ERYSIPELAS 
OF THE 
LARYNX AND PHARYNX. 
bt y 
Jr 
D. BRYSON DEL A VAN, M. D., 
NEW YORK. 
(Read before the American Laryngological Association, 
June 24, 1885.) 
Reprinted from the New York Medical Journal, September 12, 1885. 
NEW YORK: 
D. APPLETON & CO., 
1, 3, & 5 Bond Street. 
1885. Reprinted from the New York Medical Journal for September 12, 1885. 
ERYSIPELAS OF THE 
LARYNX AND PHARYNX* 
By D. BRYSON DELAVAN, M. D. 
SINCE the remarkable and exhaustive thesis of Cornil, which 
appeared in the “Archives generates de medecine ” in 1862, 
little new knowledge has been advanced, either in the pathology, 
the clinical features, or the treatment of this affection. Morell 
Mackenzie, in his excellent resume of the subject, tells us that erv- 
sipelas of the mucous membrane of the pharynx and larynx is, patho- 
logically, similar to the same malady when situated on the skin, and 
that it occurs either primarily or by extension from the face alono- 
the mucous tracts of the mouth, nose, or ear. Its causes are the 
same as those which give rise to it when situated upon the external 
parts of the body, although it has been most often observed in the 
course of general epidemics of the disease. Of eighteen patients 
seen, in whom the pharynx was affected, fifteen were under the age 
of thirty, and two thirds were females. Again, on inspecting the 
pharynx, the appearance of the mucous membrane when affected 
with erysipelas differs considerably according to the form of the 
disease which is present; the local phenomena are generally very dif- 
ferent from those of tonsillitis, but sometimes can not be distinguished 
from those of simple inflammation of the part. Cornil makes three 
divisions of the malady, viz.: (1) erysipelas with simple redness; 
(2) erysipelas with phlyctaenulae; and (3) erysipelas terminating in 
gangrene. Erysipelas most commonly reaches the larynx from the 
pharynx, but the former organ may be primarily affected while the 
pharynx remains healthy. According to one author, quoted by 
Mackenzie, the disease may extend still farther down the respiratory 
* Read before the American Laryngological Association, June 24, 1885. 2 
ERYSIPELAS OF THE LARYNX AND PHARYNX. 
tract. In cases which come under the first division the diagnosis 
must remain doubtful except where the throat lesion is accompanied 
by manifestations upon the skin. 
As to the prognosis, the dictum of Hippocrates—namely, “ When 
erysipelas extends from within outward it is a favorable symptom, 
but when it removes to the internal surfaces it is a deadly one”— 
has been confirmed by modern observation. In nine cases analyzed 
by Cornil where the face was first attacked, seven deaths occurred ; 
whereas, in nine other instances where the enanthem preceded the 
skin eruption, seven recoveries took place. Mackenzie states that 
he has seen but four cases in the whole course of his practice. 
From the foregoing statements it would appear that the disease 
in question has been so long ago recognized, and its nature so well 
understood, as to render its introduction at the present time unneces- 
sary. In searching for the records of authentic cases in available 
American literature, however, we are surprised to find but a single 
instance in which the disease has been described, namely, the one 
reported last year by Dr. T. A. De Blois. The case reported by Dr. 
William Porter, of St. Louis, was that of an Englishman whom 
Dr. Porter attended while residing in London. Whether it is more 
rare in this country than in Europe, or whether, on the other hand, 
it is either allowed to pass unrecognized or else regarded as a sim- 
ple and ordinary complication of the general affection unworthy of 
special mention, it is impossible to say. That the condition is an 
important one no one will question, while the very general nature of 
the treatment suggested proves that additional light upon the sub- 
ject is greatly to be desired. With the intention of awakening a 
sufficient interest in it to secure a more careful recording of such 
cases as may arise, together with the methods and results of their 
treatment, the following histories are presented: 
Edward Smith, aged twenty-nine, of robust appearance, had always 
enjoyed good health. On February 10, 1883, two months after admis- 
sion to the Workhouse, applied at the dispensary, complaining of chilli- 
ness, general muscular soreness, and pain in the bones. There was slight 
soreness of the throat, and pain in deglutition, which he stated he had 
first felt upon the right side. The tonsils were congested and slightly 
enlarged, particularly the right. 
February 11th, 12th.—Felt much worse and experienced more dys- 
phagia. He also complained of a feeling of dryness in the nasal passages 
and inability to breathe through the nose. Described the nasal condition 
as being like a “cold in the head.” The pulse was somewhat accelerated, 
and there was a slight rise of temperature. ERYSIPELAS OF THE LARYNX AND PHARYNX. 
3 
lJfth.—Was transferred to the hospital, all of the above symptoms 
being exaggerated. Temperature 102°, pulse 96, respirations 27. Tongue 
and teeth covered with sordes; tonsils and pharynx deeply congested. 
At this time also an herpetic eruption appeared on the face, below and to 
the outer side of the angle of the mouth. 
15th.—On the morning of this day an erysipelatous redness, attended 
with swelling, appeared upon the upper lip, adjoining the alas of the nose, 
and fading off upon the cheeks. There was also severe pain in the back 
of the head and the neck. The appetite was good, and there was little 
malaise. The temperature, however, was 104°, pulse 96, respirations 24. 
17th.—The swelling and redness had extended to the margin of the 
hair, and had invaded the neck. The face was covered with blisters. 
The pulse was running and intermittent at 80, and the tongue black and 
dry. Severe pain still continued in the back of the neck. 
18th.—Did not appear to suffer much pain. Erysipelas not extending. 
19th.—Patient fell into a semi-conscious condition, from which it 
was impossible to arouse him, and questions put to him met with no 
response. 
21st.—Semi-consciousness continued, but the patient began to be very 
restless and delirious. His hands were kept in constant motion, and it 
was almost impossible to keep him in bed. The facial swelling had 
subsided, and exfoliation of the epidermis had begun. The tongue was 
still black and thickly coated. The pulse and temperature were normal. 
22d.—Patient was more rational and able to answer questions. 
23d.—Was again slightly delirious, constantly sitting up in bed and 
throwing off the bedclothes, and fighting any one who came near him. 
Temperature 97°, pulse 50, respirations 21. 
24th.—The delirium became active and of an hilarious character, the 
patient singing, shouting, and constantly arranging the bedclothes, and 
imitating the actions of tne ward attendants. The condition of the 
tongue had cleared somewhat, and tne appetite had returned. 
26th.--Patient was slightly irrational. Tongue clean; exfoliation of 
epidermis of face, neck, and ears progressing. Temperature and pulse 
normal. 
Marrli 3d.—Delirium entirely gone. Exfoliation almost complete. 
Hair began to fall out. During the whole illness there was obstinate 
constipation. 
12th.- -Patient was discharged, apparently cured. 
On the morning of March 16th, however, the attention of the house 
surgeon was called to Smith on account of his wild appearance and 
strange actions. He was wandering aimlessly about the corridors, and 
seemed suhen and morose. This continued until the morning of the 
18th, when he was transferred to the hospital again. He would pay no 
attention to those about him, answered questions a long while after they 
were put to him, imagined that his fellow-workmen were trying to annoy 
him, and that every ane was plotting against him. While in the hospital 4 
ERYSIPELAS OF THE LARYNX AND PHARYNX 
he had delusions of a religions character at times, and at other times he 
imagined that some one whom he did not know was constantly urging 
him to the performance of a variety of strange actions, and he believed 
that he must obey. lie was treacherous, and would strike at the at- 
tendant whenever a good opportunity presented. His nights were rest- 
less and sleepless, and the constant hallucination of an outside impelling 
influence kept him busily engaged, while he would hide under the bed, 
flx himself in various grotesque positions, arrange the bedclothes, and at 
times sit and stare at some one object for half an hour. If given some- 
thing to do, he did it well, and while busy was happier and more satis- 
fied to stay in the ward, but, when unemployed during the day, would 
constantly walk up and down, watching an opportunity to escape. Dur- 
ing the five days he remained in the hospital he had no rise of tempera- 
ture, his pulse was somewhat accelerated and weak, and his appetite good. 
As soon as his transfer could be effected, he was sent to the Insane Asy- 
lum at Ward’s Island, where, when last heard from, he still remained. 
The following case occurred in the wards of the New York Almshouse 
Hospital during the service of the writer in the spring of 1882. Unfor- 
tunately, careful notes were not taken at the time, and it will, therefore, 
be possible to report only as much as can be given from memory. The 
patient was an aged pauper of about seventy years, large, somewhat 
stout, and decidedly rheumatic. She was attacked with what at first 
seemed an acute laryngitis. The disease, however, spread rapidly in 
both directions, involving both the lungs and the pharynx, producing in 
the former distinct and widespread broncho-pneumonia, and in the lat- 
ter an intense congestion. The mucous membrane here was also cede- 
matous, and of a dark, purplish color. So peculiar was its appearance, 
and so threatening the extent of the oedema, that a larvngoscopic exami- 
nation was made to ascertain the probable necessity for tracheotomy. 
Although in a state of general tumefaction and of the same dark color 
as the pharynx, there was an ample rima glottidis, but marked hoarse- 
ness of the voice. The constitutional symptoms were slight, considering 
the nature and severity of the attack. By degrees the inflammation 
extended from the pharynx to the lips, whence, apparently having re- 
ceived a fresh impetus, it spread over the face. Meanwhile, the co- 
existence of diarrhoea, mild delirium, and continued high temperature 
rendered the general condition grave. This period marked the height 
of the attack. The lungs were first to improve, and the disappearance 
of the pneumonia was followed by a subsidence of the laryngeal and 
pharyngeal inflammation and a marked improvement in general. Strange 
to say, as desquamation occurred in the face and neck, the erysipelas 
extended, by slow degrees, over the whole body, the march being slow, 
the general symptoms mild, and no great extent of surface being involved 
at any one time. At the end of several weeks this process was com- 
pleted by involvement and subsequent desquamation of the legs and 
feet. The patient recovered. ERYSIPELAS OF THE LARYNX AND PHARYNX. 
5 
The case first related would, if classified according to the method 
of Cornil, belong to division number two, since it was decidedly 
severe in its nature, and the presence of phlyctaenulae, although not 
mentioned in the history by my house surgeon, was distinctly ob- 
served by myself. The features of the case which especially dis- 
tinguish it are, first, the occurrence of the disease idiopathically in 
a patient who, so far as could be learned, had not been exposed to 
any erysipelatous infection; secondly, the distinct limitation of the 
disease to the tonsil fora period of three days; and, thirdly, the 
marked cerebral disturbance and subsequent insanity. 
No especial cause of irritation was apparent in the tonsil; the 
man had been to all appearances unusually strong and healthy, and 
the sanitary condition of the premises was at the time tolerably good. 
The limitation of the inflammation and its absolutely benign appear- 
ance at the beginning of the attack were sufficient to disarm sus- 
picion as to its true nature, and entirely out of harmony with the 
subsequent severity of the symptoms. By far the gravest of these 
was the effect of the disease upon the brain. So far as could be 
ascertained, the patient had never before manifested any sign of 
mental aberration. Ilis insanity, therefore, bore such a distinct 
relation to the attack that, beyond question, the one was intimately 
associated with the other. Of course, it is by no means unusual 
for facial erysipelas of the ordinary type to be complicated with de- 
lirium and coma, and even with the more serious cerebral symptoms 
indicating meningitis, so that it is not surprising to find it developed 
by the form under special consideration. The mechanism of this 
metastasis, however, is a matter of much interest. Formerly, it was 
explained as being a localized manifestation of a general morbid 
condition. At present, believers in the germ theory will maintain 
that it is due to an incursion of the bacillus of erysipelas from the 
frontier regions to the interior. Before accepting the foregoing it 
seems but just to call attention to the possibility of direct extension 
of the disease from the deeper layers of the olfactory region, and 
through the cribriform plate of the ethmoid bone, to the meninges; 
or, as is still more likely, from the surface of the face in the vicinity 
of the nose, forehead, and eyelids, through the anastomosis of the 
angular branch of the facial and other superficial facial vessels with 
the ophthalmic vein.* 
As has been long ago pointed out by Mr. Spencer Watson, of 
London, and others, in cases of severe inflammation of the nasal 
* Quain’s "Elements of Anatomy,” eighth edition, London, 1878, vol. i, p. 484. 6 
ERYSIPELAS OF THE LARYNX AND PHARYNX. 
cavities an important point from the clinical aspect is that the intra- 
cranial symptoms come on very insidiously, and that the nasal disease 
is often quite overlooked, so that the appearance of meningitis seems 
inexplicable, or is attributed to some other cause. Mr. Frank Ogston 
reports a case (“British Medical Journal,” May 16, 1885) in which 
the post-mortem examination showed that the exciting cause was 
an inflammation of the nasal mucous membrane which had spread 
through the orbital plate of the ethmoid bone and the dura mater to 
the arachnoid membrane, which it had attacked, and the inflammation 
had spread along the subarachnoid space. 
Careful examination of the dura mater showed that it was healthy 
except a small patch which covered the orbit, which was thickened, 
roughened on the side toward the bone, and covered with a layer of 
lymph on the side next the brain, by which it was glued to the 
arachnoid. The orbital plate of the right side presented a canary- 
yellow appearance and a congested and roughened state of the bone. 
On cutting through this, the nasal cavity was found to be filled with 
a thick, creamy pus, which welled out. into the brain cavity. Dr. 
McNaught, in a succeeding number of the same journal, reports two 
similar cases, both of which were attended with fatal results. There 
were no autopsies. In both cases a very profuse discharge of foetid 
pus took place suddenly from both nostrils. Although there was 
nothing especial pointing to the frontal sinuses in these cases, Dr. 
McNaught thought that there would be little doubt that the menin- 
gitis had been set up by continuity from inflammation of the mu- 
cous membrane lining these cavities.* 
While it is extremely improbable that in ordinary conditions of 
chronic inflammation the disease should thus extend itself, still it is 
by no means difficult to believe that a violent phlegmonous lesion 
of the deeper structures of the olfactory region might communicate 
itself to the neighboring highly vascular structures of the brain 
cavity. Still more reasonable is it to suppose that an erysipelas, in- 
volving the integument of the nose, forehead, and eyelid, should be 
conveyed to the brain-cavity by the way of the ophthalmic vein. The 
influence of inflammatory conditions of the middle ear and of the 
frontal sinus in exciting cerebral complications is well attested. 
By whatever process it may have occurred in the case under 
consideration, there was established, without doubt, a meningitis, at 
first acute. Subsequently the acute attack passed into the chronic 
* “Report on Laryngology,” Dr. F. H. Hooper, “Boston Med. and Surg. Jour.,” 
August 20, 1886. ERYSIPELAS OF THE LARYNX AND PHARYNX. 
7 
form, presenting the symptoms of this condition typically described 
toward the end of the history. 
Case number 2 is more after the usual course of the disease. 
The patient was old, feeble, and lithiatic. She was housed in a 
crowded, ill-ventilated hospital ward, in which, although there may 
not actually have been another case then, erysipelas was never, for 
any great length of time, absent. 
That the original seat of the disease was the larynx is plain, 
while its extension to the lungs on the one hand, and to the pharynx 
and the general surface on the other, renders the case one of rare and 
peculiar interest. 
In an article published in the “ Rivista Clinica e Terapeutica,” 
No. 1, 1885, Dr. F. Massei, of Naples, endeavors to prove, from a 
study of thirteen cases, that the so-called primary oedema of the 
larynx, or phlegmonous laryngitis, corresponds clinically to a locali- 
zation of erysipelas in the larynx. He describes the objective symp- 
tom of the disease as being a marked swelling, which, beginning at 
the epiglottis, extends to the mucous membrane of the arytseno- 
epiglottic ligament and the inter-arytamoid space, causing dyspnoea, 
dysphagia, and aphonia. The onset is generally sudden, and the 
laryngoscope shows such intense swelling that the interior of the 
larynx can not be demonstrated. Blood and pus are occasionally 
poured forth from spontaneous rupture of the mucous membrane. 
Often the swelling migrates, decreasing on one side and increasing 
on the other. The prognosis is, either recovery or else death by 
asphyxia or pneumonia. 
Massei considers the disease erysipelatous for the following 
reasons: 
1. Its rapid development and its tendency to wander, as well 
as its predilection for parts in which the lymphatics are abundant. 
2. The constitutional symptoms, which resemble those of ery- 
sipelas. 
3. Its want of resemblance, from its migratory character, to the 
ordinary forms of laryngitis. 
4. The tendency of the disease to extend to the lungs; and, 
finally, its occurrence during the course of epidemics of erysipelas. 
He concludes: 
1. There is a primary erysipelas of the larynx. 
2. Many cases reported as primary oedema of the larynx are really 
cases of erysipelas; this occurs more commonly than is generally 
supposed. 8 
ERYSIPELAS OF THE LARYNX AND PHARYNX. 
3. There are two forms: in the first the local manifestations 
precede the general; in the second they close the scene. 
4. The best methods of treatment are applications of cold, scari- 
fication, and, finally, if asphyxia threatens, tracheotomy. 
It will be seen that Massei’s observations relate solely to the 
larynx. Although somewhat general in their nature, they are given 
as supplementing the views of the writers quoted above. 
As to treatment, this of course must be both local and constitu- 
tional. Morell Mackenzie has had beneficial results in two cases of 
pharyngeal erysipelas from the insufflation twice daily of morphia, 
one quarter grain, diluted with starch, while ice was constantly sucked 
and bromide of potassium given every four hours. lie believes that 
hot soothing inhalations should not be used so long as there is any 
chance of arresting the inflammation. Should gangrene supervene, 
antiseptic gargles must be employed. Iron, and, if necessary, quinine, 
ammonia, and stimulants should be administered, and a most nutri- 
tious diet insisted upon, while the danger of asphyxia must be borne 
constantly in mind. 
By a careful study of the special conditions and necessities of 
individual cases, and by the prompt application of such measures as 
shall meet the given indications, much may be done, without doubt, 
to relieve the patient and hasten recovery. 
It is hoped that the discussion of this paper may elicit minor 
suggestions more definite and more useful than any we have been 
able to give. In general, it may be said that in local treatment the 
effect upon the patient of such drugs as morphia, etc., must be care- 
fully remembered. The use of the spray apparatus, as contrasted 
with the older methods for making applications, promises well for 
additional comfort and success. 
The writer is certain that, as house surgeon ten years ago in a 
large public hospital in which the erysipelas pavilions formed an 
important part of the service, both laryngeal and pharyngeal cases 
were occasionally presented. Unfortunately, their real nature was 
not then recognized, and in the lapse of time which has since occurred 
the recollection of the facts connected with them has become too 
indistinct to enable him to refer to them with any confidence or 
accuracy. 
Disc ussion. 
Dr. De Blois said: My case, to which the reader has just referred, 
closely simulated follicular tonsillitis, and I treated it as such for twenty- 
four hours. The pharynx was involved in the inflammatory process, and ERYSIPELAS OF THE LARYNX AND PHARYNX. 
9 
both tonsils were equally affected. On the next day it appeared to have 
extended to the nasal cavities. There was a discharge from the nose, and 
what was much like a diphtheritic membrane in the posterior nasal 
cavities. There was no appearance on the face of any skin affection. 
There was some malaise, but the patient did not have a higher tempera- 
ture than would be usual in the course of a severe tonsillitis. On the 
fourth day, when the disease passed on to the nasal cavities, the inflam- 
mation of the tonsils was somewhat improved. Later erysipelatous 
redness appeared over the bridge of the nose. The internal manifesta- 
tions meanwhile became somewhat better, and the case progressed to 
a very severe attack of facial erysipelas. She subsequently recovered. 
The point which I wished to bring out was, the difficulty of diagnosis. 
Dr. Rice.—It would seem strange that erysipelas of the larynx and 
pharynx should be such an infrequent disease when the conditions are so 
favorable to its development. Cases of facial erysipelas are very com- 
mon when at the same time the patient is suffering with extensive 
ulcerations of the nose and pharynx, which, we should suppose, would 
invite an extension of the disease to this locality. And yet this is a rare 
occurrence. Ulcerations on the cutaneous surface are almost always 
attacked; on the mucous membrane it is the exception. I am con- 
vinced that erysipelas of the larynx does exist where a diagnosis is 
not made. I remember in the erysipelas wards of Charity Hospital there 
were two cases (which were called “oedema glottidis ”) where trache- 
otomy was done; the inflammation here was probably of an erysipelatous 
nature. 
Dr. Roe.—An interesting case of erysipelas of the larynx and pharynx 
came under my observation about a year and a half ago, in a lady, about 
thirty-seven years of age, of a nervous sanguine temperament. She was 
under treatment for naso-pharyngeal catarrh. The attack seemed to he 
due to exposure during a slight fall of snow, in the course of which she 
rubbed her face with snow. Within six hours afterward she had well- 
marked facial erysipelas. This went on its usual course, but soon as- 
sumed a severe type. Within thirty-six hours afterward she had delirium. 
The erysipelas extended to the neck and into the pharynx, also into the 
larynx, causing marked oedema of the larynx and pharynx, so that there 
was severe dyspnoea for about twenty-four hours. One night I remained 
in the house expecting to have to perform tracheotomy before morning. 
I used the usual course for erysipelas—i. e., mild alkaline sprays, with 
a little alcohol—which seemed to have a very quieting and soothing effect, 
and soon the erysipelas began to subside in the face and gradually in the 
larynx and pharynx. In about four days the symptoms in that region 
disappeared. These cases must be unusual, as Dr. Delavan has said, 
although often attributed, probably, to other causes. 
Dr. Cohen.—Having seen the admirable effects of the hypodermic 
injection of hydrochlorate of pilocarpine in facial erysipelas in hospital 
practice, it occurs to me that it would be an admirable method of treat- 10 
ERYSIPELAS OF THE LARYNX AND PHARYNX. 
ing these rare cases. Its action in doses of one sixth of a grain is very 
prompt. 
Dr. Delavan, in closing the discussion, said: There seems to be no 
reason why any inflammatory condition of the pharynx—such as diph- 
theria, follicular tonsillitis, or peritonsillar abscess—should not excite an 
attack of erysipelas, so that a case beginning as a simple attack of one of 
the former affections may result in the latter. With regard to the use of 
pilocarpine, I have found the dose recommended to be, in some cases, 
excessive, and would urge the employment of this potent drug in smaller 
quantities, one twentieth of a grain often being sufficient. 
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