Common Membranous SoreThroat.

BY

J. SOLIS-COHEN, M. IX,PHILADELPHIA.

KKPRFNTKD FROM

ffitjr ‘Neto Yorft JiSeftical Journalfor March S3, 1889.

Reprinted from the New York Medical Journalfor March 23, 1889.

COMMON MEMBRANOUS SORE THROAT.

J. SOLIS-OOHEN, M. D.,PHILADELPHIA.

Described by authors under the following heads: Non-malignant membranous sore throat, diphtheritic sore throat,herpetic sore throat, aphthous sore throat, croupous angina,common membranous angina, herpes pharyngis, herpes gut-turalis, angina membranacea, seu herpetiformis, sen aphthosa.A rather frequent form of sore throat, often confoundedwith diphtheria, occurring at all seasons, characterized bythe exudation of products eventually fibrinous which coagu-late upon the surface of the mucous membrane into a pelli-cle or pseudo-membrane.

The characteristic features are preceded for two or threedays by those of ordinary sore throat. In most instancesthese symptoms supervene upon chill, with febrile reactionand subsequent manifestations of general systemic dis-turbance, such as headache, nausea, and intense fever, thetemperature rising to 103° to 105°. Then the pain in-creases, glutition becomes painful for a few days, and theconditions to be described presently are observed. Recov-ery is usually spontaneous within ten days or less. In some

subjects recurrences take place at short intervals for weeksor months, or even during years, 1 y f ir> ~ry

The disease is usually unilateral, anfl,..tlj^^Teepondifi^

2 COMMON MEMBRANOUS SORE THROAT.

submax ill ary and cervical lymphatic glands sometimes be-come moderately swollen. Tt is maintained by some ob-servers of unquestionable authority that within a few hoursof invasion the initial feature of the local expression of thisdisease may always be detected on the palate and uvula,sometimes on the tonsils, less frequently on the pharynx, andoccasionally on the hard palate. Small vesicles of the sizeof a millet-seed or somewhat larger are seen either isolatedor in groups, with contents more or less turbid and sur-rounded by more or less vivid zones of inflammation. Act-ual tumefaction has been described (Potain, “ Gaz. deshop.,” 1879, No. 11). Occasionally the vesicles disappearwithout traces after a day or two, and then there will be nomembranous exudation. Some authors (Bosworth and oth-ers) restrict the term herpetic sore throat to these rare in-stances. So rarely is a case seen sufficiently early to detectthe vesicular stage that this initial feature has been denied(Vogel). I have seen it in a very few instances. Most fre-quently the vesicles undergo rupture in from twenty-four tothirty-six hours, and the ruptured tissues present as smallirregular excoriations which become covered almost imme-diately with a grayish-white plastic exudation. This exu-dation extends and becomes coalesced into contiguouspatches which have commenced in the same manner. Ul-cerated mucous surfaces in other parts of the body oftenbecome covered with the same sort of deposit during theattack, and even cutaneous surfaces likewise, but to a lessextent. In some instances the vesiculation is limited to theuvula, sometimes to its posterior and inferior surfaces; andthen sometimes the false membrane does not form uponthe surface of the excoriations, but the mucous membranebecomes simply swollen and pasty looking. In some in-stances, and chiefly in children, the false membrane ex-tends into the larynx. In some cases there is also herpes

Common membranous sore throat. 3

at the corner of the mouth, or on the inner surface of thelips or cheek, or on the tongue. In most instances the ton-sils become slightly swollen, and then covered with a whit-ish or yellowish-white exudation, but slightly adherent.Sometimes there are accumulations of viscid, ropy, and tur-bid mucus. The soft palate and often its anterior fold, espe-cially that portion in front of the swollen tonsil, acquires afissured or corrugated aspect in many instances, and themembranous coating is distributed upon it more or less ir-regularly. If this be removed comparatively early, the sur-face is often found eroded and sometimes slightly haemor-rhagic. When removed at a later date, the mucous mem-brane appears normal, the erosions having healed upmeanwhile.

The affection has been regarded as a herpes zoster ofthe trifacial nerve, the result of irritation of the spheno-pala-tine ganglion (Herzog, “Pester, med.-chir. Presse,” 1880,No. 19;

“ Jahrb. fur Kind.,” 1880, December 23d).A membranous sore throat precedes some, cases of en-

teric fever, and attends the advanced stages of some casesof phthisis and syphilis, due to the lowered vitality whichprevents reproduction of healthy epithelium. That form ofsore throat is not the variety under discussion.

Exposure to emanations from the products of inefficienthouse drainage, ill-ventilated water-closets, or other foetid ac-cumulations, is often the apparent predisposing cause. Themost frequent immediate cause of the attack is exposure tocold while the body is overheated or its cutaneous surfaceis in a state of active perspiration. Some patients are at-tacked almost annually, some oftener than once in a season.The disease is often contracted by susceptible subjects dur-ing the prevalence of diphtheria, and then it may become astarting-point for that disease. Under similar conditionsit is sometimes endemic. Females are attacked more fre-

4 COMMON MEMBRANOUS SORE THROAT.

quently than males, and young males more frequently thanmature males. In some instances several females in a familyor in a household will be attacked while all the males es-cape, probably because their vocations take them away fromthe continuous influence of the contagium in-doors.

The general subjective symptoms are those of acute sorethroat, with marked febrile disturbances usually sthenic intype. The parts affected feel dry and hot, these sensationsin many instances extending toward the ear, in some intothe posterior nasal passages, in a few into the larynx. Glu-tition is often both difficult and painful. AVhen the larynxis involved, there will be superadded hoarseness, dyspnoea,and cough.

Great difficulty is often experienced in diagnosis, espe-cially because the disease is rarely caught sight of duringthe vesicular stage. Sometimes one or more of the excori-ations left by the rupture of the vesicles can be detected.Sometimes small isolated islets of pseudo-membrane indi-cate recent formation by their transparency and their originfrom a vesicle by their shape (Peter). The co-existence ofcutaneous herpes is a corroborative indication, but is by nomeans an infallible guide. In many instances differentia-tion from diphtheria is impossible, the more so that diph-theria is sometimes precipitated by a membranous sorethroat. On the whole, the elevated temperature—103°-105° F.—so out of proportion to the mildness of the symp-toms, and the absence of any history of possible exposureto infection from diphtheria, especially when the patient isa female, may he regarded as important factors of diagnosisin doubtful cases. The distinction from mycotic sore throatis easy, because the latter is apyretic and intermittinglycontinuous, and presents evidences of theLeptothrix buccalisunder microscopic inspection of the pseudo-membranousproduct.

COMMON MEMBRANOUS SORE THROAT. 5

The tendency of the disease is to recovery, except insome rare instances in which the larynx becomes involvedand life gets into jeopardy from mechanical obstructionto respiration. In the majority of instances recovery isspontaneous in from seven to ten days. Occasionally, andespecially in children, death ensues by apnoea from theresults of extension of false membrane into the larynx.Recurrences are not infrequent. In some individuals theyare so frequent as to constitute a chronic membranous sorethroat. One of my patients had recurrences during a periodof fifteen years. In these instances there is usually somelocal cause for recurrences at work in the patient’s dwelling.In my own practice several patients, whose attacks were atleast annual, and some of which were still more frequentduring a series of years, acquired thorough immunity fromrecurrence after yielding to my urgent advice to move intomore salubrious quarters.

Under debilitated conditions of system, common mem-branous sore throat will not be unlikely to merge into pha-gedenic ulcerous sore throat.

Paralysis of the palate sometimes follows recovery fromcommon membranous sore throat.

When the diagnosis of common membranous sore throatcan be made out with certainty, there is nothing calling forspecial treatment; but the treatment pursued in ordinarysore throatmay be generally followed with advantage. It ispractically a self-limited disease with a tendency to recovery.When foetor exists, as during the detachment of patches ofexudation, antiseptic and detergent sprays may be employed.Solutions of borax, boric acid, carbolic acid, potassiumpermanganate, hydrogen peroxide, etc., are appropriate.Lemon-juice is often an agreeable and an efficient applica-tion. In those individuals, especially strumous and tuber-culous subjects, in whom there is a constitutional proclivity

COMMON MEMBRANOUS SORE THROAT.6

to chronicity, or to the recurrence of the peculiar manifes-tations, more active measures will he required. Locally,frequent application of the dilute acids—say, every day or

two—affords the most satisfactory results. Internally, ironand cinchona preparations should be administered. Opiumin small doses is of special efficacy, not as a narcotic, butas a gentle stimulant or nervous tonic. Nux vomica andarsenic may be employed for similar purposes. The dietshould be highly nutritious and easily assimilable. Unne-cessary exposure should be avoided. Supporting measuresgenerally, hygienic as well as medicinal, should be persistedin. When membranous sore throat exhibits a tendency tophagedsena, the treatment for gangrenous sore throat be-comes indicated. Common membranous sore throat mayinvite an attack of diphtheria, or the diagnosis may be indoubt. In that case the prudent course is to treat theaffection as diphtheria, but to avoid the recommendationfor diphtheria of some indifferent remedy during the exhi-bition of which a case of membranous sore throat has endedin recovery. When extension to the larynx occurs andthreatens suffocation, tracheotomy or intubation to avertdeath should be practiced, as in croup or diphtheria.

In cases of recurrent or chronic membranous sore throatthe cause should be searched for in the dwelling of thepatient or in his place of vocation. Should either of thesebo found unhealthy, nothing short of change to healthiersurroundings will be likely to be of permanent service.

1481 Walnut Street, Philadelphia, February 7, 1889.

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