The presence of freshly' swollen, slightly painful submaxillary glands and an odor from the mouth which may be absent in children without teeth are important symptoms. A considerable swelling of the mueous membrane of the throat may be recognized by the thiek speech, and some difficulty in breathing which may give rise to a distinct stridor. Inspection will show characteristic findings in the different forms.
Catarrhal Angina In catarrhal angina the pharyngeal mucosa is much reddened, more or less syvollen and coated with mucus; the tonsils are sometimes deeidedly swollen, at other times only slightly. Small hemorrhages are sometimes visible in the epithelial layer. There are sometimes circumscribed inflammatory areas, at other times the membrane is generally inflamed. Catarrhal angina ineludes most of the milder forms of sore throat although there are cases with severe disturbances. It usually lasts from two to three days, rarely a week.
Follicular Angina (see Plate 43) Nomenclature.Follieular angina and lacunar angina are used by many authors as synonymous terms while others distinguish two dis tinct eonditions. Under follicular angina should be included eases in which the lymph-follicles of the tonsils and other adenoid tissue are inflamed and swollen. In lacuna'. angina there is an inflammatory exudative process of the surface of the tonsil, localized mainly in the crypts and the tissue surrounding them. Follieular angina is differen tiated from the eatarrhal form by the swollen lymph-follicles under the nmeous membrane, whieh at first appear as grayish yellow dots, later studding the surfaee of the tonsil in the form of yellowish ele vated points. The swelling of the follicles either rapidly subsides, or they rupture, producing a small superfieial ulcer which heals rapidly-, The rounded spots, and the absence of confluence, differentiate this eondition from lacunar anffina.
Laeunar Angina (see Plate 43) Angina lacunaris is characterized by the development of a grayish yellow, or yellow, mucopurulent exudate, on the surface of the tonsil, in the beginning often covering the whole tonsil, but in a short time taking on a distinctly laeunar type. The tonsil is swollen, the rest of the pharynx presenting the picture of a catarrhal inflammatory process. It may
be unilateral or bilateral. Constitutional symptoms, glandular swelling, and difficulty in swallowing, are more severe than in the forms just described. It usually' runs its course in two or three days, but may last a week or longer; a longer course is produced by first one side and then the other becoming involved. The exudate is thrown off on the second or third day, leaving superficial epithelial erosions, the other symptoms disappearing soon after.
Retronasal Angina (Pharyngitis superior, pharyngeal angina, adenoiditis, araygdalite pharynges) Retronasal angina was formerly not considered a distinct condition, and its importance has only been recognized during the last few years. The recognition of the condition is of great importance during childhood. Its clinical picture is very much like that of angina of the tonsIls. One of the first symptoms is the difficulty in breathing, nith the nasal voice, and some earache and deafness. There is a profuse inueopurulent dis charge from the nose, and tenacious mucus will be seen clinging to the posterior pharyngeal wall, which is reddened and presents an uneven surface owing to the swollen patches of lymphoid tissue. If posterior rhinoscopy is possible, it will be seen that the pharyngeal tonsil is also subject to catarrhal, follicular, and exudative inflammatory processes. If an examination is made with the finger the swelling in the vault of the pharynx can be felt. The cervical glands are swollen. Its course is very much like that of lactinar angina, long-continued elevations in temperature being not UrICOM111011 however.
Unusual conditions do not always run a typical course. Gastric symptoms, with continued fever and an enlarged spleen, show a picture very much like typhoid. They also occasionally simulate meningitis. In small children with irritable nervous systems, the acute febrile affection may cause nervous symptoms. The fever, particularly in retronasal angina, sometimes runs a very unusual cours.e, being at times intermittent at other times remittent, and accompanied by chills. Some very susceptible children have attacks of this kind at such short intervals that a chronic form (Fisch') is produced, causing a severe general disturbance.