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Chapter II.

Sore Throat.

The popular term "sore throat" includes a large number of diseases seated in and about the back part of the mouth and the upper part of the larynx, or entrance to the windpipe. Like most popular terms, it does not admit of strict definition. It may mean a mere congestion of the mucous membrane, attended with slight hoarseness; or it may mean a severe inflammation of the soft palate, tonsils and neighbouring parts, running on to ulceration or abscess.

The general symptoms of inflammatory sore throat, are pain, often-times very severe, in the part affected, greatly increased by swallowing, or attempts to swallow, hoarseness of the voice, sometimes increasing to such an extent that the voice becomes a mere whisper, a profuse secretion of slimy mucus, which at first is exceedingly difficult and painful to get rid of, and cough of a very irritating and harsh kind. These local symptoms are accompanied for the most part with a general feverishness, marked by a quick pulse, a hot, dry skin, a white and furred tongue, thirst, loss of appetite, and not seldom pains in the back and limbs, and other symptoms of catarrh.

If the complaint runs on unchecked, the local symptoms become more severe. The secretion of mucus is more profuse, and is generally accompanied by great secretion of saliva, the pain and difficulty of swallowing are greater, so that even fluids can only be swallowed in very small quantities, and produce a feeling of suffocation; the tonsils enlarge to such an extent that they nearly meet, and difficulty of breathing is added to the other symptoms; abscesses may form in the tonsils, and the complaint is then called quinsey, or without going into abscess, superficial ulceration may take place on the mucous membrane of the tonsils or palate. If abscess occurs the symptoms are generally greatly relieved as soon as the abscess breaks or is opened.

On examining the throat internally, in the first stage of the complaint, the whole of the mucous membrane is seen to be of a much deeper colour than that of the rest of the mouth, often a deep crimson tint, it is greatly swollen, as may be seen by the thickening of the soft palate and uvula. In the more advanced stages, the tonsils are greatly enlarged so as to form projecting tumours. In this stage there is considerable swelling externally, and pressure below the ears, under the jaw, gives great pain.

In persons subject to quinsey, the inflammation commences in the tonsils and extends to the rest of the throat, and the tonsils swell with great rapidity, and often in the course of twenty-four or six-and-thirty page 6 hours, become so much enlarged as to prevent swallowing, and render even speech impossible. In these cases the expectoration of mucus is enormous. I have frequently seen a quart brought up in a day.

The causes of inflammatory sore throat are generally, either exposure to wet and cold, great exertion of the muscles as in speaking, the presence of an epidemic, or direct contagion.

Some persons are peculiarly liable to sore throat. If they get their feet wet, or are exposed to a cold wind, or even a slight draught, if they stand or sit in damp clothes, if in short they expose themselves to any of those influences which commonly produce what is called a "cold," they are immediately attacked with sore throat. Those whose profession requires long and severe exertion of the voice, such as clergymen or barristers, are also peculiarly liable to sore throat. Sore throat is often epidemic, and I have always noticed that at times when scarlatina is epidemic, sore throat is so also. It frequently happens that when the children in a house are laid up with scarlatina, the adults are suffering from sore throat. It is always very difficult to prove contagion, but I think it is generally acknowledged that simple inflammatory sore throat may be contagious, as diphtheritic sore throat undoubtedly is.

Treatment.—If sore throat of an inflammatory kind attacks a robust and healthy person, and is accompanied by much pain in swallowing, a few leeches may, with great advantage, be applied behind the jaw on each side. A couple on each side will be quite sufficient. If thought desirable, the wounds may be encouraged to bleed for a short time after the leeches have fallen off, by fomentations of warm water. A large warm linseed-meal poultice should always be applied, reaching from ear to ear, under the chin. If the complaint is attacked in its first stage, an emetic of half-a-drachm of ipecacuanha powder will sometimes apparently cut it short. At the same time, should the bowels be confined, it will be well to clear them out by a four or five grain blue pill, followed by a dose of castor oil or senna. The steam of hot water should be inhaled; and warm water, either alone, or rendered more pleasant and demulcent by the addition of gum, or an infusion of linseed frequently sipped. It is exceedingly useful in this stage to paint the affected parts with a pretty strong solution of nitrate of silver. This will, in many cases, materially shorten the duration of the malady, but it should not be used except by a professional man.

If these plans fail in arresting the disease, or if I have not been called in at the commencement, I generally give what I believe to have a specific action on inflammations of the mouth and fauces, namely, chlorate of potash. This compound has very great power over the complaint, both when applied locally in solution, as a gargle, and when taken internally. I disapprove, in toto, of giving a succession of salines and antimonials in this disease; they do far more harm than good. If the accompanying fever runs high, it may be better subdued by small doses of aconite, which will soon bring down the pulse without weakening the system. In robust persons the chlorate of potash may be used in combination with a dilute acid, as the dilute hydrochloric, and a little syrup. It may also be used as a gargle. I have, however, been in the habit of directing the patient to take it, not in large doses at intervals of three or four hours, but in frequent small doses every few page 7 minutes. Thus a tea spoonful may be taken every quarter of an hour, and slowly swallowed. In this way the necessity for gargling may be avoided, as the medicine acts locally as well as through the blood. Gargling is always an unpleasant operation, and particularly so when the person who gargles is suffering from sore throat.

If the patient is weakly, quinine and chloric ether may be be added to the mixture, or decoction of cinchona bark with chloric ether. If after the violence of the inflammation has subsided the tonsils remain enlarged, or the mucous membrane thickened or relaxed, painting with a weak solution of nitrate of silver (5 grs. to the ounce of distilled water) will be very useful. At the same time, if necessary, the skin underneath the lower jaw may be painted twice a-day with tincture of iodine.

Persons who have repeatedly suffered from inflammatory sore throats will require something more. A blister to the neck, and the internal administration of iodide of potassium, together with astringent gargles, will be most useful.

The diet throughout the complaint should be nourishing. Strong beef tea will generally be required as soon as the patient is able to swallow, and in some cases stimulants. It is surprising how rapidly a lingering case of sore throat will get well by the use of vigorous measures. I was called in on one occasion by another medical man, to see a young lady whom he had been attending for live weeks, with severe tonsillitis, and general sore throat. There was great difficulty in swallowing, the tonsils were much enlarged, and the patient, though of a robust habit of body, reduced to a state of great weakness. I found the treatment had been a very lowering one, and the diet low also. I suggested tonic medicines, and two or three glasses of old port every day, together with plenty of eggs and beef tea, &c. The next day she was considerably better, and in three or four days she was so nearly well, as to require no further medical attendance.

Malignant sore throat, such as occurs in the severest forms of scarlatina, and diphtheritic sore throat, ate of course so dangerous as to be quite beyond the range of domestic medicine. They are marked by the great depression of strength which accompanies them.

The malignant sore throat of scarlatina is extremely fatal. It comes on early in the disease, sometimes on the first, sometimes on the second day of the rash. The throat swells both externally and internally, sloughs rapidly form on the tonsils : an offensive muco-purulent discharge proceeds from the mouth and nostrils; the patient's lips, teeth, and tongue are day and black; breathing is carried on with much difficulty, and is attended with frequent fits of coughing, which seem as if they would suffocate the patient. The pulse is from the first small and rapid, and the debility extreme. Gradually, if the case terminates fatally, the breathing becomes more and more laboured, the countenance livid, the pulse feebler and feebler, until death terminates a most painful scene.

The treatment is directed locally by powerful astringents, or caustics, to check the sloughing, by the internal administration of quinine or bark, together with brandy, wine, eggs, and beef tea to support the strength.

The peculiar form of sore throat, called diphtheria, has of late years attracted much attention, both on account of its great rarity page 8 (until lately,) and of the frightful mortality which attends it. It has been singularly localized—some places have suffered from it most severely, while in others it has never been seen. In that part of London in which I practised for several years, we had a large number of cases.

Diphtheria attacks all classes, but seems to be especially fatal among the well-fed and comfortably-housed members of the middle and upper classes. It frequently follows scarlatina and measles. There is considerable difference of opinion as to its real nature and causes, but one thing is clear,—that the true diphtheria is a deposit of a sort of false membrane, something like that of croup, on the mucous membrane of the tonsils, soft palate, uvula, &c., and extending into the pharynx, or opening of the gullet, and into the larynx or upper part of the windpipe, and upwards into the nostrils. This false membrane or diphtheritic deposit is of very various thicknesses. I have seen it so thin as to look like a patch of whity-brown paper, placed on the palate, and I have seen it as thick as washleather, and of very much the same colour and appearance. If removed by force, it is formed again in a few hours, unless at the same time the diseased state of the blood which causes the deposit, is removed or changed. Some cases are comparatively slight, that is to say the deposit of false membrane is not extensive, but all cases are dangerous and require the most prompt and active treatment.

A case or two will illustrate the subject better than a laboured description:

I was called up about 20 a.m. to see a young lady in London, at a time when diphtheria was very rife. When I reached the house I found my patient, (who was a delicate girl of about 12 years of age,) sitting up in bed, breathing laboriously, and troubled with a very harsh cough. On examining the throat, I found a well marked, but not very extensive diphtheritic deposit on both tonsils, the rest of the throat internally was red and inflamed, I found the pulse about 124 and very feeble and small. There was profuse ichorous discharge from both nostrils. The skin was soft and clammy. It was stated that the young lady had been suffering from a slight cold, as was supposed, for a few days, but went to bed tolerably well. In the night she awoke her parents by her loud harsh cough. The father immediately sent for me.

I at once applied a caustic to the throat in order to check the progress of the deposit: ordered a tablespoonful of port wine, and some strong beef tea every hour, and a draught containing ten grains of chlorate of potash, ten drops of muriated tincture of steel and chloric ether with water, every half-hour. I saw her again at 60 a.m. There was no further progress of the disease; the pulse was much slower and fuller, and the extremities warmer. From this time she gradually improved, and in two days the diphtheritic deposit had entirely disappeared. Now this was a very mild case, but had it not been treated promptly, it would doubtless have been very dangerous. The great depression of the vital powers so early in the disease, snowed that had it gone on a little longer unchecked, the result would have been very serious.

I was called in to a child on July 25th: he was suffering from severe sore throat immediately following scarlatina. On examination there page 9 was a slight diphtheritic deposit perceptible. He was treated in the usual manner, and very rapidly improved. On the 27th the throat had lost all trace of diphtheria, and was only like an ordinary sore throat. On the 30th I found him running about, and on examination, it was clear that there was not much improvement since the 27th. He had taken no medicine during the intervening days. The parents, however, did not send up for any medicine, and I saw no more of the child until the 5th of August, when he was brought to me by his parents. He was much worse. I found a perforating ulcer of the soft palate, as large as a split pea, and a thick diphtheritic deposit covering part of the palate, the whole of the tonsils and back of the pharynx. He was put on the same course of treatment as before, and wine, beef tea, &c. freely given; he rallied and seemed likely to recover, but again relapsed, and died on the 12th, just a week after he was brought to me a second time.

Another case which occurred about the same time, illustrates the milder form of the disease. A mother who was nursing her child in an attack of scarlatina, was herself attacked by the disease. On the second day of the eruption there was a well marked diphtheritic deposit on the tonsils and pillars of the fauces. The usual treatment was adopted, and the patient, who is a very sensible clear-headed woman followed up the orders about chlorine to the very letter. She rapidly recovered. In this as in all the other cases of diphtheria I have seen, amounting to about thirty, the debility, feebleness, and quickness of the pulse, were out of all proportion to the local symptoms, and required the most energetic use of stimulants and tonics. This is to my mind the most marked distinction between the ordinary sore throat and diphtheria.

The infant child of the above patient was subsequently attacked with diphtheria. The disease was at first confined to the tonsils and soft palate. There was very great difficulty in getting down either medicine, wine or beef tea. The child lingered for a fortnight. It had an abscess beneath the jaw which broke externally, and the wound took on the diphtheritic action. Ultimately the mouth was nearly covered with the deposit, but it was not until the disease attacked the larynx that the child died, which happened about three weeks after it was first attacked. This was the most protracted case I have ever seen.

In the fatal cases, the diphtheritic deposit covers the tonsils and soft palate, and extends sometimes into the windpipe. In many instances the patient undoubtedly dies suffocated, in some cases from suffocation and debility combined, and in others apparently more from the blood poisoning than from the local disease.

The treatment of this disease so formidable in itself, so dreadful when it enters a family, sweeping off, as it often does, three or four children one after another, has been the subject of much controversy. One point however is undoubted, that it is absolutely necessary to support the system in every way. For this purpose the most nutritious diet combined with stimulants will be required. In the bad cases, wine or even brandy must be given in quantities that seem startling to the uninitiated, and at intervals much shorter than is usual in most other diseases. It is trifling with a disease so rapid in its course, and page 10 so fatal in its results, to give stimulants every three or four hours. They must be administered every half-hour or every hour, according to circumstances: at the same time small quantities of very strong beef tea, and yolk of egg may be given. It is generally useless to attempt to give solid food—the patient is not in a condition to masticate it, or to digest it. The object must be to give nutriments in the most concentrated and most digestible form.

The local treatment must consist in poultices and fomentations externally, and caustics internally, if the disease is in its early stage, and within reach of caustics. It is useless to apply caustics in the most advanced stages, when the diphtheritic membrane has extended into the larynx. As for internal medicines, I have found the most useful to be a combination of chlorate of potash, muriated tincture of iron and quinine, taken in frequent small doses. The quinine is given in order to support the strength and counteract the debilitating effects of the blood poison. Of course particular symptoms will require their own especial treatment. There are also sequels of the disease which will need treatment, but the consideration of these would lead us too far from our immediate subject.

Plenty of chloride of lime should be kept in the patient's room, to which a little muriatic acid should be added occasionally. In this way more chlorine gas will be liberated than by merely using the chloride of lime. The chlorine acts as a disinfectant, and also as a local application of considerable power.

It is useless to dilate further on the treatment of this disease, since no one would ever think of undertaking a case of this kind, unless he were a fully qualified medical man.

We have spoken of several forms of acute sore throat, it now remains to say a few words upon the more chronic forms. These may follow the acute disease, or they may have arisen from repeated slight attacks of inflammation which have scarcely been noticed.

It is very common to find, on examining the throat, that the tonsils are greatly enlarged, the mucous membrane redder than natural, the blood vessels more prominent, and the uvula long and relaxed. The state of the throat causes no positive pain, and not much inconvenience. It causes a slight hawking cough, with the expectoration of a tough mucus, and a constant hoarseness and huskiness of the voice; but it renders the throat exceedingly liable to acute attacks of inflammation. A very slight cold will also cause such an aggravation of the symptoms as to produce great swelling of the tonsils, and a most harassing cough. The relaxed uvula, thus subjected to repeated attacks of inflammation, completely loses its power of contraction, becomes an inch long or even longer, hangs down and irritates the glottis, and causes attacks of un-controllable cough of the most distressing and painful kind.

Now in these cases a thorough cure ought to be effected as soon as this state of things is discovered, unless the patient prefers allowing the chronic inflammation to go on for the term of his natural life.

The cure may be effected in some cases without any medical treat-ment Whatever. Removal to a dry, hot climate, from England, will generally cure them thoroughly in two or three months. But people don't care to emigrate in order to get rid of a sore throat, nor do they page 11 care to leave even one part of the country for another, higher and drier. Therefore medicine must come in.

In tolerably recent cases, astringent gargles, containing alum or tannin, are very useful. A gargle of two drachms of dilute sulphuric acid, one drachm of tincture of capsicum, and eight ounces of water, is good when there is a relaxed condition of the uvula and tickling cough. At the same time blisters should be used externally, or a series of mustard plasters applied. Generally speaking tonic medicines are required, as the very existence of a chronic inflammation indicates a certain debility in the system. A generous diet, containing a fair allowance of wine or malt liquor is also necessary. With this, plenty of exercise in the fresh air, and well ventilated rooms are essential. In the more obstinate cases; with greatly enlarged tonsils, iodine may be given, either in the form of iodide of potassium, combined with infusion of quassia, or gentian, or cascarilla, or in the form of syrup of iodide of iron, a most useful and elegant preparation.

When iodine is necessary externally, it is well to blister with a strong solution of iodine applied to the neck.

Nitrate of silver, either in the solid form or in solution, may, as explained before, be used with great advantage. It should be applied daily, or every other day.

When the uvula has become very long it is impossible to bring it back to its natural state : the only remedy is the surgical one of cutting a piece off. This is done in a moment with a pair of scissors, and is perfectly effectual.

When repeated attacks of sore throat have taken place, the tonsils become permanently enlarged, and medicine has no effect on them; nor will any local applications bring them back to their healthy state. In these cases they must be removed by the knife. The operation is almost painless, and the cure is permanent and perfect.