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Tubercular Pharyngitis

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TUBERCULAR PHARYNGITIS.

In children, the subjects of tuberculosis, the pharynx, like any other part of the body, may become affected as a consequence of the diathetic state. The pharyngeal complaint is only a part of the general disease ; but it may occur in children in whom no pulmonary symptoms are present, and in subjects who have not previously suffered from delicacy of the throat.

Morbid mucous membrane is the seat of ulceration, which is limited at first to one side of the fauces. The ulcers are due to the caseation and breaking down of gray granulations themselves, and not to the development of these granules around a sore formed by the disin tegration of ordinary cheesy matter, such as may result from proliferation of the cellular contents of a glandular follicle. Frankel states that in a previously sound portion of the velum palati he has been able to follow the whole process with the eye. Thus the gray nodules have sprung up, have become caseous and disintegrated, and have been replaced by ulcers under his own immediate observation. On microscopic examination, the base of the ulcer is seen to be infiltrated with round cells, which permeate the sub-mucous tissue, and even reach to the muscles. The same cells also infiltrate the cellular tissue of the glandulaa. The special gland cells are often in a state of fatty degeneration, and tend to become cheesy.

The other organs of the body are also the seat of the gray granulation.

Symptoms.—The first symptom pointing to the throat is soreness, and this seems to be exceptionally severe, for the child makes it the subject of continual complaint. In deglutition the pain often shoots up to the ears, and usually becomes so great on taking solids that no persuasions can in duce the child to swallow anything but liquid food. In addition to pain, there is sometimes difficulty in.deglutition, and liquids may return through the mouth and nose.

On examination of the throat, the mucous membrane is seen to be ul cerated. The ulcers generally begin on one side—on the tonsil or one of the pillars of the fauces, and spread slowly to the soft and hard palate and the back of the pharynx. According to Frankel, they begin as gray isolated or confluent nodules, which afterwards undergo caseous degeneration and ulceration. They tend to spread transversely rather than in a vertical di rection, and seldom penetrate deeply into the tissues. The floor of the ulcer is irregular and cheesy ; the borders are congested and undermined.

In the neighbourhood of the sores, gray miliary nodules can be distinctly seen dotting the mucous membrane. If the uvula is not invaded by the destructive process, it often becomes atrophied. In the opposite case, it swells to a considerable thickness, and may be dotted over with hard nod ules. Eventually it may be eaten away.

The ulceration may spread extensively. In a case reported by Dr. Gee —a child six years old—the whole of the pharynx down to its union with the gullet was covered with yellow purulent matter. The mucous mem brane was extensively destroyed, so as to lay bare the pharyngeal muscles. The soft palate, back and front, was in the same condition. The uvula was destroyed, as well as the mucous membrane of the tongue, half way to the foramen cEecum. The right tonsil was gone, and the ary-epiglottidean folds were ulcerated superficially. The true vocal cords and the larynx below them were unaffected.

As a consequence of the ulceration, the voice acquires a nasal quality, as it does in most cases of pharyngitis. The glands of the neck become enlarged along the borders of the sterno-mastoid muscles, and at the angles of the jaw.

When the case is first seen, the general nutrition of the child is not. necessarily unsatisfactory. The degree to which it is impaired depends in a great measure upon the period at which the pharyngeal affection arises in the general disease. If it occur early, the child, although thin, is not emaciated. His thinness is no doubt chiefly clue to the influence of the cachexia upon nutrition, but is probably also in part the consequence of dif ficulty and pain in swallowing, which is a bar to the taking of sufficient food. The general symptoms are those of tuberculosis. There is fever, but sel dom a very high temperature, the evening rise not often passing beyond 102° or 103°. There is usually cough, and an examination of the chest may detect signs of consolidation ; but in some cases no evidence of tuber cle can be discovered at first in either the chest or the abdomen. As the disease advances, however, signs of mischief become manifest in other parts of the body. Spots of dulness may be discovered at the apices of the lungs ; a secondary catarrhal pneumonia becomes developed ; signs of tubercular peritonitis are to be discerned, or symptoms of tubercular men ingitis occur ; and sometimes a persistent purging is set up, with all the signs of tubercular ulceration of the intestines.

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