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PRACTICAL STRATEGIES IN PEDIATRIC DIAGNOSIS AND THERAPY ISBN: 0–7216–9131–5

Second Edition
Copyright © 2004, 1996, Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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NOTICE

Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and
clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current product information provided by the manufacturer
of each drug to be administered to verify the recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge
of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher
nor the authors assumes any liability for any injury and/or damage to persons or property arising from this
publication.

First Edition copyrighted 1996.

Library of Congress Cataloging-in-Publication Data

Practical strategies in pediatric diagnosis and therapy / [edited by] Robert M. Kliegman,
Larry A. Greenbaum, Patricia S. Lye.—2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0–7216–9131–5
1. Pediatrics—Decision making. 2. Pediatrics. I. Kliegman, Robert. II. Greenbaum,
Larry A. III. Lye, Patricia S.
[DNLM: 1. Pediatrics. WS 200 P895 2004]
RJ47.P724 2004
618.92—dc22 2003069724

Executive Publisher: Judith Fletcher

Developmental Editors: Wendy Buckwalter Coffman/Dana Lamparello
Senior Project Manager: Robin E. Davis
Book Designer: Gene Harris

Printed in the United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to those master clinician-educators
who have inspired us with their clinical wisdom,
enthusiasm, empathy, and insight. At no time in the history of
pediatrics have these adaptable master clinician-educators
been needed more to inspire young students and residents and
to provide encouragement and clinical guidance to the
practicing pediatrician.

In this light, we dedicate this edition to the memory of

Dr. David A. Lewis, Associate Professor of Pediatrics,
Director of Residency Training, Pediatric Cardiologist, and
master clinician at the Children’s Hospital of Wisconsin.
His teaching will be missed by us all.
Contributors

Uri S. Alon, MD R. Alexander Blackwood, MD, PhD

Professor of Pediatrics, University of Missouri at Kansas City Associate Professor of Pediatrics and Pediatric Infectious Diseases,
School of Medicine; Pediatric Nephrologist and Director, Bone and University of Michigan Medical School, Ann Arbor, Michigan
Mineral Disorders Clinic, Children’s Mercy Hospital, Kansas City, Recurrent Infection
Missouri
Acid-Base and Electrolyte Disturbances
Andrew Bleasel, MBBS, PhD
Staff Specialist, Neurology and Neurophysiology, Westmead
R. Stephen S. Amato, MD, PhD Hospital and Children’s Hospital at Westmead, Sydney, Australia
Clinical Professor of Pediatrics, Tufts University School of Paroxysmal Disorders
Medicine, Boston, Massachusetts; Chief, Pediatrics Service and
Director, Medical Genetics, Eastern Maine Medical Center, Bangor,
Maine Laurence A. Boxer, MD
Dysmorphology Henry and Mala Dorfman Family Professor in Pediatric
Hematology/Oncology, University of Michigan Medical School;
Director, Pediatric Hematology/Oncology, C. S. Mott Children’s
Stephen C. Aronoff, MD Hospital, Ann Arbor, Michigan
Professor and Chair, Department of Pediatrics, Temple University Recurrent Infection
School of Medicine; Temple University Children’s Medical Center,
Philadelphia, Pennsylvania
Fever of Unknown Origin Ben H. Brouhard, MD
Professor of Pediatrics and Associate Dean, Case Western Reserve
University School of Medicine; Executive Vice President of Medical
Jane P. Balint, MD Affairs and Chief of Staff, MetroHealth System, Cleveland, Ohio
Hematuria
Clinical Associate Professor, Ohio State University; Pediatric
Gastroenterologist, Columbus Children’s Hospital, Columbus, Ohio
Jaundice
Gale R. Burstein, MD, MPH
Medical Officer, Division of HIV/AIDS Prevention, Centers for
Sharon Bartosh, MD Disease Control and Prevention, Atlanta, Georgia
Sexually Transmitted Diseases
Associate Professor of Pediatrics, University of Wisconsin School of
Medicine; Chief, Division of Pediatric Nephrology, University of
Wisconsin Children’s Hospital, Madison, Wisconsin Vimal Chadha, MD
Hypertension
Assistant Professor of Pediatrics, Virginia Commonwealth University
School of Medicine; Chair, Section of Pediatric Nephrology, Virginia
Commonwealth University Medical Center, Richmond, Virginia
Stuart Berger, MD Acid-Base and Electrolyte Disturbances
Professor of Pediatrics, Medical College of Wisconsin; Medical
Director, Herma Heart Center, Children’s Hospital of Wisconsin,
Milwaukee, Wisconsin John C. Chandler, MD
Heart Failure Pediatric Surgeon, Children’s Hospital of the Greenville Hospital
System, Greenville, South Carolina
Abdominal Masses
Brian W. Berman, MD
Professor of Pediatrics, Case Western Reserve University School of
Medicine; Vice Chair for Community–Physician Affairs and Chief, Bruce H. Cohen, MD
Division of General Academic Pediatrics, Rainbow Babies and Staff, Section of Pediatric Neurology, Department of Neurology,
Children’s Hospital, Cleveland, Ohio Cleveland Clinic Foundation, Cleveland, Ohio
Lymphadenopathy; Pallor and Anemia Headaches in Childhood

David J. Beste, MD Robert J. Cunningham III, MD

Medical Director, Speech and Audiology, Children’s Hospital of Chair, Medical Subspecialty Pediatrics and Head, Section of
Wisconsin, Milwaukee, Wisconsin Pediatric Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio
Neck Masses in Childhood Proteinuria
vii
viii Contributors

Leona Cuttler, MD Larry A. Greenbaum, MD, PhD

Professor of Pediatrics, Case Western Reserve University School of Associate Professor, Department of Pediatrics, Medical College of
Medicine; Chief, Division of Endocrinology, Diabetes, and Wisconsin; Children’s Hospital of Wisconsin, Milwaukee,
Metabolism, Rainbow Babies and Children’s Hospital, Cleveland, Wisconsin
Ohio Delirium and Coma
Short Stature

Marjorie Greenfield, MD
Jack S. Elder, MD Associate Professor of Reproductive Biology, Case Western Reserve
Professor of Pediatrics and Carter Kissell Professor of Urology, Case University School of Medicine; Associate Professor of Obstetrics
Western Reserve University School of Medicine; Director, Pediatric and Gynecology and Pediatrics, University Hospitals of Cleveland,
Urology, Rainbow Babies and Children’s Hospital, Cleveland, Ohio Cleveland, Ohio
Acute and Chronic Scrotal Swelling; Ambiguous Genitalia Menstrual Problems and Vaginal Bleeding

Susan Feigelman, MD Ajay Gupta, MD

Associate Professor of Pediatrics, University of Maryland School of Staff, Section of Pediatric Neurology and Epilepsy, Department of
Medicine, Baltimore, Maryland Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
Failure to Thrive and Malnutrition Headaches in Childhood

Thomas Ferkol, MD Peter L. Havens, MD

Associate Professor of Pediatrics, Washington University School of Professor of Pediatrics and Epidemiology, Medical College of
Medicine; Director, Cystic Fibrosis Center, St. Louis Children’s Wisconsin; Consultant in Infectious Diseases, Children’s Hospital of
Hospital, St. Louis, Missouri Wisconsin, Milwaukee, Wisconsin
Respiratory Distress Meningismus and Meningitis

Michele A. Frommelt, MD Jeffrey S. Hyams, MD

Associate Professor of Pediatrics, Medical College of Wisconsin; Professor of Pediatrics, University of Connecticut School of
Children’s Hospital of Wisconsin, Milwaukee, Wisconsin Medicine, Farmington, Connecticut; Head, Division of Digestive
Cyanosis
Diseases, Connecticut Children’s Medical Center, Hartford,
Connecticut
Gastrointestinal Bleeding
Peter C. Frommelt, MD
Associate Professor of Pediatrics, Medical College of Wisconsin;
Director of Pediatric Echocardiography, Children’s Hospital of
Wisconsin, Milwaukee, Wisconsin David M. Jaffe, MD
Cyanosis Dana Brown Professor of Pediatrics, Washington University School
of Medicine; Director, Division of Emergency Services, St. Louis
Children’s Hospital, St. Louis, Missouri
Fever without Focus
Michael W. L. Gauderer, MD
Professor of Surgery, University of South Carolina School of
Medicine; Adjunct Professor of Bioengineering, Clemson
University; Chief, Pediatric Surgery, Children’s Hospital of the Candice E. Johnson, MD, PhD
Greenville Hospital System, Greenville, South Carolina Professor of Pediatrics, University of Colorado School of Medicine;
Abdominal Masses Attending Physician, Children’s Hospital, Denver, Colorado
Dysuria

Mitchell E. Geffner, MD
Professor, University of Southern California Keck School of Hugh F. Johnston, MD
Medicine; Physician and Director of Fellowship Training, Division Professor, Departments of Psychiatry and Educational Psychology,
of Endocrinology, Diabetes, and Metabolism, Childrens Hospital University of Wisconsin Medical School; University of Wisconsin
Los Angeles, Los Angeles, California Hospital and Clinics, Madison, Wisconsin
Disorders of Puberty Unusual Behaviors

Manju E. George, MD Virginia Keane, MD

Resident in Dermatology, University of Kansas Medical Center, Associate Professor of Pediatrics, University of Maryland School of
Kansas City, Kansas Medicine, Baltimore, Maryland
Rashes and Skin Lesions Failure to Thrive and Malnutrition

William M. Gershan, MD Carolyn M. Kercsmar, MD

Associate Professor of Pediatrics, Medical College of Wisconsin; Professor of Pediatrics, Case Western Reserve University School of
Pediatric Pulmonologist, Children’s Hospital of Wisconsin, Medicine; Director, Children’s Asthma Center, Rainbow Babies and
Milwaukee, Wisconsin Children’s Hospital, Cleveland, Ohio
Cough Respiratory Distress
 Contributors ix
Robert M. Kliegman, MD Amy Jo Nopper, MD
Professor and Chair, Department of Pediatrics, Medical College of Associate Professor of Pediatric Dermatology, University of
Wisconsin; Pediatrician-in-Chief and Pam and Les Muma Chair in Missouri–Kansas City School of Medicine; Chief, Section of
Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin Pediatric Dermatology, Children’s Mercy Hospital, Kansas City,
Airway Obstruction in Children; Acute and Chronic Abdominal Pain Missouri
Rashes and Skin Lesions

Subra Kugathasan, MD
Associate Professor of Pediatrics, Medical College of Wisconsin; Susan R. Orenstein, MD
Children’s Hospital of Wisconsin, Milwaukee, Wisconsin Professor of Pediatrics, Division of Pediatric Gastroenterology,
Diarrhea University of Pittsburgh School of Medicine; Children’s Hospital of
Pittsburgh, Pittsburgh, Pennsylvania
Vomiting and Regurgitation
Robert M. Lembo, MD
Associate Professor of Clinical Pediatrics and Director, Medical
Education, Department of Pediatrics, New York University School of Michael J. Painter, MD
Medicine; Attending Physician, Bellevue Hospital Center, New York, Professor of Neurology and Pediatrics, Division of Child Neurology,
New York University of Pittsburgh School of Medicine; Children’s Hospital of
Fever and Rash Pittsburgh, Pittsburgh, Pennsylvania
Hypotonia and Weakness

David A. Lewis, MD
Associate Professor of Pediatrics, Division of Pediatric Cardiology; Cynthia G. Pan, MD
Director, Graduate Medical Education Program, Medical College of Associate Professor of Pediatrics, Medical College of Wisconsin;
Wisconsin, Milwaukee, Wisconsin (Deceased) Medical Director, Dialysis Unit and Nephrology, Children’s Hospital
Syncope and Dizziness of Wisconsin, Milwaukee, Wisconsin
Polyuria and Urinary Incontinence

Gregory S. Liptak, MD, MPH

Professor of Pediatrics, University of Rochester Medical Center; Andrew N. Pelech, MD
Attending Physician, Strong Memorial Hospital, Rochester, New York Associate Professor of Pediatrics, Division of Cardiology, Medical
Mental Retardation and Developmental Disability College of Wisconsin; Children’s Hospital of Wisconsin, Milwaukee,
Wisconsin
Heart Sounds and Murmurs
Patricia S. Lye, MD
Associate Professor, Department of Pediatrics, Medical College of
Wisconsin; Children’s Hospital of Wisconsin, Milwaukee, Wisconsin John M. Peters, DO
Earache Assistant Professor of Pediatrics, Division of Pediatric
Gastroenterology, University of Pittsburgh School of Medicine;
Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Saleem I. Malik, MD Vomiting and Regurgitation
Associate Director, Comprehensive Epilepsy Center, Cook
Children’s Hospital, Fort Worth, Texas
Hypotonia and Weakness Emory M. Petrack, MD
Associate Clinical Professor, Department of Pediatrics, Case
Western Reserve University School of Medicine; President, Petrack
Kelly W. Maloney, MD Consulting, Inc., Cleveland, Ohio
Assistant Professor of Pediatrics, Medical College of Wisconsin, The Irritable Infant
Milwaukee, Wisconsin
Splenomegaly
Philip A. Pizzo, MD
Professor of Pediatrics and of Microbiology and Immunology; Dean,
Andrea C. S. McCoy, MD Stanford University School of Medicine, Stanford, California
Associate Professor of Pediatrics, Temple University School of Fever and Neutropenia
Medicine and Temple University Children’s Medical Center,
Philadelphia, Pennsylvania
Fever of Unknown Origin Robert M. Reece, MD
Clinical Professor of Pediatrics, Tufts University School of
Medicine; Visiting Professor of Pediatrics, Dartmouth Medical
Daniel W. McKenney, MD School; Director of Child Protection Program, The Floating
Associate Professor of Pediatrics, Nephrology and Hypertension Hospital for Children at New England Medical Center, Boston,
Division, University of Louisville, Louisville, Kentucky Massachusetts
Renal Failure Child Abuse

James J. Nocton, MD Michael J. Rivkin, MD

Associate Professor of Pediatrics, Medical College of Wisconsin; Associate Professor of Neurology, Harvard Medical School; Attending
Director, Pediatric Residency Training Program, Children’s Hospital Physician, Department of Neurology; Director, Developmental
of Wisconsin, Milwaukee, Wisconsin Neuroimaging Laboratory, Children’s Hospital, Boston, Massachusetts
Arthritis Stroke in Childhood
x Contributors

Mark S. Ruttum, MD Francisco A. Sylvester, MD

Professor of Ophthalmology, Medical College of Wisconsin; Chief Associate Professor of Pediatrics, University of Connecticut School
of Pediatric Ophthalmology, Children’s Hospital of Wisconsin, of Medicine; Pediatric Gastroenterologist, Connecticut Children’s
Milwaukee, Wisconsin Medical Center, Hartford, Connecticut
Eye Disorders Gastrointestinal Bleeding

John R. Schreiber, MD, MPH Robert R. Tanz, MD

Professor of Pediatrics and Pathology, Case Western Reserve Professor and Director of Medical Education, Department of
University School of Medicine; Chief, Division of Infectious Pediatrics, Northwestern University Feinberg School of Medicine;
Diseases, Allergy, Immunology, and Rheumatology, Rainbow Babies Attending Physician, Division of General Academic Pediatrics,
and Children’s Hospital, Cleveland, Ohio Children’s Memorial Hospital, Chicago, Illinois
Lymphadenopathy Sore Throat

J. Paul Scott, MD John G. Thometz, MD

Professor, Medical College of Wisconsin; Attending Physician, Professor of Orthopaedic Surgery, Medical College of Wisconsin;
Children’s Hospital of Wisconsin, Milwaukee, Wisconsin Chief, Pediatric Orthopaedic Surgery and Medical Director,
Bleeding and Thrombosis Orthopaedic Surgery, Children’s Hospital of Wisconsin, Milwaukee,
Wisconsin
Back Pain in Children and Adolescents
Stanford T. Shulman, MD
Professor of Pediatrics, Northwestern University Feinberg School of
Medicine; Chief, Division of Infectious Diseases, Children’s George H. Thompson, MD
Memorial Hospital, Chicago, Illinois Professor of Orthopaedic Surgery and Pediatrics, Case Western
Sore Throat
Reserve University School of Medicine; Director, Pediatric
Orthopaedics, Rainbow Babies and Children’s Hospital, Cleveland,
Ohio
Garry S. Sigman, MD Gait Disturbances
Professor, Northwestern University Feinberg School of Medicine;
Director, Adolescent Medicine, Evanston Northwestern Healthcare,
Evanston, Illinois
Chest Pain George F. Van Hare, MD
Associate Professor of Pediatrics, Stanford University School
of Medicine; Director, Pediatric Arrhythmia Center, Lucile Packard
Mark L. Splaingard, MD Children’s Hospital at Stanford University Medical Center; Director,
Professor of Pediatrics, Medical College of Wisconsin; Director of Pediatric Arrhythmia Center, University of California, San Francisco,
Pediatric Pulmonary Care, Children’s Hospital of Wisconsin, Children’s Hospital, San Francisco, California
Palpitations and Arrhythmias
Milwaukee, Wisconsin
Apnea and Sudden Infant Death Syndrome

Kristine G. Williams, MD, MPH

Charles A. Stanley, MD Instructor of Pediatrics, Division of Pediatric Emergency Medicine,
Professor of Pediatrics, University of Pennsylvania School of Washington University School of Medicine, St. Louis, Missouri
Fever without Focus
Medicine; Chief, Division of Endocrinology, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
Hypoglycemia
Martha S. Wright, MD
Associate Professor of Pediatrics, Case Western Reserve University
Rita Steffen, MD School of Medicine; Associate Director, Pediatric Emergency
Staff, Department of Pediatric Gastroenterology, Cleveland Clinic Medicine, Rainbow Babies and Children’s Hospital/University
Foundation, Cleveland, Ohio Hospitals of Cleveland, Cleveland, Ohio
Constipation Bites

Elaine Wyllie, MD
Frederick J. Suchy, MD
Head, Section of Pediatric Neurology and Pediatric Epilepsy,
Professor and Chair, Department of Pediatrics, Mount Sinai School of
Cleveland Clinic Foundation, Cleveland, Ohio
Medicine; Pediatrician-in-Chief, Mount Sinai Hospital, New York, Paroxysmal Disorders
New York
Hepatomegaly
Robert Wyllie, MD
Chair, Department of Pediatric Gastroenterology, Cleveland Clinic
William J. Swift, MD Foundation, Cleveland, Ohio
Professor Emeritus of Child and Adolescent Psychiatry, University Constipation
of Wisconsin Medical School and Wisconsin Psychiatric Institute
and Clinic, Madison, Wisconsin; Regional Medical Officer and
Psychiatrist, U.S. Department of State, Pretoria, South Africa
Unusual Behaviors
Preface

Most children’s hospitals and pediatric residency training programs This text is intended to help the reader begin with a specific chief
have multiple educational conferences, such as professor rounds, complaint that may encompass many disease entities. In a user-
patient management conference, clinicopathologic conference, and friendly, well-tabulated, and illustrated approach, the text will help
senior resident intake rounds. In these high-quality learning activi- the reader differentiate between the many disease states causing a
ties, experienced master clinician-educators lead a discussion of a common chief complaint. The inclusion of many original tables and
particular patient-based issue, permitting the trainees to see how a figures should help the reader identify distinguishing features of
master clinician thinks through diagnostic or therapeutic challenges. diseases and work through a diagnostic and/or therapeutic approach
The advice given is derived from the knowledge accumulated over to the problem using decision trees. Modified, adapted, and borrowed
many years of clinical experience and careful analysis of the medical artwork and tables from other outstanding sources have been added
literature. The synthesis of the facts of the case with the clinician’s as well. The combination of all of these illustrations and tables will
practical experience and knowledge of the literature often results in help provide a quick visual guide to the differential diagnosis or
the diagnosis and the appropriate treatment strategy. These master treatment of the various diseases under discussion.
clinician-educators provide wisdom that gives clarity to confusing
clinical cases and helps to reconcile discrepancies between practice We greatly appreciate the hard work of our contributing authors.
and theory. Writing a chapter in this type of format is quite different from
In addition, master clinician-educators focus on the importance writing in the format of a disease-based book. In addition, we greatly
of a detailed history and a complete physical examination. The chief appreciate the efforts of Judy Fletcher of Elsevier, whose patience
complaint directs the questioning during the history, whereas the and expertise contributed to the publication of this book. We are all
physical examination focuses on clues obtained by the history. also greatly appreciative of Carolyn Redman of the Department of
Laboratory and other studies are then employed to support the Pediatrics at the Medical College of Wisconsin, whose editorial
diagnosis, not to make the diagnosis. assistance and organization has made this edition a reality. The
The goal of this book is to put into a written text the oral teach- authors also wish to make a special acknowledgment to Dr. Brendan
ing rounds–based approaches toward clinical problem solving of the M. Reilly, for his courtesy and assistance. Finally, we acknowledge
many expert clinician-educators who present at teaching confer- the support and, at times, sacrifice of our families: Sharon, Jonathan,
ences. The combination of clinical experience and evidenced-based Rachel, Alison, and Matthew Kliegman; Jordan, Harry, and Irene
strategies will provide guidance in developing a differential diagno- Greenbaum; and Dale, Erin, John, and Therese Lye, whose
sis, then a specific diagnosis, and finally the appropriate therapy of understanding helped make the time and effort put into this book
common pediatric problems. This book is arranged in chapters that meaningful.
cover specific chief complaints, mirroring clinical practice. Patients
do not usually present with a chief complaint of cystic fibrosis; ROBERT M. KLIEGMAN
rather, they may present with a cough, respiratory distress, or chronic LARRY A. GREENBAUM
diarrhea.
PATRICIA S. LYE
1 Sore Throat

Robert R. Tanz Stanford T. Shulman

Sore throat is a common chief complaint. Each year approximately The enteroviruses (coxsackievirus and echovirus) can cause sore
20 million patients in the United States visit physicians because of throat, especially in the summer. High fever is common, and the
throat complaints. The majority of these illnesses are nonbacterial throat is slightly red; tonsillar exudate and cervical adenopathy are
and neither necessitate nor are alleviated by antibiotic therapy unusual. Symptoms resolve within a few days. Enteroviruses can
(Tables 1-1 to 1-3). Acute streptococcal pharyngitis, however, warrants
accurate diagnosis and therapy to prevent serious suppurative
and nonsuppurative complications. Furthermore, life-threatening
Table 1-1. Etiology of Sore Throat
infectious complications of streptococcal and nonstreptococcal
oropharyngeal infections may manifest with mouth pain, pharyngitis, Infection
parapharyngeal space infectious extension, and airway obstruction Bacterial (see Tables 1-2, 1-3)
(Tables 1-4 and 1-5). Viral (see Tables 1-2, 1-3)
Fungal (see Table 1-3)
Neutropenic mucositis (invasive anaerobic mouth flora)
VIRAL PHARYNGITIS Tonsillitis
Epiglottitis
Most episodes of pharyngitis are caused by viruses (see Tables 1-2 Uvulitis
and 1-3). It is difficult to clinically distinguish between viral and Peritonsillar abscess (quinsy sore throat)
bacterial pharyngitis with a very high degree of precision, but certain Retropharyngeal abscess (prevertebral space)
clues may help the physician. Accompanying symptoms of conjunc- Ludwig angina (submandibular space)
tivitis, rhinitis, croup, or laryngitis are common with viral infection Lateral pharyngeal space cellulitis-abscess
but rare in bacterial pharyngitis. Buccal space cellulitis
Many viral agents can produce pharyngitis (see Tables 1-2 Suppurative thyroiditis
and 1-3). Some cause distinct clinical syndromes that are readily Lemierre disease (septic jugular thrombophlebitis)
diagnosed without laboratory testing (see Tables 1-1, 1-4, and 1-6). Vincent angina (mixed anaerobic
In pharyngitis caused by parainfluenza and influenza viruses, bacteria–gingivitis–pharyngitis)
rhinoviruses, coronaviruses, and respiratory syncytial virus (RSV), Irritation
the symptoms of coryza and cough often overshadow sore throat,
which is generally mild. Influenza virus may cause high fever, Cigarette smoking
cough, headache, malaise, myalgias, and cervical adenopathy in addi- Inhaled irritants
tion to pharyngitis. In young children, croup or bronchiolitis may Reflux esophagitis
develop. RSV is associated with bronchiolitis, pneumonia, and croup Chemical toxins (caustic agents)
in young children. RSV infection in older children is usually indis- Paraquat ingestion
tinguishable from a simple upper respiratory tract infection. Smog
Pharyngitis is not a prominent finding of RSV infection in either age Dry hot air
group. Parainfluenza viruses are associated with croup and bronchi- Hot foods, liquids
olitis; minor sore throat and signs of pharyngitis are common at the Other
outset but rapidly resolve. Infections caused by parainfluenza, Tumor, including Kaposi sarcoma, leukemia
influenza, and RSV are often seen in seasonal (winter) epidemics. Wegener granulomatosis
Adenoviruses can cause upper and lower respiratory tract disease, Sarcoidosis
ranging from ordinary colds to severe pneumonia. The incubation Glossopharyngeal neuralgia
period of adenovirus infection is 2 to 4 days. Upper respiratory tract Foreign body
infection typically produces fever, erythema of the pharynx, and fol- Stylohyoid syndrome
licular hyperplasia of the tonsils, together with exudate. Enlargement Behçet disease
of the cervical lymph nodes occurs frequently. When conjunctivitis Kawasaki syndrome
occurs in association with adenoviral pharyngitis, the resulting Posterior pharyngeal trauma—pseudodiverticulum
syndrome is called pharyngoconjunctival fever. Pharyngitis may last Pneumomediastinum
as long as 7 days and does not respond to antibiotics. There are many Hematoma
adenovirus serotypes; adenovirus infections may therefore develop Systemic lupus erythematosus
in children more than once. Laboratory studies may reveal a leuko- Bullous pemphigoid
cytosis and an elevated erythrocyte sedimentation rate. Outbreaks Syndrome of periodic fever, aphthous stomatitis,
have been associated with swimming pools and contamination in pharyngitis, cervical adenitis (PFAPA)
health care workers.

3
4 Section One  Respiratory Disorders

lasts less than 7 days, but severe pain may impair fluid intake
Table 1-2. Infectious Etiology of Pharyngitis and necessitate medical support.
Definite Causes Coxsackievirus A16 causes hand-foot-mouth disease. Vesicles
can occur throughout the oropharynx; they are painful, and
Streptococcus pyogenes (Group A streptococci) they ulcerate. Vesicles also develop on the palms, soles, and,
Corynebacterium diphtheriae less often, on the trunk or extremities. Fever is present in most
Arcanobacterium haemolyticum cases, but many children do not appear seriously ill. This
Neisseria gonorrhoeae disease lasts less than 7 days.
Epstein-Barr virus
Parainfluenza viruses (types 1–4) Primary infection caused by herpes simplex virus (HSV) usually
Influenza viruses produces high fever with acute gingivostomatitis, involving vesicles
Rhinoviruses (which become ulcers) throughout the anterior portion of the mouth,
Coronavirus including the lips. There is sparing of the posterior pharynx in herpes
Adenovirus (types 3, 4, 7, 14, 21, others) gingivostomatitis; the infection usually occurs in young children.
Respiratory syncytial virus High fever is common, pain is intense, and intake of oral fluids is
Herpes simplex virus (types 1, 2) often impaired, which may lead to dehydration. In addition, HSV
may manifest in adolescents with pharyngitis. Approximately 35%
Probable Causes
of new-onset HSV-positive adolescent patients have herpetic lesions;
Group C streptococci most patients with HSV pharyngitis cannot be distinguished from
Group G streptococci patients with other causes of pharyngitis. The classic syndrome of
Chlamydia pneumoniae herpetic gingivostomatitis in infants and toddlers lasts up to 2 weeks;
Chlamydia trachomatis data on the course of more benign HSV pharyngitis are lacking. The
Mycoplasma pneumoniae differential diagnosis of vesicular-ulcerating oral lesions is noted in
Table 1-6. A common cause of a local and large lesion of unknown
etiology is aphthous stomatitis (Fig. 1-1). Some children have a
cause meningitis, rash, and two specific syndromes that involve the combination of periodic fever (recurrent at predictable fixed times),
oropharynx: aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA); this
syndrome is idiopathic and may respond to oral prednisone or
Herpangina is characterized by distinctive discrete, painful, gray- cimetidine. PFAPA usually begins before the age of 5 years and is
white papulovesicular lesions distributed over the posterior characterized by high fever lasting 4 to 6 days, occurring every 2 to
oropharynx (Table 1-6). The vesicles are 1 to 2 mm in diame- 8 weeks, and resolving spontaneously.
ter and are initially surrounded by a halo of erythema before Infants and toddlers with measles often have prominent oral
they ulcerate. Fever may reach 39.5°C. The illness generally findings early in the course of the disease. In addition to high fever,
cough, coryza, and conjunctivitis, the pharynx may be intensely and
diffusely erythematous, without tonsillar enlargement or exudate.
The presence of Koplik spots, the pathognomonic white or blue-
Table 1-3. Additional Potential Pathogens Associated
white enanthem of measles, on the buccal mucosa near the mandibu-
with Sore Throat
lar molars provides evidence of the correct diagnosis before the rash
Bacteria develops.
Fusobacterium necrophorum (Lemierre disease)
Neisseria meningitidis
Yersinia enterocolitica INFECTIOUS MONONUCLEOSIS
Tularemia (orpharyngeal)
Yersinia pestis PATHOGENESIS
Bacillus anthracis
Chlamydia psittaci Acute exudative pharyngitis commonly occurs with infectious
Secondary syphilis mononucleosis caused by primary infection with Epstein-Barr virus
Mycobacterium tuberculosis (EBV) (Table 1-7). Mononucleosis is a febrile, systemic, self-limited
Lyme disease lymphoproliferative disorder that is usually associated with
Corynebacterium ulcerans hepatosplenomegaly and generalized lymphadenopathy. The pharyn-
Leptospira species gitis may be mild or severe, with significant tonsillar hypertrophy
Mycoplasma hominis (possibly producing airway obstruction), erythema, and impressive
tonsillar exudates. Regional lymph nodes may be particularly
Virus enlarged and slightly tender.
Coxsackievirus A, B Infectious mononucleosis usually occurs in adolescents and
Cytomegalovirus young adults; EBV infection is generally milder or subclinical in
Viral hemorrhagic fevers preadolescent children. In United States high school and college
Human immunodeficiency virus students, attack rates are 200 to 800 per 100,000 population per year.
(HIV) (primary infection) EBV is transmitted primarily by saliva.
Human herpesvirus 6
Measles
Varicella CLINICAL FEATURES
Rubella After a 2- to 4-week incubation period, patients with infectious
Fungus mononucleosis usually experience an abrupt onset of malaise, fatigue,
Candida species fever, and headache, followed closely by pharyngitis. The tonsils are
Histoplasmosis enlarged with exudates and cervical adenopathy. More generalized
Cryptococcosis adenopathy with hepatosplenomegaly often follows. Fever and
pharyngitis typically last 1 to 3 weeks, while lymphadenopathy and
 Table 1-4. Distinguishing Features of Parapharyngeal–Upper Respiratory Tract Infections

Submandibular Postanginal
Retropharyngeal Space Lateral Laryngotracheo- Sepsis*
Peritonsillar Abscess (Ludwig Pharyngeal Masticator bronchitis Bacterial (Lemierre
Abscess (Cellulitis) Angina)* Space* Space* Epiglottitis (Croup) Tracheitis Disease)

Etiology Group A Staphylococcus Oral anaerobes† Oral anaerobes† Oral anaerobes† Haemophilus Parainfluenza Moraxella Fusobacterium
streptococci, oral aureus, oral influenzae virus; influenza catarrhalis, necrophorum
anaerobes† anaerobes,† group A type b adeno-virus S. aureus,
streptococci, and respiratory H. influenzae
“suppurative syncytial virus type b or
adenitis” less common nontypable
Age Teens Infancy, preteens, Teens Teens Teens 2–5 yr 3 mo–3 yr 3–10 yr Teens
occasionally teens
Manifestations Initial episode of Fever, dyspnea, Fever, dysphagia, Severe pain, Pain, prominent Sudden-onset Low-grade fever, Prior history of Prior
pharyngitis, stridor, dysphagia, odynophagia, fever, trismus, trismus, fever high fever, barking cough, croup with pharyngitis
followed by drooling, stiff stiff neck, dysphagia, Swelling not “toxic ” hoarseness- sudden onset with sudden-
sudden worsening neck, pain, dyspnea; airway edematous always evident appearance, aphonia, of respiratory onset fever,
of unilateral cervical obstruction, appearing, muffled voice, stridor; mild distress, high chills,
odynophagia, adenopathy, swollen tongue painful lateral anxiety, pain, retractions; fever, “toxic” odynophagia,
trismus, hot swelling of and floor of facial (jaw) or retractions, radiograph appearance, neck pain,
potato (muffled) posterior mouth (tender) neck swelling dysphagia, shows hoarseness, septic
voice, drooling, pharyngeal space Muffled voice (induration) drooling, “steeple sign” stridor, thrombo-
displacement Descending May lead to stridor, sitting of subglottic barking phlebitis
of uvula mediastinitis (rare) Lemierre up, leaning narrowing on cough, tripod of internal
Lateral neck disease forward tripod anteroposterior sitting jugular vein
radiograph position, neck view position; with septic
reveals swollen cherry-red radiograph emboli
retropharyngeal swollen as per croup (e.g., lungs,
prevertebral space: epiglottis plus ragged joints),
Chapter 1  Sore Throat

infants, >1 × Usually not tracheal bacteremia

width of adjacent hoarse or air column
vertebral body coughing
(>2–7 mm); teens, Lateral neck
> 1/3 × width of radiograph
vertebral body shows “thumb
(>1–7 mm) sign” of
CT distinguishes swollen
cellulitis epiglottis
from abscess
Treatment Penicillin for Airway Airway Penicillin, Penicillin, Airway Airway Airway Clindamycin,
abscess and management, management clindamycin, clindamycin, management management management penicillin, or
cellulitis nafcillin, Penicillin, ampicillin- ampicillin- (intubation), (rare) (frequent cefoxitin
Aspiration for ceftriaxone, clindamycin, sulbactam sulbactam ceftriaxone Cool mist, intubation)
abscess (needle ampicillin- ampicillin- Surgical drainage racemic Ceftriaxone
or I and D) sulbactam sulbactam usually required epinephrine, with or
Needle is preferred Surgical drainage Rarely surgical dexamethasone without
if an abscess drainage nafcillin

†
Peptostreptococcus, Fusobacterium, Bacteroides (usually melaninogenicus).
*Often odontogenic; check for tooth abscess, caries, tender teeth.
CT, computed tomography.
5
6 Section One  Respiratory Disorders

Group A streptococci are characterized by the presence of group

Table 1-5. “Red Flags” Associated with Sore Throat A carbohydrate in the cell wall, and they are further distinguished by
Fever > 2 weeks several kinds of cell wall protein antigens (M, R, T). These protein
Duration of sore throat > 2 weeks antigens are useful for studies of epidemiology and pathogenesis.
Trismus
Drooling EPIDEMIOLOGY
Cyanosis
Hemorrhage Group A streptococcal pharyngitis has been endemic in the United
Asymmetric tonsillar swelling or asymmetric cervical States; epidemics occur sporadically. Episodes peak in the late
adenopathy winter and early spring; rates of group A streptococcal pharyngitis
Respiratory distress (airway obstruction or pneumonia) are highest among children aged 5 to 11 years old.
Suspicion of parapharyngeal space infection Spread of group A streptococci in classrooms and among family
Suspicion of diphtheria (bull neck, uvula paralysis, thick members, especially in crowded living conditions, is common.
membrane) Transmission occurs primarily by inhalation of organisms in large
Apnea droplets or by direct contact with respiratory secretions. Pets do not
Severe, unremitting pain appear to be a frequent reservoir. Untreated streptococcal pharyngi-
“Hot potato” voice tis is particularly contagious early in the acute illness and for the first
Chest or neck pain 2 weeks after the organism has been acquired. Antibiotic therapy
Weight loss effectively prevents disease transmission. Within 24 hours of institu-
tion of therapy with penicillin, it is difficult to isolate group A strep-
tococci from patients with acute streptococcal pharyngitis, and
infected children can return to school.
hepatosplenomegaly subside over 3 to 6 weeks. Malaise and lethargy Molecular epidemiology studies of streptococcal pharyngitis
can persist for several months, possibly leading to impaired school have shown that numerous distinct strains of group A streptococci
or work performance. circulate simultaneously in the community during the peak season.
“DNA-fingerprinting” techniques further demonstrate that children
DIAGNOSIS with streptococcal pharyngitis serve as a community reservoir for
strains that cause invasive disease (e.g., sepsis, streptococcal toxic
Laboratory studies of diagnostic value include atypical lymphocytosis; shock syndrome, cellulitis, necrotizing fasciitis) in the same geographic
these lymphocytes are primarily EBV-specific, cytotoxic T lympho- area and season.
cytes that represent a reactive response to EBV-infected B lympho-
cytes. A modest elevation of serum transaminase levels, reflecting CLINICAL FEATURES
EBV hepatitis, is common. Tests useful for diagnosis include detec-
tion of heterophile antibodies that react with bovine erythrocytes The classic patient with acute streptococcal pharyngitis has a sudden
(most often detected by the monospot test) and specific antibody onset of fever and sore throat. Headache, malaise, abdominal pain,
against EBV viral capsid antigen (VCA), early antigen (EA), and nausea, and vomiting occur frequently. Cough, rhinorrhea, conjunc-
nuclear antigen (EBNA). Acute infectious mononucleosis is usually tivitis, stridor, diarrhea, and hoarseness are distinctly unusual and
associated with a positive heterophile test result and antibody to suggest a viral etiology.
VCA and EA (Fig. 1-2). Examination of the patient reveals marked pharyngeal erythema.
The findings of acute exudative pharyngitis together with Petechiae may be noted on the palate, but they can also occur in viral
hepatomegaly, splenomegaly, and generalized lymphadenopathy pharyngitis (see Table 1-7). Tonsils are enlarged, symmetric, and red,
suggest infectious mononucleosis. Early in the disease and in cases with patchy exudates on their surfaces. The papillae of the tongue
without liver or spleen enlargement, differentiation from other may be red and swollen; hence the designation “strawberry tongue.”
causes of pharyngitis, including streptococcal pharyngitis, is difficult. Anterior cervical lymph nodes are often tender and enlarged.
Indeed, a small number of patients with infectious mononucleosis Combinations of these signs can be used to assist in diagnosis; in
have a throat culture positive for group A streptococci. Serologic particular, tonsillar exudates in association with fever, palatal
evidence of mononucleosis should be sought when splenomegaly or petechiae, and tender anterior cervical adenitis strongly suggest
other features are present or if symptoms persist beyond 7 days. infection with group A streptococci. However, other diseases can
produce this constellation of findings. Some or all of these classic
TREATMENT characteristics may be absent in patients with streptococcal pharyn-
gitis. Younger children often have coryza with crusting below the
Patients with infectious mononucleosis require supportive treatment. nares, more generalized adenopathy, and a more chronic course, a
Corticosteroids may be indicated for acute life-threatening conditions, syndrome called streptococcosis.
such as airway obstruction caused by enlarged tonsils. When rash accompanies the illness, accurate clinical diagnosis is
easier. Scarlet fever, so-called because of the characteristic fine,
diffuse red rash, is essentially pathognomonic for infection with
GROUP A STREPTOCOCCAL INFECTION group A streptococci. Scarlet fever is rarely seen in children younger
than 3 years old or in adults.
In the evaluation of a patient with sore throat, the primary concern is
usually accurate diagnosis and treatment of pharyngitis caused by SCARLET FEVER
group A streptococci, which accounts for about 15% of all episodes
of pharyngitis. The sequelae of group A streptococcal pharyngitis, The rash of scarlet fever is caused by infection with a strain of group A
especially acute rheumatic fever and acute glomerulonephritis, at one streptococci that contains a bacteriophage encoding for production
time resulted in considerable morbidity and mortality in the United of an erythrogenic (redness-producing) toxin, usually erythrogenic
States and continue to do so in other parts of the world. Prevention of (or pyrogenic) exotoxin A. Scarlet fever is simply group A strepto-
acute rheumatic fever in particular depends on timely diagnosis of coccal pharyngitis with a rash and should be explained as such to
streptococcal pharyngitis and prompt antibiotic treatment. patients and their families. Although patients with the streptococcal
Table 1-6. Vesicular-Ulcerating Eruptions of the Mouth and Pharynx

Recurrent
Scarifying
Systemic Inflammatory Ulcerative
Lupus Bowel Stomatitis
Hand-Foot- Erythematosus Disease Aphthous Behçet Vincent (Sutton
Gingivostomatitis Herpangina Mouth Disease Chickenpox (SLE) (IBD) Stomatitis Disease Stomatitis Disease)

Etiology Herpes simplex Coxsackievirus Coxsackievirus Varicella- Unknown; Unknown; Unknown Unknown; Unknown; Unknown
virus (HSV) I A, B; echovirus A, coxsackie- zoster virus autoimmune autoimmune vasculitis or
or HSV virus B anaerobic
(rarely) (rarely) bacteria
Location Ulcerative vesicles Anterior fauces Tongue, buccal Tongue, Oral, nasal Lips, tongue, As in IBD Oral (similar Gingiva; Tongue;
of pharynx, (tonsils), soft mucosa, gingiva, mucosa; buccal to IBD); ulceration buccal
tongue, and palate (uvula), palate, palms, buccal palate, mucosa, genital at base of mucosa
palate less often soles, mucosa, pharynx, oropharynx ulcers teeth
plus lesions of pharynx anterior marked buccal
mucocutaneous oral cavity cutaneous mucosa
(perioral) lesions;
margin trunk > face
Age Less than 5 yr 3–10 yr 1 yr–teens Any age Any age Any age Teens and Teens, adult- Teens; if Teens
adulthood hood, younger,
occasionally consider
<10 yr immuno-
deficiency
and blood
dyscrasia
Manifestations Fever, mouth pain, Fever, sore Painful bilateral Fever, pruritic Renal, central Multiple Similar to Painful Fever, Deep,
toxic, fetid throat, vesicles, cutaneous nervous recurrences; IBD ulcerations bleeding large,
breath, drooling, odynophagia; fever vesicles, system, painful (heal gums; painful
anorexia, cervical summer out- painful oral arthritis, ulcerations without gray ulcera-
lymphadenopathy; breaks; 6–12 lesions cutaneous, 1–2 mm, but scarring); membrane tions;
Chapter 1  Sore Throat

cracked, swollen lesions (2 to hematologic, may be uveitis, relapsing;

hemorrhagic 4 mm papule) other organ 5–15 mm arthralgia, scarring
gums; secondary → vesicle → involvement; arthritis, with
inoculation ulceration; ulcers lower distortion
possible (fingers, headache, minimally to gastro- of mucosa
eye, skin); myalgias moderately intestinal
reactivation with painful; may ulceration
long latency be painless (similar to
(any age) IBD);
recurrences;
spontaneous
remissions
Treatment Avoid dehydration; Avoid Avoid Avoid Specific therapy Specific Topical Topical Oral Topical
acyclovir if dehydration; dehydration; dehydration, for SLE therapy cortico- cortico- hygine; cortico-
immuno- rarely, secondary for IBD steroids; steroids; tetra- steroids,
compromised secondary infection; must oral cycline anal-
aseptic acyclovir if exclude (viscous) wash gesics;
meningitis or immuno- SLE, IBD, lidocaine must rule
myocarditis compromised human out
immuno- malig-
deficiency nancy by
virus (HIV), biopsy
Behçet
7

disease
8 Section One  Respiratory Disorders

Table 1-7. Manifestations of Infectious Mononucleosis

(Epstein-Barr Virus)
Common
Fever (1–2 weeks)
Lymphadenopathy (bilateral, minimally tender, primarily
cervical nodes with axillary, inguinal, epitrochlear,
supraclavicular nodes)
Tonsillopharyngitis (exudative)
Splenomegaly
Hepatomegaly
Elevated liver enzymes (transaminases)
Malaise
Fatigue
Less Common
Rash (spontaneous or associated with ampicillin or
allopurinol)
Oropharyngeal petechiae
Figure 1-1. Aphthous stomatitis (“canker sore”). (From Reilly BM: Sore
Jaundice
throat. In Practical Strategies in Outpatient Medicine, 2nd ed.
Eyelid edema
Philadelphia, WB Saunders, 1991.)
Abdominal pain
Thrombocytopenia—purpura
Hemolytic or aplastic anemia—pallor
toxic shock syndrome are infected with group A streptococci that Severe upper airway obstruction
produce erythrogenic toxin A, most infections with group A strepto- Meningoencephalitis
cocci are not associated with unusual severity (Table 1-8). Guillain-Barré syndrome
Streptococcal toxic shock syndrome is usually associated with a Bell palsy (seventh cranial nerve)
primary cutaneous rather than a pharyngeal focus of infection. Hemophagocytic syndrome
The rash of scarlet fever has a texture like sandpaper and blanches X-linked lymphoproliferative disorder (Duncan syndrome)
with pressure. It usually begins on the face, but after 24 hours it Lymphoproliferative disorder in immunocompromised hosts
becomes generalized. The face, especially the cheeks, is red, and the Splenic rupture
area around the mouth often appears pale in comparison (circumoral Glomerulonephritis
pallor). Accentuation of erythema occurs in flexor skin creases, espe- Orchitis
cially in the antecubital fossae (Pastia’s lines). The erythema begins
to fade within a few days. Desquamation begins within a week of
onset on the face and progresses downward, often resembling that
seen after a mild sunburn. On occasion, sheetlike desquamation
occurs around the free margins of the fingernails and is usually more
coarse than the desquamation seen with Kawasaki disease. The
differential diagnosis of scarlet fever includes Kawasaki disease,
measles, and staphylococcal toxic shock syndrome (Table 1-9).

DIAGNOSIS
Although signs and symptoms may strongly suggest acute strepto-
coccal pharyngitis, laboratory diagnosis is highly recommended,
even for patients with scarlet fever (Fig. 1-3). Scoring systems for
diagnosing acute group A streptococcal pharyngitis on clinical
grounds have not proved very useful. Using clinical criteria alone,
physicians overestimate the likelihood that patients have streptococ-
cal infection. The throat culture has traditionally been used to
Figure 1-2. Typical human serologic response to Epstein-Barr virus infec- diagnose streptococcal pharyngitis. Plating a swab of the posterior
tion. At time of clinical presentation (usually 2 to 7 weeks after exposure), pharynx and tonsils on sheep blood agar, identifying β−hemolytic
anti–viral capsid antigen (VCA) response may consist of IgM and IgG colonies, and testing them for the presence of sensitivity to a bacitracin-
antibodies; anti–early antigen (EA) response is often present; and impregnated disk is the “gold standard” diagnostic test, but it takes
anti–nuclear antigen (EBNA) is usually negative. The IgM anti-VCA 24 to 48 hours to obtain results. There are a number of rapid
response usually subsides within 2 to 4 months, and the anti-EA response diagnostic tests that take less than 15 minutes. These “rapid strep”
usually disappears within 2 to 6 months. (Data from Andiman WA, tests detect the presence of the cell wall group A carbohydrate anti-
McCarthy P, Markowitz RI, et al: Clinical, virologic, and serologic evi- gen after acid extraction of organisms obtained by throat swab.
dence of Epstein-Barr virus infection in association with childhood pneu- Rapid strep tests are highly specific (generally >95%), with the
monia. J Pediatr 1981;99:880-886; Fleisher G, Henle W, Henle G, et al: throat culture used as the standard. Unfortunately, the sensitivity of
Primary infection with Ebstein-Barr virus in infants in the United States: most of these rapid tests can be considerably lower. In comparison to
Clinical and serological observations. J Infect Dis 1979;139:553-558; hospital or reference laboratory throat culture results, the sensitivities
Brown NA: The Epstein-Barr virus (infectious mononucleosis, B-lymphopro- of these tests are generally 80% to 85% and can be lower. However,
liferative disorders). In Feigin RD, Cherry JD [eds]: Textbook of Pediatric when both throat cultures and rapid tests performed in physicians’
Infectious Diseases, 2nd ed. Philadelphia, WB Saunders, 1987.) offices are compared with cultures performed in reference laboratories,
 Chapter 1  Sore Throat 9
Testing patients for serologic evidence of an antibody response to
Table 1-8. Characteristics of Severe Invasive and/or extracellular products of group A streptococci is not useful for
Toxigenic Group A Streptococcal Infection diagnosing acute pharyngitis. Because it generally takes several
Positive Culture Sites weeks for antibody levels to rise, streptococcal antibody tests are
valid only for determining past infection. Specific antibodies include
Blood antistreptolysin O (ASO), anti-DNase B, and antihyaluronidase
Soft tissue abscess (AHT). When antibody testing is desired in order to evaluate a pos-
Synovial fluid sible post-streptococcal illness, more than one of these tests should
Throat be performed to improve sensitivity.
Peritoneal fluid
Surgical wound
Cellulitis aspirate TREATMENT
Clinical Manifestations Laboratory Manifestations Treatment begun within 9 days of the onset of group A streptococcal
Fever Leukocytosis pharyngitis is effective in preventing acute rheumatic fever. Therapy
Toxic Shock* Lymphopenia does not appear to affect the risk of the other nonsuppurative
Confusion Thrombocytopenia sequela, acute post-streptococcal glomerulonephritis. Antibiotic
Headache Hyponatremia therapy also reduces the incidence of suppurative sequelae of group A
Abdominal pain Hypoalbuminemia streptococcal pharyngitis, such as peritonsillar abscess and cervical
Vomiting Hyperbilirubinemia (direct) adenitis. In addition, treatment produces a more rapid resolution of
Local extremity pain and Elevated AST, ALT, BUN signs and symptoms and terminates contagiousness within 24 hours.
swelling Renal sediment abnormalities For these reasons, antibiotics should be instituted as soon as the
Hypesthesia Coagulopathy diagnosis is supported by laboratory studies.
Cellulitis Hypoxia There are numerous antibiotics available for treating streptococcal
Scarlatiniform rash (40%) pharyngitis (Table 1-10). The drug of choice is penicillin. Despite the
Erythroderma (25%) widespread use of penicillin to treat streptococcal and other infections,
Conjunctival injection penicillin resistance among group A streptococci has not developed.
Red pharynx Penicillin can be given by mouth for 10 days or intramuscularly as a
Pneumonia with or single injection of benzathine penicillin. Intramuscular benzathine
without empyema penicillin alleviates concern with patient compliance. A less painful
Osteomyelitis alternative is benzathine penicillin in combination with procaine peni-
Vaginitis cillin. Intramuscular procaine penicillin alone is inadequate for pre-
Proctitis vention of acute rheumatic fever because adequate levels of penicillin
Desquamation are not present in blood and tissues for a sufficient time. Other
Necrotizing fasciitis β-lactams, including semisynthetic derivatives of penicillin and the
Diarrhea cephalosporins, are at least as effective as penicillin for treating group
A streptococcal pharyngitis. Their broader spectrum, their higher cost,
*Case definition of streptococcal toxic shock syndrome requires (I) isolation of group A and the lack of formal data concerning prevention of acute rheumatic
streptococci from (a) a normally sterile site (blood, synovial or peritoneal fluid) or (b) a fever relegate them to second-line status. The decreased frequency of
nonsterile site (throat, wound). (II) Severity is defined by (a) hypotension and (b) two or
more of renal impairment, coagulopathy, liver involvement, adult respiratory distress
dose administration of some of these agents may improve patient
syndrome, a generalized erythematous macular rash (with or without later desquama- compliance and makes their use attractive in selected circumstances.
tion), and soft tissue necrosis (necrotizing fasciitis, myositis, gangrene). The definitive Patients who are allergic to penicillin should receive erythro-
diagnosis requires criteria IA and IIA plus B. Criteria IB and IIA plus B are considered mycin or another non–β-lactam antibiotic, such as clarithromycin,
probable if no other identifiable cause is present.
azithromycin, or clindamycin. Resistance of group A streptococci to
ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea erythromycin has increased dramatically in areas such as Japan,
nitrogen.
France, Spain, Taiwan, and Finland, where erythromycin has been
widely used. This has not yet emerged as a major problem in the
United States, where the rate of macrolide resistance is about 5%.
the sensitivities, specificities, and overall accuracy of the office Sulfa drugs (including sulfamethoxazole combined with trimetho-
culture and the office rapid test are quite similar; the latter often prim), tetracyclines, and chloramphenicol should not be used for
performs better than the culture. treatment of acute streptococcal pharyngitis because they do not
The low sensitivity of these tests, coupled with their excellent eradicate group A streptococci.
specificity, has led to the recommendation that two swabs be
obtained from patients with suspected streptococcal pharyngitis. COMPLICATIONS
One swab is used for a rapid test. When the rapid antigen detection
test result is positive, it is highly likely that the patient has group A Suppurative Complications
streptococcal infection, and the extra swab can be discarded. When
the rapid test result is negative, group A streptococci may nonethe- Antibiotic therapy has greatly reduced the likelihood of developing
less be present; thus, the extra swab should be processed for culture. suppurative complications caused by spread of group A streptococci
Physician offices that have demonstrated that their rapid test and from the pharynx or middle ear to adjacent structures. Peritonsillar
throat culture results are comparable may be able to rely on the rapid abscess (“quinsy”) manifests with fever, severe throat pain, dyspha-
test result even when it is negative, without performing a backup gia, “hot potato voice,” pain referred to the ear, and bulging of the
culture. peritonsillar area with asymmetry of the tonsils and sometimes
In general, patients with a negative result of the rapid test do not displacement of the uvula (Fig. 1-4; see Table 1-4). On occasion,
require treatment before culture verification unless there is a partic- there is peritonsillar cellulitis without a well-defined abscess cavity.
ularly high suspicion group A streptococcal infection (e.g., scarlet Trismus may be present. When an abscess is found clinically or by
fever, peritonsillar abscess, or tonsillar exudates in addition to tender an imaging study such as a computed tomographic scan, surgical
cervical adenopathy, palatal petechiae, fever, and recent exposure to drainage is indicated. Peritonsillar abscess occurs most commonly in
a person with group A streptococcal pharyngitis). older children and adolescents.
10 Section One  Respiratory Disorders

Table 1-9. Differential Diagnosis of Scarlet Fever

Staphylococcal Toxic Staphylococcal Scalded

Scarlet Fever Kawasaki Disease Measles Shock Syndrome Skin Syndrome

Agent Group A streptococci Unknown Measles virus Staphylococcus S. aureus

aureus
Age range All (peak, 5–15 yr) Usually <5 yr <2 yr, 10–20 yr All (especially Usually < 5yr
> 10 yr)
Prodrome No No Fever, coryza Usually no No
cough,
conjunctivitis
Enanthem No Occasionally Koplik spots No Limited
Mouth Strawberry tongue, Erythema; red, cracked Diffusely red, no Usually normal Erythema
exudative pharyngitis, lips, strawberry cracked lips
palatal petechiae tongue
Rash Fine, red, “sandpaper,” Variable polymorphic Maculopapular; Diffuse erythro- Erythema, painful
membranous erythematous face, progressing derma; bullous lesions;
desquamation, trunk, and diaper from forehead desquamates positive
circumoral pallor, area; tips of fingers to feet; may Nikolsky sign;
Pastia lines and toes desquamate desquamate desquamates
10–28 days after onset
Other Cervical adenitis, Coronary artery disease; “Toxic” Shock (hypo- Fever, cracked lips;
gallbladder hydrops, fever >5 days; appearance; tension, conjunctivitis
fever conjunctival (nonpurulent) dehydration; including
injection; tender, swollen encephalitis, orthostatic);
hands and feet; cervical pneumonia; encephalopathy;
adenopathy (size >1.5 cm); fever diarrhea;
thrombocytosis; headache
pyuria (sterile);
gallbladder hydrops

Retropharyngeal abscess represents extension of infection preventing rheumatic fever, but acute glomerulonephritis is not
from the pharynx or peritonsillar region into the retropharyngeal prevented by treatment of the antecedent streptococcal infection.
(prevertebral) space, which is rich in lymphoid structures (Figs. 1-5 Pharyngitis caused by one of the nephritogenic strains of group A
and 1-6; see Table 1-4). Children younger than 4 years old are most streptococci precedes the glomerulonephritis by about 10 days.
often affected. Fever, dysphagia, drooling, stridor, extension of the Unlike acute rheumatic fever, which occurs only after group A strep-
neck, and a mass in the posterior pharyngeal wall may be noted. tococcal pharyngitis, acute glomerulonephritis also can follow group
Surgical drainage is often required if frank suppuration has occurred. A streptococcal skin infection.
Spread of group A streptococci via pharyngeal lymphatic vessels to
regional nodes can cause cervical lymphadenitis. The markedly TREATMENT FAILURE AND CHRONIC CARRIAGE
swollen and tender anterior cervical nodes that result can suppurate.
Otitis media, mastoiditis, and sinusitis also may occur as compli- Treatment with penicillin cures group A streptococcal pharyngitis
cations of group A streptococcal pharyngitis. Additional parapharyn- but is unable to eradicate group A streptococci from the pharynx in
geal suppurative infections that may mimic streptococcal disease are approximately 25% of patients (Fig. 1-7). This causes considerable
noted in Table 1-4. Furthermore, any pharyngeal infectious process consternation among such patients and their families. Penicillin
may produce torticollis if there is inflammation that extends to the resistance is not the cause of treatment failure. A small proportion of
paraspinal muscles and ligaments, producing pain, spasm, and, on these patients are symptomatic and are thus characterized as having
occasion, rotary subluxation of the cervical spine. clinical treatment failure. Reinfection with the same strain or a dif-
The differential diagnosis of torticollis is presented in Table 1-11. ferent strain is possible, as is intercurrent viral pharyngitis. Some of
Oropharyngeal torticollis lasts less than 2 weeks and is not associated these patients may be chronic pharyngeal carriers of group A strep-
with abnormal neurologic signs or pain over the spinous process. tococci who are suffering from a new superimposed viral infection;
others may be noncompliant with regard to therapy.
Nonsuppurative Sequelae Many patients who do not respond to antimicrobial treatment are
asymptomatic and are identified when follow-up culture specimens
Nonsuppurative complications include acute rheumatic fever (see are obtained, a practice that is usually unnecessary. Patients who are
Chapters 11 and 44), acute post-streptococcal glomerulonephritis compliant with regard to therapy are at minimal risk for acute rheu-
(see Chapter 25), and possibly reactive arthritis/synovitis. In addi- matic fever. One explanation for asymptomatic persistence of group A
tion, an association between streptococcal infection and neuro- streptococci after treatment is that these patients were chronic
psychiatric disorders such as obsessive-compulsive disorder and carriers of group A streptococci who were initially symptomatic
Tourette syndrome has been postulated. This possible association because of a concurrent viral pharyngitis and who did not truly have
has been called PANDAS (pediatric autoimmune neuropsychiatric acute streptococcal pharyngitis.
disorders associated with streptococci). Therapy with an appropriate Patients who are chronically colonized with group A streptococci
antibiotic within 9 days of onset of symptoms is highly effective in are called chronic carriers. Carriers do not appear to be at risk for acute
 Chapter 1  Sore Throat 11
Signs and Symptoms Compatible with GAS Available treatment options for the physician faced with a
chronic streptococcal carrier include the following:
Yes No Viral 1. Obtaining a rapid test, throat culture, or both each time the patient
pharyngitis has pharyngitis with features that suggest streptococcal pharyngitis,
Symptomatic and treating with penicillin each time a test is positive.
therapy 2. Treating with one of the regimens effective for terminating
Scarlet fever? (No antibiotics) chronic carriage.
Yes No Rapid
The first option is simple, as safe as penicillin, and appropriate for
GAS pharyngitis test many patients. The second option should be reserved for particularly
anxious patients; those with a history of acute rheumatic fever or
Positive living with someone who had it; or those living or working in nursing
Negative homes, chronic care facilities, hospitals, and perhaps schools.
Confirm with rapid test The two antibiotic treatment regimens that have been effective for
or throat culture; eradication of the carrier state are:
Treat with antibiotics Throat
culture ● Intramuscular benzathine penicillin plus oral rifampin (10 mg/kg/
dose up to 300 mg, given twice daily for 4 days beginning on the
Not GAS Negative Positive GAS day of the penicillin injection)
pharyngitis pharyngitis ● Oral clindamycin, given for 10 days (20 mg/kg/day up to 450 mg,

divided into three equal doses)

Clindamycin may be preferred because it is easier to use than intra-
Viral pharyngitis Treat with
muscular penicillin plus oral rifampin and may be somewhat more
Symptomatic therapy antibiotics effective. In controlled, comparative trials, no other antibiotic regimens
(No antibiotics) have been demonstrated to reliably terminate the chronic streptococcal
carrier state. Successful eradication of the carrier state makes evalua-
tion of subsequent episodes of pharyngitis much easier, although
GAS chronic carriage can recur upon reexposure to group A streptococci.
Sore throat persists pharyngitis
≥7 days?
RECURRENT ACUTE PHARYNGITIS
No Yes
Some patients seem remarkably susceptible to group A streptococci.
Positive The reasons for frequent bona fide acute group A streptococcal
pharyngitis are obscure, but appropriate antibiotic treatment results
1) Repeat throat culture in resolution of symptoms and eradication of group A streptococci.
2) Mono test The role of tonsillectomy in the management of patients with
Negative multiple episodes of streptococcal pharyngitis is controversial.
Fewer episodes of sore throat have been reported among patients
treated with tonsillectomy (in contrast to patients treated without
Negative Positive surgery) during the first 2 years after operation. The patients enrolled
Viral pharyngitis in that study had experienced numerous episodes of pharyngitis,
Symptomatic therapy but it appears that not all episodes were caused by group A strepto-
(No antibiotics) cocci. Of particular concern is the reported tonsillectomy complica-
Viral pharyngitis Mononucleosis tion rate of 14% and the improvement over time noted among the
nontonsillectomy patients.
No antibiotics In addition, the presence of tonsils is not necessary for group A
Figure 1-3. Management of patients with sore throat. GAS, group A streptococci to infect the throat. Tonsillectomy cannot be recom-
streptococci. mended except in unusual circumstances. It seems preferable to treat
most patients with penicillin whenever symptomatic group A strep-
tococcal pharyngitis occurs. Obtaining follow-up throat specimens
rheumatic fever or for development of suppurative complications, for culture helps distinguish recurrent pharyngitis from chronic
and they are rarely sources of spread of group A streptococci in the carriage.
community. There is no reason to exclude these carriers from school.
There is no easy way to identify chronic carriers prospectively
among patients with symptoms of acute pharyngitis. The clinician NON–GROUP A STREPTOCOCCAL INFECTION
should consider the possibility of chronic group A streptococcal
carriage when a patient or a family member has multiple culture- Certain β−hemolytic streptococci of serogroups other than group A
positive episodes of pharyngitis, especially when symptoms are mild cause acute pharyngitis. Well-documented epidemics of food-borne
or atypical. A culture specimen is usually positive for group A strep- group C and group G streptococcal pharyngitis have been reported in
tococci when the suspected carrier is symptom-free or is receiving young adults. In these situations, a high percentage of individuals
treatment with penicillin (intramuscular benzathine penicillin is rec- who have ingested the contaminated food promptly developed acute
ommended in order to eliminate concern about compliance). pharyngitis, and throat cultures yielded virtually pure growth of the
Carriers often receive multiple unsuccessful courses of antibiotic epidemiologically linked organism. There have been outbreaks of
therapy in attempts to eliminate group A streptococci. Physician and group G streptococcal pharyngitis among children. However, the
patient anxiety is common and can develop into “streptophobia.” role of these non–group A streptococcal organisms as etiologic
Unproven and ineffective therapies include tonsillectomy, prolonged agents of acute pharyngitis in endemic circumstances has been
administration of antibiotics, use of β-lactamase–resistant antibiotics, difficult to establish. Group C and group G β streptococci may be
and culture or treatment of pets. responsible for acute pharyngitis, particularly in adolescents.
12 Section One  Respiratory Disorders

Table 1-10. Treatment Regimens for Acute Streptococcal Pharyngitis

Children Adolescents/Adults Frequency Route Duration

Standard
Penicillin V 250 mg 500 mg bid-tid Oral 10 days
Benzathine penicillin G 600,000 U (weight < 27 kg) 1.2 million U (weight ≥ 27 kg) Once IM Once
Amoxicillin 125 mg (weight < 15 kg) 250 mg (weight ≥ 15 kg) tid Oral 10 days
Penicillin-Allergic Patients
Oral Dose Frequency Duration

Erythromycin
Ethylsuccinate 40 mg/kg/day up to 1000 mg/day bid 10 days
Estolate 20-40 mg/kg/day up to 1000 mg/day bid 10 days
Clarithromycin 15 mg/kg/day up to 500 mg/day bid 10 days
Azithromycin* 12 mg/kg/day Once daily 5 days
Clindamycin 10-25 mg/kg/day up to 450 mg/day tid 10 days
Cephalosporins† Varies with agent chosen 10 days
Once Daily and Short Duration Treatment Schedules
Oral Dose Frequency Duration

Azithromycin* 12 mg/kg Once daily 5 days

Amoxicillin‡ 50 mg/kg up to 750 mg Once daily 10 days
Cefadroxil 30 mg/kg up to 1000 mg Once daily 10 days
Cefixime 8 mg/kg up to 400 mg Once daily 10 days
Cefdinir 14 mg/kg up to 600 mg Once daily 10 days
Ceftibuten 9 mg/kg up to 400 mg Once daily 10 days
Cefpodoxime 10 mg/kg/day up to 200 mg/day bid 5 days
Cefdinir 14 mg/kg/day up to 600 mg/day bid 5 days
Cefuroxime‡ 20 mg/kg/day up to 500 mg/day bid 4 or 5 days
*
Maximum dose for children is 500 mg/day. Adult dosage: 500 mg the first day, 250 mg the subsequent 4 days.
†
First-generation cephalosporins (e.g., cephalexin, cefadroxil) are preferred; dosage and frequency vary among agents. Avoid use in patients with history of immediate (anaphylactic)
hypersensitivity to penicillin or other beta-lactam antibiotics.
‡
Not approved by the U.S. Food and Drug Administration for use in this manner.
From Tanz RR, Shulman ST: Pharyngitis. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Diseases. New York, Churchill Livingstone, 1997, p 204.

However, the exact role of these agents, most of which are carried
asymptomatically in the pharynx of some children and young adults,
remains to be fully characterized.
When they are implicated as agents of acute pharyngitis, groups
C and G organisms do not appear to necessitate treatment, inasmuch
as they cause self-limited infections. Acute rheumatic fever is not a
sequela to these infections, although post-streptococcal acute
glomerulonephritis has been documented in rare cases after epidemic
group C and group G streptococcal pharyngitis.

ARCANOBACTERIUM INFECTION

Arcanobacterium (formerly Corynebacterium) haemolyticum is a

gram-positive rod that has been reported to cause a scarlet fever–like
illness with acute pharyngitis and scarlatinal rash, particularly in
teenagers and young adults. Detecting this agent requires special
methods for culture, and it has not routinely been sought in patients
with scarlet fever or pharyngitis.
The clinical features of A. haemolyticum pharyngitis are indistin-
guishable from group A streptococcal pharyngitis; pharyngeal
Figure 1-4. Peritonsillar abscess (quinsy, sore throat). The left tonsil is erythema is present in almost all patients, patchy white to gray
asymmetrically inflamed and swollen; there is displacement of the uvula exudates in about 70%, cervical adenitis in about 50%, and moder-
to the opposite side. The supratonsillar space (arrow) is also swollen; this ate fever in 40%. Palatal petechiae and strawberry tongue may also
is the usual site of the surgical incision for drainage. Prominent unilateral occur. The scarlatiniform rash usually spares the face, palms, or soles.
cervical adenopathy typically coexists. (From Reilly BM: Sore throat. It is erythematous and blanches; it may be pruritic and demonstrate
In Practical Strategies in Outpatient Medicine, 2nd ed. Philadelphia: minimal desquamation.
WB Saunders, 1991.) Erythromycin appears to be the treatment of choice.
 Chapter 1  Sore Throat 13

A B
Figure 1-5. Retropharyngeal abscess. A, Lateral neck radiograph shows marked increased soft tissue (arrow) between
the upper airway and cervical spine. B, Axial computed tomographic scan shows the lower attenuation center of the abscess
(A), the anterior and leftward shift of the trachea (T), and the soft tissue mass (M) of abscess and surrounding edema. (Courtesy
of A. Oestreich, M.D., Cincinnati, Ohio.)

DIPHTHERIA of diphtheria in the former Soviet Union has been recorded (1990 to
1995), and infection has been documented in several travelers from
Western Europe.
Diphtheria is a very serious disease that is caused by pharyngeal
infection by toxigenic strains of Corynebacterium diphtheriae. It has
become very rare in the United States and other developed countries PATHOGENESIS
as a result of immunization. The handful of diphtheria cases recog-
nized annually in the United States usually occur in unimmunized The pathogenesis of diphtheria involves nasopharyngeal mucosal col-
individuals, and the fatality rate is about 5%. A relatively large outbreak onization by C. diphtheriae and toxin elaboration after an incubation
period of 1 to 5 days. Toxin leads to local tissue inflammation and
necrosis (producing an adherent grayish membrane made up of fibrin,
blood, inflammatory cells, and epithelial cells) and it is absorbed into
the blood stream. Fragment B of the polypeptide toxin binds particu-
larly well to cardiac, neural, and renal cells, and the smaller fragment
A enters cells and interferes with protein synthesis. Toxin fixation by
tissues may lead to fatal myocarditis (with arrhythmias) within 10 to
14 days and to peripheral neuritis within 3 to 7 weeks.

CLINICAL FEATURES

Acute tonsillar and pharyngeal diphtheria is characterized by

anorexia, malaise, low-grade fever, and sore throat. The grayish
membrane forms within 1 to 2 days over the tonsils and pharyngeal
walls and occasionally extends into the larynx and trachea. Cervical
adenopathy varies but may be associated with development of a “bull
neck.” In mild cases, the membrane sloughs after 7 to 10 days and
the patient recovers. In severe cases, an increasingly toxic appearance
can lead to prostration, stupor, coma, and death within 6 to 10 days.
Distinctive features include palatal paralysis, laryngeal paralysis,
ocular palsies, diaphragmatic palsy, and myocarditis. Airway obstruc-
tion (from membrane formation) may complicate the toxigenic
Figure 1-6. In a teenager, the retropharyngeal space normally does not manifestations.
exceed 7 mm when measured from the anterior aspect of the C2 vertebral
body to the posterior pharynx. In infants, the retropharyngeal space is usually DIAGNOSIS AND TREATMENT
less than one width of the adjacent vertebral body. However, during crying,
this distance may be three widths of the vertebral body. Also, under normal Accurate diagnosis requires isolation of C. diphtheriae on culture of
circumstances, the retrotracheal space does not exceed 22 mm in teenagers material from beneath the membrane, with confirmation of toxin
when measured from the anterior aspect of C- 6 to the trachea. Dotted lines production by the organism isolated. Laboratories must be fore-
depict the “thumbprint” sign, noted on a lateral neck radiograph, made by a warned that diphtheria is suspected. Other tests are of little value.
swollen epiglottis. (From Reilly BM: Sore throat. In Practical Strategies in Treatment includes equine antitoxin to neutralize circulating
Outpatient Medicine, 2nd ed. Philadelphia: WB Saunders, 1991.) toxin, as well as systemic penicillin or erythromycin.
14 Section One  Respiratory Disorders

Signs and Symptoms of bona fide

Table 1-11. Differential Diagnosis of Torticollis Acute GAS Pharyngitis
(Wryneck)
Congenital
Muscular torticollis
Positional deformation No Yes
Hemivertebra (cervicosuperior dorsal spine)
Unilateral atlanto-occipital fusion
Klippel-Feil syndrome
Probable GAS carrier Recurrent pharyngitis
Unilateral absence of sternocleidomastoid
Pterygium colli
Trauma
Muscular injury (cervical muscles) Special situation?
Family or physician
Atlanto-occipital subluxation
overly concerned? No Evaluate and treat
Atlantoaxial subluxation each symptomatic
C2–C3 subluxation episode individually
Rotary subluxation
Fractures Yes
Inflammation
Cervical lymphadenitis
Retropharyngeal abscess Throat culture Negative
Cervical vertebral osteomyelitis
Rheumatoid arthritis
Spontaneous (hyperemia, edema) subluxation with adjacent Positive
head and neck infection (rotary subluxation syndrome)
Upper lobe pneumonia
Neurologic GAS carrier Antibiotic treatment (optional)
Visual disturbances (nystagmus, superior oblique paresis) 1. Oral clindamycin or
Dystonic drug reactions (phenothiazines, haloperidol, 2. IM benzathine penicillin plus
metoclopramide) oral rifampin
Cervical cord tumor Figure 1-7. Management of patients with repeated or frequent positive
Posterior fossa brain tumor rapid tests or throat cultures. GAS, group A streptococci; IM, intramuscular.
Syringomyelia
Wilson disease
Dystonia musculorum deformans
Spasmus nutans
Other
Acute cervical disk calcification Table 1-12. Spectrum of Mycoplasma Pneumoniae
Sandifer syndrome (gastroesophageal reflux, hiatal hernia) Infection
Benign paroxysmal torticollis
Bone tumors (eosinophilic granuloma) Common
Soft-tissue tumor Primary atypical pneumonia* (with or without pleural
Hysteria effusion)
Pharyngitis
From Behrman RE (ed): Nelson Textbook of Pediatrics; 14th ed. Philadelphia: Tracheobronchitis
WB Saunders, 1992, p 1718.
Less Common
Wheezing
Rhinitis
GONOCOCCAL PHARYNGITIS Bullous myringitis
Otitis media
Myocarditis
Acute symptomatic pharyngitis caused by Neisseria gonorrhoeae Pericarditis
occurs occasionally in sexually active individuals as a consequence Meningoencephalitis—aseptic meningitis
of oral-genital contact. In cases involving young children, sexual Polyneuritis—Guillain-Barré syndrome
abuse must be suspected. The infection usually manifests as an ulcer- Transverse myelitis
ative, exudative tonsillopharyngitis but may be asymptomatic and Sinusitis
resolve spontaneously. Gonococcal pharyngitis occurs in homo- Erythema multiforme—Stevens Johnson syndrome
sexual men and heterosexual women after fellatio and is less readily Erythema nodosum
acquired after cunnilingus. Gonorrhea rarely is transmitted from the Urticaria
pharynx to a sex partner, but pharyngitis can serve as a source for Intravascular hemolysis (high-titer cold agglutinins)
gonococcemia. Arthralgia
Diagnosis requires culture on appropriate selective media
(e.g., Thayer-Martin medium). Recommended therapeutic regimens *Manifestations during pneumonia include sore throat, hoarseness, malaise, headache,
include a single intramuscular dose of 125 mg of ceftriaxone or a sin- cough, earache, chills, and fever >102°F (38.9°C). Less often there may be coryza, rash,
gle oral 500-mg dose of ciprofloxacin. Spectinomycin is ineffective pleuritis, diarrhea, or leukocytosis > 10,000/mm3.
 Chapter 1  Sore Throat 15
in gonococcal pharyngitis. Examination and testing for other sexu- Other Pathogens
ally transmitted diseases and pregnancy are recommended.
Gerber MA, Randolph MF, Martin NJ, et al: Community-wide outbreak of
group G streptococcal pharyngitis. Pediatrics 1991;87:598-603.
Feder HM Jr: Periodic fever, aphthous stomatitis, pharyngitis, adenitis: a
CHLAMYDIAL AND MYCOPLASMAL clinical review of a new syndrome. Curr Opin Pediatr 2000;12:253-256.
INFECTIONS Karpathios T, Drakonaki S, Zervoudaki A, et al: Arcanobacterium
haemolyticum in children with presumed streptococcal pharyngotonsilli-
tis or scarlet fever. J Pediatr 1992;121:735-737.
Chlamydia species and Mycoplasma pneumoniae may cause pharyn-
Komaroff AL, Branch WT, Aronson MD, et al: Chlamydial pharyngitis. Ann
gitis, although the frequency of these infections is disputed. Intern Med 1989;111:537-538.
Chlamydia trachomatis has been implicated serologically as a cause Lajo A, Borque C, Del Castillo F, et al: Mononucleosis caused by
of pharyngitis in as many as 20% of adults with pharyngitis, but Epstein-Barr virus and cytomegalovirus in children: A comparative study
isolation of the organism from the pharynx has proved more difficult. of 124 cases. Pediatr Infect Dis J 1994;13:56-60.
Chlamydia pneumoniae has also been identified as a cause of McMillan JA, Weiner LB, Higgins AM, et al: Pharyngitis associated with
pharyngitis. Because antibodies to this organism show some cross- herpes simplex virus in college students. Pediatr Infect Dis J 1993;
reaction with C. trachomatis, it is possible that infections formerly 12:280-284.
attributed to C. trachomatis were really caused by C. pneumoniae. Nakayama M, Miyazaki C, Ueda K, et al: Pharyngoconjunctival fever caused
by adenovirus type 11. Pediatr Infect Dis J 1992;11:6-9.
Diagnosis of chlamydial pharyngitis is difficult, whether by
Straus SE, Cohen JI, Tosato G, et al: Epstein-Barr virus infections: Biology,
culture or serologically, and neither method is readily available to the pathogenesis, and management. Ann Intern Med 1993;118:45-58.
clinician. Sumaya CV, Ench Y: Epstein-Barr virus infectious mononucleosis in
M. pneumoniae most likely causes pharyngitis. Serologic (positive children: I. Clinical and general laboratory findings. Pediatrics 1985;75
mycoplasma immunoglobulin M [IgM]) or, less often, culture 1003-1010.
methods can be used to identify this agent, which was found in 33% Sumaya CV, Ench Y: Epstein-Barr virus infectious mononucleosis in
of college students with pharyngitis in one study. Polymerase chain children: II. Heterophil antibody and viral-specific responses. Pediatrics
reaction (PCR) is diagnostic. 1985;75:1011-1019.
There is no need to seek evidence of these organisms routinely in Waagner DC: Arcanobacterium haemolyticum: Biology of the organism and
diseases in man. Pediatr Infect Dis J 1991;10:933-939.
pharyngitis patients in the absence of ongoing research studies of
nonstreptococcal pharyngitis. The efficacy of antibiotic treatment for
Complications
M. pneumoniae and chlamydial pharyngitis is not known, but these
illnesses appear to be self-limited. Treatment of more complicated Chow AW: Life-threatening infections of the head and neck. Clin Infect Dis
M. pneumoniae infections, such as pneumonia (Table 1-12), is 1992;14:991-1004.
indicated with erythromycin, azithromycin, or clarithromycin; doxy- de Marie S, Tham RT, van der Mey AGL, et al: Clinical infections and
cycline may be used if the patient is older than 10 years. nonsurgical treatment of parapharyngeal space infections complicating
throat infection. Rev Infect Dis 1989;11:975-982.
Fiesseler FW, Riggs RL: Pharyngitis followed by hypoxia and sepsis:
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Group A Streptococci Clinical and microbiologic aspects and treatment regimens. Arch
Otolaryngol Head Neck Surg 1993;119:521-524.
Attia MW, Zaoutis T, Klein JD, et al: Performance of a predictive model for Wald ER, Guerra N, Byers C: Upper respiratory tract infections in young
streptococcal pharyngitis in children. Arch Pediatr Adolesc Med 2001; children: Duration of and frequency of complications. Pediatrics 1991;
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Bisno AL: Group A streptococcal infections and acute rheumatic fever. White B: Deep neck infections and respiratory distress in children. Ear Nose
N Engl J Med 1991;325:783-793. Throat J 1985;64:30-38.
Bisno AL: Acute pharyngitis. N Engl J Med 2001;344:205-211.
Gerber MA, Tanz RR, Kabat W, et al: Optical immunoassay test for Group A Treatment
ß-hemolytic streptococcal pharyngitis: An office-based, multicenter
investigation. JAMA 1997;277:899-903. Gerber MA, Tanz RR: New approaches to the treatment of group A
Gerber MA, Tanz RR, Kabat W, et al: Potential mechanisms for failure to streptococcal pharyngitis. Curr Opin Pediatr 2001;13:51-55.
eradicate group A streptococci from the pharynx. Pediatrics Markowitz M, Gerber MA, Kaplan EL: Treatment of streptococcal
1999;104:911-917. pharyngotonsillitis: Reports of penicillin’s demise are premature.
Hoge CW, Schwartz B, Talkington DF, et al.: The changing epidemiology of J Pediatr 1993;123:679-685.
invasive group A streptococcal infections and the emergence of Massel BF, Chute CG, Walker AM, et al: Penicillin and the marked decrease
streptococcal toxic shock-like syndrome: A retrospective population- in morbidity and mortality from rheumatic fever in the United States. N
based study. JAMA 1993;269:384-389. Engl J Med 1988;318:280-286.
Podbielski A, Kreikemeyer B: Persistence of group A streptococci in eukary- Paradise JL, Bluestone CD, Bachman RZ, et al: Efficacy of tonsillectomy for
otic cells—A safe place? Lancet 2001;358:3. recurrent throat infection in severely affected children: Results of parallel
Tanz RR, Gerber MA, Shulman ST: What is a throat culture? Adv Exp Med randomized and nonrandomized clinical trials. N Engl J Med 1984;
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Tanz RR, Shulman ST: Streptococcal pharyngitis: The carrier state, definition Randolph MF, Gerber MA, DeMeo KK, et al: Effect of antibiotic therapy on
and management. Pediatric Annals 1998;27:281-285. the clinical course of streptococcal pharyngitis. J Pediatr 1985;106:
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shock. Arch Dis Child 1992;67:126-130. Seppala H, Nissinen A, Jarvinen H, et al: Resistance to erythromycin in group
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intermountain area of the United States. J Pediatr 1994;124:9-16. Shulman ST, Gerber MA, Tanz RR, et al: Streptococcal pharyngitis: The case
Wheeler MC, Roe MH, Kaplan EL, et al: Outbreak of group A streptococcus for penicillin therapy. Pediatr Infect Dis J 1994;13:1-7.
septicemia in children: Clinical, epidemiologic, and microbiological Snellman LW, Stang HJ, Stang JM, et al: Duration of positive throat cultures
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Another random document with
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out at an estimated cost of £1,200. Altogether a sudden spirit of
activity seemed to have superseded the lethargy or indifference
which lately had been too much visible amongst the inhabitants in all
matters of public interest, and which had already exercised a serious
and baneful influence upon the prospects of the place as a sea-side
resort. In the ensuing year the body of Primitive Methodists, which
had now become rather numerous, chiefly owing to the prosperity of
the fishing trade attracting many followers of that calling to the port,
most of whom were members of this sect, commenced and
completed a chapel in West Street. Recently it has been found
necessary considerably to enlarge the edifice, in order to furnish
more accommodation for the increasing congregation. Although the
erection of this chapel and of the other buildings mentioned above
mark undoubtedly an era of progress in the history of the town, still
we are constrained to admit that the wants they supplied were not
brought about by the spread of Fleetwood’s reputation as a
watering-place. From the first little had been done to supplement its
natural attractions by laying out elegant promenades, or improving
the state of the Cops or Poulton Road, so as to render them
agreeable rural walks for many who, after a time, grew weary of
watching the eddies and dimples of the river’s current
“Play round the bows of ships,
That steadily at anchor rode;”

or of daily rambling where the receding waves left a broad floor of

firm, unbroken sands. True, a carriage-drive and foot-way of some
pretensions to beauty had been constructed along the north shore in
1845, but the storms we have described, and other heavy seas, had
torn breaches in its wall, and made sad havoc amongst its light
sandy material, completely ruining the fair appearance of the
shoreward grass-plat, and threatening the road with that very
destruction which has since overtaken it through the continued
negligence of the residents or governing powers. There was no
public hall, such as that once contemplated, where a feeling of
fellowship might be engendered amongst the visitors. The regattas
instituted for the interest and amusement it was hoped they would
excite amongst the spectators were, as previously stated, conducted
in a desultory manner for a few years, and then abandoned; whilst
the land sports during the week of high festival were discontinued as
the Whit-week excursion trains found other outlets more attractive
than Fleetwood for their pleasure-seeking thousands; but it was not
until the North Euston Hotel was opened for military purposes, that
all hope of reviving the fading reputation of the town as a summer
resort was finally relinquished. For some little time after the
foregoing transfer, the bathing vans, as if to keep up the fiction of
the season, re-appeared with uninterrupted regularity each year
upon the beach, but even that last connecting link between the
deserted town, as far as visitors were concerned, and its former
popularity, was doomed shortly to be broken, for the ancient
machines, never renewed, and seldom repaired, were at length
unequal to the rough journey over the cobble stones, and crumbled
to pieces on the way, expiring miserably in the cause of duty, from
old age and unmerited neglect.
In the early part of 1859, a lifeboat, thirty feet in length, was
stationed here by the National Lifeboat Institution, and in the month
of September in the same year, a neat and substantial house was
built for it on the beach opposite the North Euston Hotel. After doing
good service along the coast, in rescuing several crews whose
vessels had stranded amidst the breakers on the outlying sand-
banks, this boat was superseded, in 1862, by one of larger
dimensions. In January, 1863, the erection on the beach was swept
away by the billows during a heavy gale, and in the course of a few
months the present structure in Pharos Street, far removed from the
reach of the destructive element, was raised, and the lifeboat
transferred to its safer keeping.
The census of the residents taken in 1861 showed a total of 4,061
persons, being an increase of 940 over the number in 1851, and of
1,228 over that in 1841. Hence it is seen that during the long period
of twenty years, almost from its commencement to the date now
under consideration, through fluctuating seasons of prosperous and
depressed trade, the town had succeeded in adding no more than
1,228 individuals to the roll of its inhabitants, many of whom would
be the offspring of the original settlers. Truly the foregoing picture is
not a very satisfactory one to review when we call to mind the bright
auspices under which the place was started,—the early and ample
railway accommodation, the short and well-beaconed channel, and
the safe and spacious harbour; but could we only add the extensive
area of docks, the Fleetwood of 1871 would doubtless have
presented a widely different aspect to that we are here called upon
to portray. It is scarcely just, however, to lay all the burden of this
slow rate of progress on the want of suitable berth provision for
heavily-laden vessels coming to the harbour. Fleetwood had other
means of extending its circle besides those derived from its happy
situation for shipping trade. Its merits as a watering-place were
allowed on every hand; eulogistic versions of its special charms were
circulated through the public prints; strangers flocked each summer
to its shores, and were enchanted with their visits; but after a while
the refreshing novelty wore off, and the puny efforts made by those
whose interests in the prosperity of the town were greatest, failed to
fill the inevitable void the waning newness left in its train. In the
meantime other season places, urged on by emulation, enhanced
the beauties of nature by works of art; promenades, walks, drives,
and, at no distant period, piers, were constructed to meet the
popular demands, and in that way the tide of visitors was turned
from the non-progressive and now over familiar attractions of
Fleetwood to swell the annually increasing streams which overflowed
the rising towns of Blackpool and Lytham. The year 1861 will ever be
remarkable in the history of Fleetwood as being the date at which
the town was for the first time practically diverted from that line of
progress which its founder, in too sanguine expectancy, had early
marked out for it. Its decadence as a summer resort had been too
pronounced to allow of any hope being entertained that a revulsion
was probable, or even possible, in the feelings and tastes of the
multitude, which would again people its shores, during the warm
months, with a heterogeneous crowd of valetudinarians and
pleasure-seekers. The noble hotel which had been erected by Sir P.
H. Fleetwood on the northern margin of the shore, in a style of
architecture and at an expense which bore witness to the firm
confidence of the baronet in the brilliant future awaiting the infant
town, had been sold to Government, as previously stated, in 1859,
but it was not until two years afterwards that the first detachment of
officers took up their quarters in the newly-established School of
Musketry, and Fleetwood awoke to the novel sound of martial music
and the reputation of being a military centre. Rumour, also, had for
several months been active in circulating a report that the sward
lying between the Landmark and the cemetery, and a field at the
corner of Cemetery Road, had attracted the eye of Government as a
suitable locality whereon to place barracks and lay out a rifle-
practice ground; and in February, 1861, doubt on the subject was no
longer admissible, for the contract to carry out the fresh project was
let during that month to the gentleman who had been engaged in
the necessary alterations at the North Euston Hotel. The scheme
involved the creation of residential accommodation in the field just
indicated for a small force of 220 men and 12 officers, some of the
quarters being specially designed for married soldiers, in addition to
which lavatories, a canteen, mess-room, magazine, and guard-
house, were to be erected. The work was entered on without delay,
and at no long interval, about ten months, or rather more, the whole
of the buildings were completed, and soon afterwards occupied. The
practice-ground was marked out for range firing, and butts provided,
where the targets were shortly stationed. A spacious hospital, it
should be mentioned, was constructed almost contemporaneously
with the main portion of the barrack buildings.
On Monday, the 20th of May, 1861, a mass meeting was convened
to ascertain the opinion of the inhabitants with regard to a claim of
exclusive use of the road over the Mount-hill, which had recently
been set up by Sir Peter Hesketh Fleetwood, who in order to
establish his right had caused a cobble wall to be erected round that
portion of the estate. The meeting, consisting of about three
hundred persons, was held on the pathway in dispute, which crosses
the highest point of the elevation. A platform was raised, and a
chairman, elected by the unanimous voice of the company, ascended
the rostrum, being accompanied by several of the more enthusiastic
advocates of free-road, who in the course of earnest addresses
declared that for twenty years the Mount had been dedicated to the
public service, in consideration of certain sums paid annually to the
lord of the manor out of the town’s rates, and that having been so
long the property of the people, Sir P. H. Fleetwood had now no
moral or legal title to wrest it from them. The ardent language of the
speakers aroused a sympathetic feeling in the breasts of the small
multitude, and murmurs of discontent at the attempted deprivation
of their privileges had already assumed a threatening tone, when a
gentleman who happened to be visiting the neighbourhood,
appeared upon the scene, and in a few spirited words urged the
excited listeners to some speedy manifestation of their disapproval.
Uttering a shout of indignation and defiance the crowd rushed at the
enclosure wall, tore down the masonry, and quickly opened out a
wide breach through the offending structure, after which they filled
the air with triumphant cheers and shortly retired homewards in a
comparatively orderly manner. In the course of a few months the
vexatious question was settled between the representatives of the
town and Sir P. H. Fleetwood, who on his part agreed only to retain
to himself a plot of land fifty yards square, lying on the west side of
the hill; another piece one hundred yards square, extending from
the base of the elevation to the sea; the wooden edifice on the
summit of the mound; six square yards whereon to erect a look-out
house for the Coastguards; and the gardens and cottage-lodges at
the entrance. The remainder of the Mount, amounting to about
three-fourths, was given up to the public, together with the right of
footway through the cottages just mentioned, and over the east and
west plots; the commissioners engaging, on their side, to erect and
maintain a suitable fence round the Mount, and to keep the hill itself
in a proper manner for the benefit of the inhabitants or visitors, as
well as binding themselves upon no account to raise any building on
the site. The entire ground, with the buildings, has since been given,
on much the same conditions, to the town.
 During the year 1862 the town, which for some time had lain
dormant in a commercial point of view, evinced unmistakable signs
of returning animation; trade was more active, rumour once more
hinted at the probable commencement of docks at an early date,
and ninety-five houses of moderate size were erected. In the earlier
half of the following twelve months no less than thirty-seven more
dwellings were added to the town, the foundations of several others
being in course of preparation. A branch of the Preston Banking
Company was also opened for a few hours once in each week; and
during later years has transacted business daily.
On Tuesday, the 20th of January, 1863, a storm and flood, such as
has seldom been witnessed on this coast, arose suddenly and raged
with fury for about twenty hours. The whole of the wall under the
Mount, which had been brought to light by some gales in the
previous November, after having been buried in the sand for long,
was utterly demolished, not one stone being left upon another. In
addition, the breakers penetrated with destructive violence, several
yards inland beyond the line of that barrier throughout its whole
length, from the west end of the Euston Barracks to the further
extremity of Abbot’s Walk. A wooden battery of two 32-pound guns
at the foot of the Mount, belonging to the Coastguards,[85] and used
for training the Naval Volunteer Reserve, was undermined and so
tilted that its removal became a necessity. The marine fence, which
had been constructed at an immense cost, between the Landmark
and Cleveleys, was almost entirely swept away, leaving the adjacent
country open to the inundations of the sea, which rushed over and
flooded all the land between the points just named, extending
eastward even to the embankment of the Preston and Wyre Railway.
Several of the streets at the west side of Fleetwood were under
water, as also were the fields about Poulton road and the highway
itself. The proprietor of the “Strawberry Garden,” off the same road,
and his family, were compelled to take refuge in an upper storey of
their dwelling until rescued in a boat, the following day, from their
unpleasant, if not perilous, position. It was in this hurricane that the
house erected on the shore for the reception of the lifeboat suffered
annihilation, and the boat itself narrowly escaped serious damage.
Tuesday, the 10th of March, in the same year was observed by the
residents as a general holiday and gala day, in honour of the
marriage of Albert Edward, Prince of Wales, with the Danish
Princess, Alexandra. Flags and banners floated from the windows of
nearly every habitation, as well as from the roofs of many, while the
steamships and other vessels in the harbour were gaily decorated
with bunting, which waved in rich and varied tints from their masts,
spars, and rigging. Triumphal arches of the “colours of all nations”
were suspended across the streets at several points. A large
procession of schools and friendly societies in full regalia, with their
banners and devices, paraded the different thoroughfares, and were
afterwards sumptuously entertained, the latter at their various
lodges, and the former in the large area of a cotton warehouse,
recently built on the quay by Messrs. B. Whitworth and Bros., of
Manchester. The military stationed at the School of Musketry evinced
their loyalty by discharging a feu de joie on the warren. In the
following November a scheme was proposed for the construction of
a coast railway between Fleetwood and Blackpool, to pass through
Rossall and Bispham. A survey was made of the route, and
according to the plans drawn out, the projected line was intended to
have its Fleetwood terminus at the south extremity of Poulton
Terrace, opposite the end of West Street, whence it was to run
towards the new barracks, near the cemetery, then diverge to the
south in the direction of Rossall. From Rossall its course lay towards
Bispham and thence onwards to the Blackpool terminus, which
would be located in Queen’s street, adjoining the station already
standing there. The stations, besides those at the two termini, were
to be placed at the barracks, Rossall, and Bispham. At Fleetwood the
promoters proposed to form a junction with the Preston and Wyre
Railway near the old timber pond, for the purpose of passing
carriages from one line to the other, whilst at Blackpool a similar
object would be effected with the Lytham and Blackpool Railway by
deviating eastward from Queen Street, so as to avoid the town, and
establishing a junction with the latter line near Chapel Street. On an
application being made to parliament for powers to carry out the
design, strenuous opposition was offered by the representatives of
the Preston and Wyre Railway, who pledged themselves to erect
additional stations along their track to accommodate the people
residing at Rossall, Cleveleys, and Bispham, in consequence of which
the bill for a coast-line was thrown out and the project abandoned.
On the 4th of December, 1863, the Lancaster Banking Company
established a branch here; and on the 15th of that month the
Whitworth Institute in Dock Street was publicly opened. This
handsome Hall was erected through the munificence of Benjamin
Whitworth, esq., M.P., of London, who for long resided at Fleetwood,
and during that period, and afterwards, was instrumental in giving a
marked stimulus to the foreign trade of the port by shipping each
year, on behalf of the large firm of which he is the head at
Manchester, numerous cargoes of cotton from America viâ
Fleetwood. The building is in the Gothic style of architecture. The
walls are built of bricks with stone dressings, the principal features
being the ten arcaded windows, with the stone balcony beneath
running across the entire width of the front, and the elegant
entrance. The interior comprises a spacious reading room and
library, a smoking and coffee room, provided with chess and
draughts, an assembly room, capable of containing 400 persons, and
two billiard rooms. At the time of its presentation to the inhabitants
the donor generously provided tea urns and other appliances
necessary for holding soirees, in addition to having liberally furnished
the whole of the building, including the gift of a choice and extensive
selection of books, chess and draught-men, a bagatelle-board, and a
billiard-table. The second billiard-table was added out of the surplus
funds in 1875. The Institute is vested in trustees for the use of the
town, and governed by a committee chosen from amongst the
subscribers.
During 1864-5 building continued to progress, but not with that
great rapidity which had characterised its advance in 1862 and the
earlier months of the following year. An act of parliament was
granted in 1864 to certain gentlemen for the formation of a dock in
connection with the harbour, confirming the rumour which had now
agitated the place for the last two years, and bringing conviction to
the hearts of many of the older inhabitants, whose past experience
had taught them to look with eyes of distrust on all reports which
pointed to such a happy realisation of their youthful dreams. The
inaugural ceremony of breaking the turf did not, however, take place
for some time, and will be noticed shortly. On the 17th of May, 1866,
the foundation stone of the present Roman Catholic church in East
Street was laid by Doctor Goss, bishop of Liverpool, who performed
the ceremony, attired in full ecclesiastical robes, and attended by a
numerous retinue of priests and choristers. The sacred edifice was
opened on Sunday, the 24th of November in the ensuing year. Its
general style is early English of the 13th century. The building
consists of a nave and two aisles, with an apsidal sanctuary at the
east end; it is about one hundred feet long, thirty-five feet wide, and
fifty feet in height. The exterior is built of stone, the body of the
walls being Yorkshire parpoints, whilst the dressings are of
Longridge stone. Mr. T. A. Drummond, of Fleetwood, was the builder,
and the design was drawn by E. Welby Pugin, esq., architect, the
total cost being about £4,000.
For many years, in fact ever since steamship communication had
been established between this port and Belfast, large quantities of
young cattle from Ireland were landed each season at Fleetwood,
and carried forward by rail to the markets of Preston and elsewhere.
For the benefit of the dealers, who would thus escape the railway
charges, as well as for the convenience of the graziers and other
purchasers residing in the neighbourhood, it was determined to open
a place for the public sale of such live stock at Fleetwood; the
necessary authority was obtained from the Privy Council, and on the
2nd of April, 1868, the Cattle Market, lying on the east side of that
for general produce, and consisting of sixteen large strong pens,
arranged in two rows with a road between them, was used for its
earliest transactions and much appreciated by those who were
concerned in the traffic.
Wednesday, the 2nd of June, 1869, will not readily be obliterated
from the memories of the people of Fleetwood. On that day the first
sod of the long expected dock was cut by H. S. Styan, esq., of
London, the surviving trustee of the estate under the will of the late
Sir P. H. Fleetwood, who died in 1866. The auspicious event was
celebrated with universal rejoicing, in which many-coloured bunting
played its usual conspicuous part. A large procession of the clergy,
gentry, schools, and friendly societies, enlivened by the band of the
80th regiment of Infantry from the Euston Barracks, and gay with
waving banners, accompanied Mr. Styan to the site where the
important ceremony was performed, and sent forth hearty
congratulatory cheers when the piece of turf had been duly
dissected from the ground. With all apparent earnestness and
eagerness, operations were at once commenced, and for two or
three months the undertaking, under the busy hands of the
excavators, made satisfactory progress, when suddenly several
gangs of labourers were discharged, and the works partially stopped
—
“While all the town wondered.”

Wonderment, however, was turned to a feeling of disappointment

and chagrin, when it was discovered, a little later, that the closing
year would put a period to the labours at the dock as well as to its
own epoch of time, and that its last shadows would fall on deserted
works and idle machinery. For some reason, which may fairly be
conjectured to have been an incompleted list of shareholders, the
Fleetwood Dock Company determined to suspend all operations
barely six months after they had been begun, and it is scarcely
necessary to inform our readers that the work was never resumed
under the same proprietorship. Two years subsequently, in 1871, the
Lancashire and Yorkshire Railway Company obtained an act of
parliament to carry out, on a larger scale, the undertaking which
their predecessors had abandoned almost in its birth. The dock,
which embraces an area of nearly ten acres, being one thousand
feet long, by four hundred feet wide, has already been in course of
formation for more than two years, and although the labour is being
pushed forward by the contractors, Messrs. John Aird and Sons, of
Lambeth, with as much expedition as is consistent with good
workmanship, the completion of this much-needed accommodation
is not expected until some time in 1877. The dock walls are built
with square blocks of stone, surmounted by a broad and massive
coping of Cornish granite, and filled in behind with concrete, the
whole having an altitude of thirty-one feet, and being placed on a
solid concrete foundation fourteen feet wide. The walls themselves
vary in width as they approach the surface, being in the lower half of
their distance 12½ feet, then 10½ feet, and in the highest section
8½ feet wide. The lock entrance communicates with the north
extremity of the dock, and is two hundred and fifty feet long by fifty
feet wide, being protected at each end by gates, opening,
respectively, into the dock and the channel now in process of
excavation to the bed of the river Wyre. Lying to the south of the
dock is the recently-constructed timber pond, covering an area of
14½ or 15 acres, and having a depth of 15 feet. The pond is
connected with the dock by means of a gateway, so arranged in the
southern wall of the latter that two feet of water will always remain
in the former after the tide has ebbed below the level of its floor.
The timber pond has no other entrance beyond the one alluded to.
Sir John Hawkshaw, previously mentioned in connection with the
visit of Queen Victoria to Fleetwood, is the eminent engineer from
whose designs the dock is being constructed.
The prospect, or indeed certainty, of materially increased trade
when the dock is thrown open has not been without effect upon the
town generally, but its stimulating influence is most remarkable in
the large number of houses which, during the last few years, have
sprung into being. Streets have been lined with habitations where
recently not a dwelling existed, and others have had their vacant
spaces filled in with buildings. Handsome shops have been erected
in Dock Street, East and West Streets, and other localities, whilst
many of the residences in Church Street have been remodeled and
converted into similar retail establishments. Everywhere there is a
spirit of activity visible, contrasting most pleasingly and favourably
with the passive inertitia which pervaded the place for a considerable
period previous to the commencement of the dock operations. In
1875 the commissioners determined to do something towards
protecting the northern aspect of the Mount from the devastations of
the waves, whose boisterous familiarity had already inflicted serious
injury on its feeble sandy sides, and seemed disposed, if much
longer unchecked, to reduce the venerable pile to a mere matter of
history. A public promenade, fenced with a substantial wall of
concrete, was laid out at the base of the hill, extending from near
the west extremity of the Mount Terrace to the commencement of
Abbot’s Walk. The damaged side of the mound itself has been
levelled and sown with grass-seed, so that in course of time the
marine walk will have a lofty sloping background of green sward,
and form the prettiest, as it was doubtless the most needed, object
in the neighbourhood.
On the 1st of January, 1875, a number of gentlemen,
denominated the Fleetwood Estate Company, Limited, and consisting
of Sir Jno. Hawkshaw, knt., of Westminster; Thos. H. Carr, J. M.
Jameson, C.E., and Philip Turner, esqrs., of Fleetwood; Capt. Henry
Turner and Sturges Meek, esq., C.E., of Manchester; Thomas Barnes,
esq., of Farnworth; James Whitehead, esq., of Preston; Joshua
Radcliffe, esq., of Rochdale; Samuel Burgess, esq., of Altringham;
William Barber Buddicom, esq., C.E., of Penbedw, Mold; and Samuel
Fielden, esq., of Todmorden; purchased the lands, buildings,
manorial rights and privileges (including wreckage, market-tolls, and
advowson of the church), of the late Sir P. H. Fleetwood, in and near
this town, from the trustees of his property, for £120,000, subscribed
in equal shares. Although negotiations were satisfactorily concluded
in 1874, it was not until the month just stated that the actual
transfer was effected, and the gentlemen enumerated became lords
of the soil. We must not omit to name that a portion of the
Fleetwood estate, amounting to about 600 acres, lying between the
old and present railway embankments, had been acquired in a
similar manner, for £25,000, in 1871, by the Lancashire and
Yorkshire Railway Company. Under the new proprietorship leases for
building purposes are sold or let, as formerly, for terms of 999 years.
 In closing this account of Fleetwood as a watering-place and
town, and before delineating its career as a seaport, it should be
stated that the census of the inhabitants taken in 1871 yielded a
total of 4,428 persons, of whom 2,310 were males, and 2,118
females; but in the limited period which has elapsed since that result
was obtained the population has grown considerably, and the
increase during a similar interval after any of the previous official
returns cannot be taken as a criterion of the present numerical
strength of the residents.
Fleetwood was started in 1839 as a distinct port with customs
established by an order of the Treasury; subsequently in 1844 it was
reduced to a creek under Preston; then two years later elevated to a
sub-port; and finally in 1849 reinstated in its first position of
independence. The iron wharf was completed in 1841, and is
constructed of iron piles, each of which weighs two and three
quarter tons, driven seventeen feet below low water mark, and
faced with plates of the same metal, seven or eight inches thick,
which are rivetted to the flanges of the piles, and filled in at the back
with concrete. The wooden pier, about 400 feet in length, and
abutting on the north extremity of this massive structure, was
finished in 1845, and roofed over shortly afterwards. On the 22nd of
July in the ensuing year, the last stone of the wharf wall, erected by
Mr. Julian A. Tarner, of Fleetwood, and extending fourteen hundred
feet from the south end of the iron wharf in the direction of the
railway, was laid; and at the same time the coal-shoots connected
with the new portion of the quay were approaching completion.
The improvement of the harbour was entrusted to Captain
Denham, R.N., F.R.S., under whose superintendence the seaward
channel of the river was buoyed and beaconed, being rendered safe
for night navigation by the erection of a marine lighthouse, in 1840,
at the foot of Wyre, nearly two miles from the mouth of the river at
Fleetwood. This lighthouse was the first one erected on Mitchell’s
screw-pile principle. The house in which the lightkeepers lived was
hexagonal in form, and measured 22 feet in diameter, from angle to
angle, and nine feet in height. It was furnished with an outside door
and three windows; and divided within into two compartments, one
of which was supplied with a fireplace and other necessaries, whilst
the second was used purely as a dormitory. The lantern was twelve-
sided, 10 feet in diameter and 8 feet in height to the top of the
window, the illumination it produced being raised about 31 feet
above the level of the highest spring-tide, and 44½ feet above that
of half-tide. A few years since, in 1870, this lighthouse was carried
away by a vessel, and for some time a light-ship occupied the
station, but subsequently another edifice, similar in appearance and
construction to the original one, was raised about two hundred yards
south of the same site.
Captain Denham, having accomplished his survey of the river and
harbour, issued the following report in 1840:—
“The river Wyre assumes a river character near Bleasdale Forest, in
Lancashire, and after crossing the line of road between Preston and
Lancaster, at Garstang, descends as a tortuous stream for five miles
westward; then, in another five mile reach of one-third of a mile wide,
north-westward, sweeping the light of Skippool, near Poulton-le-Fylde, on
its way, and bursting forth from the narrows at Wardleys, upon a north
trend, into the tidal estuary which embraces an area of three miles by
two, producing a combined reflux of back-water, equal to fifty million
cubical yards, and dipping with such a powerful under-scour during the
first half-ebb, as to preserve a natural basin just within its coast-line
orifice, capable of riding ships of eighteen or twenty feet draft, at low
water spring tides; perfectly sheltered from all winds, and within a cable’s
length of the railway terminus, nineteen miles from Preston, and in
connection with Manchester, Lancaster, Liverpool, and London. It is on the
western margin of this natural dock that the town, wharfs, and
warehouses are rising into notice, under the privilege of a distinct port,
and abreast of which, the shores aptly narrow the back-water escape into
a bottle-neck strait of but one-sixth the width of the estuary, so impelling
it down a two-mile channel as scarcely to permit diminishment of its three
and four-mile velocity until actually blended with the cross-set of the Lune
and Morecambe Bay ebb waters. Thus, the original short course of Wyre
to the open sea, is freed from the usual river deposit, its silting matter
being kept in suspension until transferred and hurried forth at right angles
by the ocean stream. It is, therefore, the peculiar feature and fortune of
Wyre that, instead of a bar intervening between its bed or exit trough and
 the open sea, a precipitous river shelf, equal to a fall of forty-seven feet in
one-third of a mile, exists.”
The first steam dredger, of 20 horse power, was launched on the
21st of January, 1840, and the important work of deepening and
clearing the channel at once commenced.
At a meeting of the Tidal Harbour Commissioners held at the port
on the 21st October, 1845, it was stated that the harbour dues were
—for coasting vessels, 1d. per ton, and for foreign ships, 3d. per
ton; whilst the light charges were in all cases 3d. per ton. At the
same time it was observed that the whole of the dues amounted in
1835 to £36 2s. 0d., and in 1845 to £528 9s. 5d. (In 1855 the dues
on similar accounts reached £1,520; and in 1875, £2,427.) The
Walney light was reported to be a great tax on vessels coming to
Fleetwood, as they were charged 3d. a ton per year, commencing on
the 1st of January; so that if a vessel arrived at the port on the 28th
of December, a charge was made for the year just closing, and a
further sum demanded from the craft on going out in the month of
January. This was not the case with regard to similar taxes in other
localities, where one payment exempted a ship for twelve months;
and consequently the regulation acted in some degree as a deterrent
to traders, who might under a more liberal arrangement have been
induced to have availed themselves in larger numbers of the facilities
offered by the new haven. The total length of useful wharfage in
1845 extended over 1,000 feet, being well supplied with posts and
rings, and possessing no less than sixteen hand cranes, thirteen of
which were for the purpose of unloading vessels at the quay. There
was a depth of five feet at low-water spring tides from the marine
lighthouse, at the foot of Wyre, to the wharf, and it was proposed to
dredge until ten feet had been obtained.
On examining the state of the shipping trade of the harbour
during the year 1845, it is discovered that the imports and exports of
foreign produce and home manufacture, respectively, far outstripped
those of any of the few preceding years. There had been vessels
laden with guano from Ichaboe, sugar from the West Indies, flax
from Russia, and timber from both the Baltic and Canada, making in
all twenty-three ships of large tonnage, only two of which returned
with cargoes, in far from complete stages of fulness, from the
warehouses of Manchester, Preston, or other adjacent commercial
towns. The coasting trade had also given earnest of its progressive
tendencies by a remarkable increase in the number of discharges
and loadings over those of the previous twelve months, and
notwithstanding the four hundred feet of extra wharfage, forming
the wooden pier, just opened, the demands for quay berths could
not always be supplied.
New bonding warehouses were erected towards the close of 1845
at the corner of Adelaide and Dock Streets, the temporary ones
previously in use being abandoned, and comprised three stories
capable of providing accommodation for 400 hogsheads of sugar at
one time, as well as spacious vaults and other conveniences for
duty-bearing articles. The goods allowed to be warehoused were
wine, spirits, tea, tobacco, East India goods, and goods in general.
In 1846 prosperity continued to reward the efforts put forth by the
authorities of the young haven. Twelve vessels arrived from America
with timber, and nine similarly laden from the Baltic; tobacco, sugar,
and other commodities were imported in two ships from the Indies;
but the event which kindled the brightest anticipations in the breasts
of the inhabitants and others interested in the success of the port
was the arrival of the barque “Diogenes,” chartered by Mr. Evans, of
Chipping, with the first cargo of cotton ever landed at Fleetwood. In
it was welcomed an introduction to the chief trade of the county, and
a happy augury of future activity in an import which would not only
of itself materially assist the financial condition of the harbour, but
would also be the means of spreading its reputation throughout the
commercial world, and extending its field of action to a degree which
could scarcely be foretold. How these pleasant visions have been
fulfilled the reader is perhaps aware, but if not a glance at the tables
of coasting and foreign trade, given a little later, will furnish the
necessary information. On the 12th of February, immediately the
novel consignment just referred to, which “afforded a suitable
opportunity,” had come to hand, a public dinner was given by their
fellow-townsmen to Frederick Kemp and John Laidlay, esqrs., as a
mark of respect for their assiduous efforts to develope the
mercantile resources of the place. During the evening Mr. Laidlay
remarked that “within a short period the trading intercourse of the
port had extended to various and distant portions of the world, the
products of Africa, the West Indies, and North America having been
imported; and stretching our arm still further, a cargo from the East
Indies may be stated as almost within our grasp.” Mr. Evans, in
alluding to his transatlantic shipment, affirmed that in bringing it by
way of Fleetwood, he had effected a saving of at least a farthing per
pound; and continued,—“When the order was given, it could not
have been imported into Liverpool without loss.”
In the latter part of the year a testimonial was presented by the
inhabitants of the town to Henry Smith, esq., of Fleetwood, manager
of the North Lancashire Steam Navigation Company, as a tribute to
his untiring and successful attempts to promote steamship traffic
and advance the interests of the place, and in the course of a
speech made on the occasion, Mr. Smith said:—“In 1842 I first
visited Fleetwood at the request of the London board of directors, it
then presented a most gloomy aspect—a splendid modern ruin, no
shipping, no steamers, no passengers for the trains, and yet it
required no very keen discernment to learn that all the facilities for
trade and commerce existed here, but life was wanting; here was
one of the finest and safest harbours, certainly the best lighted and
marked port on the west coast, being as easily made by night as by
day, with that wonderful natural phenomenon, the Lune Deep,
making it a safety port to take in fog by sounding—a thing having no
parallel in England.... What changes have we witnessed here since
1842? I have seen your population without employment, and now
there is more work than there are hands to perform—the wages
from one shilling a day have advanced to two shillings and sixpence
and three shillings; then indeed was your port without a ship, now
there is a general demand for more quay room, although since then
upwards of 1,000 feet have been added to the wharfage; then your
railway receipts were £100, this year they have attained £1,500 per
week.” This unfortunate gentleman was killed in the June following,
through a collision on the London and North Western Railway; and
there can be no hesitation in affirming that, had his career of
usefulness and activity not been thus prematurely cut short, the
trade of Fleetwood would have developed, in the long period which
has elapsed since his death, into something more important than it
presents to day.
The following authentic returns of the whole business of the port
in 1846 forms a favourable comparison with those of 1840, the year
in which the railway was opened, when they amounted to 57,051
tons of imports, the exports being proportionately small:—
COASTING.

Imports. Exports.
1846. January 59 ships 11,564 tons. 59 ships 11,875 tons.
” February 60 ” 11,251 ” 62 ” 11,208 ”
” March 72 ” 11,252 ” 70 ” 11,289 ”
” April 63 ” 10,971 ” 66 ” 11,098 ”
” May 61 ” 11,539 ” 121 ” 11,790 ”
” June 61 ” 10,637 ” 97 ” 14,715 ”
” July 81 ” 13,413 ” 94 ” 14,274 ”
” August 80 ” 13,194 ” 93 ” 16,042 ”
” September 94 ” 13,515 ” 65 ” 11,609 ”
” October 64 ” 11,472 ” 71 ” 13,158 ”
” November 63 ” 11,094 ” 51 ” 8,619 ”
” December 41 ” 7,785 ” not obtained.
799 ships 137,687 tons. 849 ships 135,677 tons.
Foreign 24 ” 6,935 ” 13 ” 2,703 ”
Total 823 ships 144,622 tons. 862 ships 138,380 tons.

The animated appearance of the harbour was described in 1846

by a gentleman connected with the town, as here quoted:—“With
two Indiamen at their berths, the splendid steamers alongside,
schooners, small craft innumerable dotting the river, wharfmen,
porters, etc., removing merchandise from vessel to wagon, and vice
versa, the cranes in constant operation, goods-trains arriving and
preparing for departure, give the pier-head and harbour an air of
bustle and activity, and are themselves a pleasing indication of what
our commerce may become; of the trade which vigilance, patience,
and effort, may secure to the harbour and railway.”
The twelve months of 1847 proved anything but a re-assuring
time. The foreign imports suddenly fell off to six cargoes, four of
which were timber from America, the two remaining being guano
and timber from Hamburg. One left for Mexico and Hong Kong,
laden with British goods, silk, wine, and spirits from the bonding
warehouses. The coasting returns also showed a diminution of
almost fifty discharges at the quay, as compared with the previous
year, and a corresponding decrease in the exports; but in spite of
the sudden dispiriting experience, we find from the annexed extract
out of the annual official report concerning the harbour, that the
future was regarded hopefully:—“There is every probability of the
business increasing at this Port, as an extensive trade with the Baltic
is expected, and most of the goods now in warehouse under bond
will no doubt be taken out for home consumption during the present
year.” 1848 was marked by an increase of nine in the number of
foreign importations; and of the fifteen large vessels which arrived,
one was from France with wines and spirits for re-exportation to
Mexico, two were from the Baltic and Hamburg with timber, eleven
from Canada with timber, and one from Russia with flax. The
importers of timber carried on, and used sedulous efforts to extend,
a healthy retail trade in the adjoining districts and in the west of
Yorkshire. The export trade was still inconsiderable, although
gradually increasing, but it was expected, from the convenient
situation of the harbour to the manufacturing towns, and the local
dues upon vessels and goods being much lower than at other ports,
that both it and the imports would, before many years had passed
over, become very extensive, more especially as the Lancashire and
Yorkshire Railway Company had recently acquired a right to the line
between Fleetwood and Preston, and were offering every facility and
inducement to shippers and manufacturers, with the view of making
this haven the inlet and outlet for goods to and from the towns and
villages on their several lines. During the twelve months eighteen
small importations of paper from the Isle of Man took place, and it
was necessary for the officers connected with the customs to keep a
strict guard upon the wharf to prevent the smuggling of that and
other dutiable articles by the numerous passenger and coasting
vessels from the above island, as well as from Scotland and Ireland.
In 1849 the foreign imports were more than doubled, the excess
being chiefly due to the increase of timber-laden vessels. Six of the
total number sailed outwards with cargoes of warehoused goods,
and nine with coal and salt. The coasting trade underwent a most
remarkable rise of about four hundred cargoes inwards, and two
hundred outwards, the principal of the former being iron ore, pig
iron, and, more occasionally, grain; and of the latter, coal. The
barque “Isabella” discharged 609 bales of cotton at Fleetwood from
America in July, 1850, being the second cargo landed here, and later
in the year another consignment of 400 bales was brought by the
same vessel. In 1851 the only novel feature was the arrival of a
large shipload of currants; the value of British goods exported
amounted to £90,000, besides which there were considerable
quantities of merchandise sent outwards from bond. The main
foreign business in 1852 was in timber and dried fruits, but such
importations were seriously diminished during the ensuing year by
the high price of the latter and by a temporary misunderstanding
between the railway company and one of the chief timber
merchants, through which several consignments intended for the
Wyre were diverted elsewhere; in addition five large cargoes were
lost at sea and not replaced. The coasting trade continued to expand
until 1856, when its zenith was reached, since when it has been
characterised by a gradual decline, and the last report, that of 1875,
is as little encouraging as any, with one exception, of its degenerate
predecessors. The fourth freight of cotton, consisting of 1,327 bales,
made its appearance in the ship “Cleopatra,” in the spring of 1857,
and was consigned to Messrs. Benjamin Whitworth and Brothers, of
Manchester, etc. Shortly afterwards, barely two weeks, the
“Favourite” arrived with a further consignment for the same firm,
and gave the signal for the real commencement of a prosperous
trade in that commodity with America, which rapidly developed until
the outbreak of civil war in the transatlantic continent brought it
somewhat abruptly to a close in 1862. In a comparative statement
of charges between Liverpool and Fleetwood, issued during that
flourishing time, it was demonstrated that on a vessel of 500 tons,
cotton in and coals out, the following saving in favour of this port
could be effected:—
£ s. d.
Charges on Ship 66 0 0
” on Cargo inwards 96 8 4
” on Cargo outwards 8 6 8
Total saving £170 15 0

Supposing the cargo to have been consigned to parties in Preston,

a further advantage, amounted to £230 0s. 0d. in carriage would be
gained, raising the entire saving to £400 15s. 0d.
During late years, the business firm just alluded to, whose
interests in, and efforts for, the welfare of the port have so long
been unflagging, has made a vigorous attempt to revive the
American cotton importations. For the last few seasons several of
their shipments, about ten, have annually arrived, and there is every
prospect that when the dock is completed many more vessels will be
chartered. A large shed for the reception of cotton was erected in
1875, in Adelaide Street, by Messrs. B. Whitworth and Bros., who
have also established a permanent office in the town.
In 1859 the trade between Fleetwood and Belfast had developed
to such an extent that a larger covered area for the temporary
warehousing, loading, and discharging of goods was urgently called
for, and towards the close of that year a space of about 190 feet in
length, by 30 feet wide, was walled in and roofed over on the quay,
adjoining the building then in use for the same purposes. Four years
later, in 1863, two steam cranes were placed on the wharf by the
North Lancashire Steam Navigation Company. Subsequently other
cranes, working on a similar principle, have been added to those
experimental ones, and gradually the old system of hand-labour at
the quay-side has been superseded by the adoption of this more
expeditious and economical plan. Shortly before the last-named
facilities had augmented the conveniences of the wharf, a fresh
description of mooring appliance was laid down in the harbour, and
consisted of two longitudinal ground chains of 1,000 feet each,
attached at intervals of 50 feet to two sets of Mitchell’s screws,
which were worked into the clay in the bed of the stream. The bridle
chains, shackled above to the mooring buoys, were secured below to
the ground links between the attachments of the screws, the buoys
being so arranged that each vessel was held stem and stern, instead
of swinging round with the tide, or stranding with one end on the
large central sandbank, as heretofore.
From 1862 to the present date, the story of the haven, with the
exceptions of the trawling fleet and the Belfast line, which will be
treated of directly, is not one which will awaken envy in the breasts
of those whose interests are bound up in rival ports, nor indeed can
it be a source of congratulation to those whose interests might
ordinarily be supposed to be best promoted by its prosperity. It is
true that the foreign trade for seven years after 1862 was in a state
of fluctuation rather than actual decline, but the three succeeding
years were stationary at the low figure of 21 imports each, after
which there was a slight improvement, raising the annual numbers
to 24, 32, and, in 1875, 33, due more to the staunch allegiance of
Messrs. B. Whitworth and Bros., whose cotton again appeared on
the wharf, than to any inducements offered to them or others by
increased facilities or more appropriate accommodation. The
coasting trade has already been referred to, so that there is no
necessity to recapitulate facts but just laid before our readers. It is
proper, however, to mention a few statistics respecting the trade in
exports of coal, the chief business, and below are given the numbers
of tons shipped, mostly to Ireland, in each of the specified years:—
1855 31,490
1860 23,652
1865 16,225
1866 12,315
 1867 10,912
1868 6,809
1869 24,741
1870 43,653
1871 51,473
1872 54,794
1873 55,447
1874 56,939
1875 71,353

The large and sudden increase from 1869 is mainly owing to

several screw steamships having been extensively engaged in the
traffic, and there is every probability, from the addition within the
last few months of a new and handsome coal-screw, and other
indications, that this branch of commerce will continue to develope
with equal, if not greater, rapidity. Again, it should be remembered,
when considering the falling off in the numerical strength of the
coasting vessels trading here, that those now plying are of much
greater carrying capacity than formerly, and consequently the actual
exports and imports have not suffered diminution in anything like
the same proportion as the ships themselves. A series of tabular
statements of all the most important and interesting matters
connected with the harbour from the earliest obtainable dates has
been prepared from the official returns made to the custom-house
during each twelve months, and subjoined will be found a list of the
vessels retained on the register as belonging to the port at the end
of the years indicated, with their tonnages and the number of hands
forming the crews:—
Steam Sailing
Year. Tonnage. Hands. Tonnage. Hands.
Vessels. Vessels.
1850 3 739 49 15 560 54
1851 3 739 49 21 856 77
1852 3 739 49 24 1495 104
1853 4 806 54 31 4002 196
1854 2 560 32 41 5337 261
1855 3 586 35 49 4933 267
1856 4 978 52 51 5458 280
 1857 3 952 49 71 7839 391
1858 4 968 54 79 8168 427
1859 4 968 54 76 6930 392
1860 4 968 54 84 12075 570
1861 5 1508 74 93 14760 640
1862 4 1249 62 89 13957 602
1863 4 1249 62 85 12147 567
1864 5 1355 71 81 10338 513
1865 6 1372 74 83 9757 479
1866 6 1372 74 80 8831 454
1867 6 1779 90 77 9265 451
1868 6 1779 90 85 11226 515
1869 5 1239 70 99 12601 587
1870 7 1797 93 104 12546 609
1871 7 1571 81 115 13642 690
1872 7 1571 81 133 15161 789
1873 7 1994 92 150 19379 947
1874 7 1994 122 162 22598 1045
1875 9 2671 160 165 22655 1061

The foregoing tables, taken by themselves, would seem to imply

that from the year 1868, the business of the place had been
characterised by a rapid and most satisfactory increase, but
unfortunately for such a deduction, the ships registered as belonging
to any port afford no clue to the number actually engaged in traffic
there, hence it happens that many vessels hailing from Fleetwood,
as their maternal port, are seldom to be observed in its waters.
The following are the annual records of the foreign and coasting
trade of the harbour, in which the Belfast and all other steamships
are included under the latter heading:—
VESSELS WITH CARGOES.

Foreign Trade. Coasting Trade.

Year. Inwards. Outwards. Inwards. Outwards.
1844 8 1 436 327
1845 23 2 580 473
1846 24 13 799 927
1847 6 1 752 913
 1848 15 5 873 857
1849 36 15 1247 1059
1850 38 14 986 1014
1851 35 13 943 932
1852 32 12 951 823
1853 22 7 1093 919
1854 23 6 1119 983
1855 21 4 1101 971
1856 10 4 1181 1120
1857 18 7 1130 1150
1858 26 13 1020 986
1859 38 20 1023 865
1860 71 30 1123 813
1861 68 28 953 713
1862 41 7 884 560
1863 27 10 795 615
1864 35 6 783 610
1865 29 2 868 623
1866 39 2 762 612
1867 37 4 737 573
1868 26 3 689 512
1869 28 3 730 512
1870 21 4 694 573
1871 20 6 545 526
1872 21 3 697 621
1873 24 3 696 670
1874 32 6 703 587
1875 33 2 659 589

The particulars given below, concerning the vessels belonging to

Fleetwood, will form an interesting and useful accompaniment to the
foregoing:—

New Vessels[86] Lost at Broken-up Transferred to other

Registered. Sea. (condemned). Ports.
Year. No. Tons. No. Tons. No. Tons. No. Tons.
1850 — — — — — — — —
1851 — — 1 83 — — 1 27
1852 — — — — — — — —
1853 3 199 2 62 — — 1 44
1854 1 128 — — — — 8 1003
1855 2 104 1 595 — — 5 562
1856 3 484 1 23 — — 4 294
1857 8 364 1 26 — — — —
1858 5 239 4 1050 — — 1 54
1859 3 97 5 739 — — 3 726
1860 3 865 — — 1 29 2 74
1861 8 1012 — — — — 7 518
1862 5 534 1 416 — — 12 1844
1863 2 226 4 1308 — — 4 318
1864 2 201 9 3363 — — 3 666
1865 2 273 1 538 — — 2 517
1866 4 520 5 1449 1 16 2 64
1867 3 439 6 605 — — 2 214
1868 5 588 — — — — — —
1869 6 512 1 518 — — — —
1870 8 1610 2 683 2 65 1 424
1871 10 991 — — — — 2 339
1872 15 1588 3 427 — — 1 42
1873 19 2921 6 1966 — — 2 120
1874 15 2928 5 2304 1 32 — —
1875 9 2410 4 2021 1 16 4 300

Now that the dock is no longer a mere word and promise, but has
at length a definite signification and a material existence, there is
every appearance that those into whose hands the fortunes of the
port may be said to have been entrusted have no intention of any
dilatory action in furthering the interests of their charge. Already, in
1875, a powerful steam dredger has been purchased at a cost of
£12,000 and set to its labours in the channel and harbour. This
dredger, which has superseded the older and much smaller one,
launched in 1840 and used until recently, was built by Simonds and
Company, of Renfrew, on the Clyde, and is of 100-horse power,
being capable of raising 250 tons of sand, shingle, etc., in an hour.
In addition it is able to work in twenty-six feet of water, whereas the
original one was obliged to wait until the tide had ebbed to fourteen
feet before operations could be commenced, so that really the work
which can be accomplished by the new machine is out of all
proportion to that which its predecessor could effect. Several iron
pontoons, or lighters, furnished with false bottoms to expedite the
business of discharging them, formerly performed by hand and
spade, have also been obtained; and the bed of the river seaward
from Fleetwood is rapidly being relieved of its superabundance of
tidal deposits and scourings, which is carried by the lighters beyond
the marine lighthouse at the foot of the Wyre and deposited in the
Lune.
Steamboat traffic was, and is, the most important branch of
shipping connected with the port, but notwithstanding the support
and encouragement which has been so freely extended to the
Belfast line, sundry attempts by the same company to establish sea-
communications between Fleetwood and other places have
invariably ended in complete failures. In the context we have
endeavoured to trace a brief outline of the steamship trade of the
harbour from its earliest days up to our time. The North Lancashire
Steam Navigation Company was established in 1843, and
commenced operations by running the “Prince of Wales” and the
“Princess Alice,” two large and fast iron steamships for that date,
between this port and Belfast on each Wednesday and Saturday
evening, the return trips being made on the Monday and Friday. In
that year, however, the number of trips was increased to three per
week, the fares for the single journey being, saloon, 15s.; and deck,
3s. Another steamship the “Robert Napier,” of 220 horse-power,
sailed also from Fleetwood in 1843, every Friday morning, at 10 a.m.
for Londonderry, calling at Portrush, and returned on Tuesday, the
fares being, cabin, 20s.; and deck, 5s. In 1844 we find that
communications, through the exertion and enterprise of the above
company, were open between Fleetwood and Belfast, Londonderry,
Ardrossan, and Dublin, respectively. The Ardrossan line consisted of
two new iron steamboats, “Her Majesty,” and the “Royal Consort,”
each of which was 300 tons register, and 350 horse-power, the fares
being, cabin, 17s.; and deck, 4s. The Dublin trip was performed
once, and afterwards twice, a week each way, by the iron steamship
“Hibernia,” which called off Douglas, Isle of Man, to land passengers,
but after a year’s trial this communication was closed. In the
summer of 1845, an Isle of Man line was opened by the steamship
“Orion,” which ran daily, except Sundays; and at the same season
the Belfast boats commenced to make the double journey four days
a week, whilst the Londonderry route was abandoned. As early as
1840, on the completion of the Preston and Wyre Railway, a daily
steam communication had been established to Bardsea, as the
nearest point to Ulverston and the Lakes; and in the month of
September, 1846, on the completion of Piel Pier, it was transferred to
that harbour, and continued by the steamship “Ayrshire Lassie,” of
100 horse-power, the fares being, saloon, 2s.; and deck, 1s. In the
following year this boat was superseded by a new steamer, the
“Helvellyn,” of 50 tons register and 75 horse-power, which continued
to ply for many years, in fact, almost until this summer line was
closed, at a comparatively recent date, about eight or ten years ago.
The Fleetwood and Ardrossan steamers discontinued running in
1847, and at the same time an extra boat, the “Fenella,” was placed
on the Isle of Man route, whilst the Belfast trips were reduced to
three double journeys per week. After a few years experience the
Isle of Man line, a season one only, was given up; but the Belfast
trade, continually growing, soon obliged the company to increase
the number of trips, and step by step to enlarge and improve the
boat accommodation. We need not trace through its different stages
the gradual and satisfactory progress of this line, but our object will
be sufficiently attained by stating that the two steamships were
shortly increased to three. Afterwards larger and finer boats, having
greater power, took the places of the original ones, and at the
present day the fleet consists of four fine steamers of fully double
the capacity of the original ones, which cross the channel from each
port every evening except Sunday.
In the year 1874 the whole of the interests of Frederick Kemp,
esq., J.P., of Bispham Lodge, in the Fleetwood and Belfast steam line
were acquired by the Lancashire and Yorkshire and London and
North Western Railway Companies, at that time owners of the larger
share, and now practically sole proprietors. Up to the date of this
transaction the vendor had been intimately and personally
associated with the traffic as managing-owner from its first
institution, in addition to which he was the chief promoter of the
Ardrossan and Isle of Man routes.
With the solitary exception of the service whose progress has just
been briefly traced out, there is perhaps no single branch of industry
which has assisted so ably in maintaining and stimulating such
prosperity as the town of Fleetwood has enjoyed, throughout its
chequered career, as the fishing traffic. In the earliest years of the
seaport, shortly before the Belfast steamer communication was
established, a second pilot boat, named the “Pursuit,” arrived in the
river from Cowes, but finding little occupation the crew provided
themselves with a trawl-net and turned their long periods of vigil to
profitable account by its use. This sensible plan of launching out into
another field of labour when opportunities of prosecuting their more
legitimate avocation failed them was not of long duration, probably
no more than a few months, for on the Irish line of steamships
commencing to ply the pilots secured berths as second officers, and
their boat was laid up. The “Pursuit” soon became a tender to a
government ship engaged in surveying; and about ten or twelve
months later was purchased by some gentlemen, denominated the
Fleetwood Fishing Company, and, together with four more boats,
hired from North Meols, Southport, sent out on fishing excursions. At
the end of one year the hired sloops were discharged, and five
similar craft bought by the company, thus making a fleet of six
smacks belonging to the place, connected with the trawling trade. In
the course of three or four years the whole of the boats were sold,
as the traffic had not proved so remunerative a venture as at first
anticipated; and one only remained in the harbour, being purchased
by Mr. Robert Roskell, of this place. Shortly afterwards a Scotch
smack arrived from Kirkcudbright, and in about twelve months the
two boats were joined by three or four from North Meols, owned for
the most part by a family named Leadbetter, which settled here.
Almost simultaneously another batch of fishing craft made its
appearance from the east coast and took up a permanent station at
Fleetwood. The success which attended the expeditions of the deep-
sea trawlers was not long in being rumoured abroad and attracting
others, who were anxious to participate in an undertaking capable of
producing such satisfactory results. Year by year the dimensions of
the originally small fleet were developed as new-comers appeared
upon the scene, and added their boats to those already actively
prosecuting the trade. To trace minutely each gradation in the
prosperous progress of this line of commerce would be wearisome to
the reader, and is in no way necessary to the object we have in view.
It will be sufficient for the purpose to state that in 1860 the number
of fishing smacks on the Fleetwood station amounted to thirty-two,
varying in tonnage from 25 to 50 tons each and built at an average
cost of £500 each, the lowest being £400 and the highest £1,000.
The following will illustrate the plan by which men in the humble
sphere of fishermen were enabled to become the proprietors of their
own craft: A shipmaster supplied the vessel on the understanding
that £100 was deposited at once, and the remainder paid by
quarterly instalments, no insurance being asked for or proffered
regarding risk. The arrangement entered into by the smack-owners
for the conveyance of fish to shore, when they were engaged out at
sea in their calling was most simple and business-like. The boats
kept company during fishing, and on a certain signal being given one
of the number, according to a previous agreement, received the
whole of the fish so far caught by her fellow craft and returned
home, for which service her men were paid 2s. each by the other
crews, who continued their occupation and arrived in harbour
generally on Friday. For the next week another smack was selected,
and thus all in turn performed the mid-week journey. At present
there are no less than eighty-four sloops belonging to this port,
pursuing the business of fishing, and the arrangements both for their
purchase and the landing of the captured fish have undergone a
revolution. All boats are now paid for when they leave the
shipbuilder’s yard, and the former custom of a mid-week relief, has
been relinquished, each sloop returning and discharging as occasion
requires. A fishing boat’s crew usually consists of four men and a