength of one dram of the salt to one pint of water. When it is used with the pencil or probang, it may be applied much stronger than this.

"We find some patients who can not use a gargle to advantage, and in some of the severe cases the throat is so paralyzed as to prevent its use; in these cases we will have to employ other plans for local applications. I do not like the use of the probang to make local applications to the throat. Instead of this I use inhalation, preferring the spray apparatus, either air or steam, to any other apparatus. But it does not require an instrument; for, as we have already shown, an inhalation can be given with nothing but a vessel to hold the fluid and a heated iron to raise a vapor. The vapor of vinegar and water answers an excellent purpose, as does an infusion of tansy, or of baptisia. In using the spray apparatus we may use the same remedies named for gargles. A solution of carbolic acid, grains five to grains ten to water four ounces, has been highly recommended. I have also used the sulphurous acid alone, or diluted with water, with excellent results."

A five per cent solution of pyrozone is especially useful in those cases where the ulcers are foul.

"The external application in this, as in many other diseases of the throat, is a flannel wrung out of cold vinegar, with a dry flannel over it. We call it the vinegar pack, but a cold-water pack to the throat will answer the purpose."

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.