The observant practitioner will in all such cases notice peculiarities which serve to call his attention to the throat ; thickness of speech, liability to sore throat, occasional difficulty in deglutition, even when pain is not spoken of, such as fluids returning by the nose; deafness, and especially the sound of the cough which may be descnbed as a throat-cough : but whenever the symptoms are not fully explained by the stethoscope, an inspection of the throat is a wise precautionary measure before pronouncing a ffiagnosis.
c. 'Ulceration of the fauces occurs in three distinct forms : (1) As the residue of an acute attack ; (2) as a primary disorder in scrofulous and cachectic states; (3) as a consequence of syphilitic poisoning. After quinsy, the ulcer is generally pretty far for ward, after scarlatina the tonsil is the usual site of ulceration; the scrofulous ulcer is very often in the velum, the syphilitic usually reaches toward.s the back of the pharynx. That resulting from an acute attack is generally superficial ; the scrofulous is deep, but has flabby, perhaps jagged edges, which do not project ; it often exists as a complete perforation of the velum ; the syphili tics, again, is deep and rounded, with elevated serpiginous and defined borders.
Bo far as diagnosis is concerned, these conditions might be accurately de termined by a correct history. In regard to treatment, the division of most importance is into the syphilitic and non-syphilitic ulceration. Both the other forms are, in great measure, constitutional. and must be met rather by such remedies as are suited to the general condition of the patient, than by those which have merely a local effect. In the female sex there is both greater dif ficulty in making out the previous existence of primary syphilis, and ter nnwillincness to confess that such may have been its cause than in mafer: to say nothing of the reluctance felt by the medical man in even hinting such a possibility. When the ulcer is rounded and excavated, with elevated marFins, we must endeavor, by seeking in other directions for evidence of syplulitio poisoning, to obtain some indication that may aid in solving the doubt which such a condition will naturally raise in the mmd.
d. The name diphtheria; or diphtheria, has been applied to an epidemic disease which has hitherto been seldom observed in this country, but has been fully described by French authors. Recently it has prevailed pretty extensively, and it is worthy of notice that it has been associated with scarlatina, so that in numerous cases it has been impossible to say whether the throat affection belonged to this peculiar disorder, or whether it was only what used to be called malignant sore-throat, a form of scarlatina in which the eruption on the skin was prevented or suppressed. Indeed, it has seemed that in many cases the disease commencing as an exuda tion on the fauces, has termipated in sloughing ulcer.
Diphtheritis, properly so called, is attended with less febrile disturbance than scarlatina, and does not usually present the typhoid characters of malignant sore-throat. There is usually
some degree of fever, with malaise and general discomfort, and sore-throat; on inspection, large patches of whitish lymph are seen more or less extensively covering the uvula, tonsils, and pharynx; when these are detached, the mucous membrane is left raw and inflamed. In milder cases the affection terminates after a few days in gradual recovery; in the more severe forms the patient sinks exhausted from the persistence of the fever, and inability to take nourishment; or sloughing of the throat may supervene. It is a disease especially of childhood, and indicates the same con stitutional tendency to that form of plastic exudation which is of so much moment when it invades the trachea in croup. During the late epidemic the larynx has been little involved, but when the exudation tends to spread in this direction, it becomes a very formidable disease.
True aphtha3 are less common on the fauces than on the tongue and lips ; but a somewhat analogous formation is frequently ob served there, which may be either a true exudative process, or merely the inspissated secretion of some of the follicles. These spots may be mistaken for ulceration, and it is only necessary to warn the student of this possibility ; though, probably, the mis take is not a very important one.
§ 3. The Glandular Structures.—The inflammation of the fauees sometimes extends to the submaxillary region, and subsequently excites inflammation of the salivary glands; but these glands are also liable to be primarily affected. The swelling, though ac companied with difficulty in swallowing, is chiefly external ; the parotid, as the largest gland, gives the principal feature to the disease, which has hence been called parotitis—better known by its familiar epithet, "mumps." It is chiefly a disease of childhood and youth, and is not characterized by much febrile distur bance; it is sometimes of importance as causing the disfiguring abscesses which are apt to occur under the jaw in scrofulous subjects, when the surrounding textures become involved in the inflammation which primarily attacks the salivary glands. This disorder.furnishes us with the most marked examples of metas tasis ; the testicle and the mamma being each liable to inflamma tion during its continuance.
Chronic enlargements of the cervical glands occur from a variety of causes in scrofulous constitutions ; and these are ever apt, on the occasion of any little excitement or inflammatory action, to terminate in abscess. In almost every case of suppu rative cutaneous affection of the face or scalp, they exist in greater or less degree ; but when the individual is free from con stitutional taint, they are not of much moment ; the cause being removed, the effect of necessity ceases in a healthy person.