ACUTE INFLAMMATIONS OF THE PHARYNX 101 and especially nowadays glandular fever. Tertiary syphilis may closely simulate the ulceration of Vincent's angina, and the fact that the two condi- tions may coexist means that serological tests may be inconclusive. TREATMENT. The condition responds readily to systemic antibiotics such as penicillin and erythromycin, and to metronidazole (Flagyl) tablets, giving 200 mg thrice daily. Apart from this, warm gargles of sodium bicarbonate solution will help to remove the membrane. The patient and his relatives must be warned about the infectious nature of the disease. The patient should be confined to his room, and his dishes must be thoroughly cleaned. DIPHTHERIA Because of the success of inoculation there is now almost no part of the Western world where the diphtheria bacillus exists as a virulent strain. If it is isolated on a throat swab it will be so avirulent that it will respond to penicillin therapy. The attenuated strain will not cause membrane formation which characterizes the typical infection. Unfortunately some of the developing countries do not have a successful programme of inoculation, and in these the disease is still found. It affects those in the first 10 years of life, particularly in the 2-3 years age group. Incubation takes 2-7 days and the onset is insidious with a temperature of some 39-5 °C. The disease is characterized by the appearance of a false membrane on the tonsils, soft palate and posterior pharyngeal wall (Plate K,2). The colour of the membrane is usually grey, but it may be white, yellow or dark brown. It is firmly attached to the mucosa, and leaves a bleeding surface when it is removed, after which it quickly re-forms. The cervical glands are enlarged, often markedly so, and tender. The disease may affect the nasal cavities and nasopharynx to produce a foetid and bloodstained discharge. Diphtheria may spread to involve the larynx and trachea where membrane formation imperils the airway. When the disease is suspected a throat swab is taken and treatment is started without delay. A dose of antitoxin, 10 000 units in a mild case and up to 80 000 units in a severe one, is given. The Corynebacterfum diphtheriae is sensitive to antibiotics, particularly penicillin and erythromycin, and one of these should be ordered together with the antitoxin to prevent complications. ULCERS OF THE MOUTH AND PHARYNX The epithelium of the mouth and pharynx may be involved in a number of conditions which produce ulceration. Vincent's angina has already been described, and the chronic ulcerations will be discussed in Chapter 23. Leucoplakia is described on 115p. . Streptococcus viridans produces characteristic small shallow ulcers with a yellow centre distributed on the soft palate and palatoglossal arches. Each ulcer resembles the effect of a scratch with a finger-nail. They respond to antiseptic gargles such as hexetidine (Oraldene). Shallow ulcerations may be found with pneumococcal and streptococcal infections, and are treated by systemic penicillin.