Manual of Surgery Volume II Part 52

The _treatment_ of these forms consists in improving the general condition of the patient, and in employing a mouth-wash, such as peroxide of hydrogen, Condy's fluid, chlorate of potash, or boro-glyceride. The superficial ulcers may be touched with silver nitrate or with a 1 per cent. solution of chromic acid.

_Ulcerative stomat.i.tis_ is frequently met with in debilitated subjects with decayed teeth, and is specially liable to occur during the course of acute febrile diseases in which sordes acc.u.mulate about the teeth and gums. It also occurs in syphilitic subjects while under treatment by mercury--_mercurial stomat.i.tis_. Some patients show a special susceptibility to mercury, and one of the first signs of intolerance of the drug is some degree of stomat.i.tis, which may ensue after a comparatively small quant.i.ty has been administered. It begins in the gums, which become swollen and spongy, growing on to the teeth and into the interstices. The gums a.s.sume a bluish-red colour and bleed readily, and the teeth may become loose and fall out. The tongue may share in the swelling--mercurial glossitis. There is also profuse salivation, and the breath has a characteristically offensive odour.

In severe cases the alveolar margin of the jaw undergoes necrosis. A similar condition occurs in lead and in phosphorus poisoning, and in patients suffering from scurvy.

The _treatment_ consists in removing the cause, and in employing antiseptic and astringent mouth-washes. The internal administration of chlorate of potash is also indicated, as this drug is excreted in the saliva. Loose teeth should not be removed as they become fixed again when the stomat.i.tis subsides.

_Gangrenous stomat.i.tis_, or cancrum oris (Fig. 245), has already been described (Volume I., p. 102).

[Ill.u.s.tration: FIG. 245.--Cancrum Oris.

(Mr. D. M. Greig's case.)]

#Roof of the Mouth.#--_Suppuration_ in the muco-periosteum of the palate is usually secondary to suppuration at the root of a carious tooth. It may also arise in excoriations caused by an ill-fitting tooth-plate, or from the impaction of a foreign body, such as a fish or game bone, in the mucous membrane. The inflammation begins close to the alveolus, and may spread back along the palate. The muco-periosteum becomes swollen, red, and exceedingly tender, and, as pus forms, is raised from the bone, forming a prominent, firm, elongated swelling, which on bursting or being incised gives exit to foul-smelling pus.

The _syphilitic gumma_, which begins as a rounded indolent swelling, is usually situated in the middle line near the posterior edge of the hard palate. The swelling gradually softens and ulcerates, and a sequestrum may separate and leave a perforation in the palate (Fig.

246). The treatment consists in employing the usual remedies for tertiary syphilis. If the perforation persists and causes trouble by allowing food to pa.s.s into the nose, or by giving a nasal tone to the voice, it may be closed by an operation on the same principle as that performed for cleft palate, or an obturator may be fitted to occlude the opening.

[Ill.u.s.tration: FIG. 246.--Perforation of Palate, the result of Syphilis, and Gumma of Right Frontal Bone.

(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]

_Tuberculous_ disease is chiefly met with in the form of lupus which has spread from the nose or lips, and it may lead to widespread destruction of the soft tissues, or even to perforation of the bony palate.

Mucous cysts, dermoids, adenomas, lipomas, and fibromas are occasionally met with. _Papillomatous thickening_ of the mucous membrane sometimes occurs in a.s.sociation with leucoplakia. It resists anti-syphilitic treatment, but yields to sc.r.a.ping with the sharp spoon. _Endotheliomas_, or _mixed tumours_, similar to those met with in the parotid gland, also occur in young subjects, and grow in the submucous tissue of the soft palate, usually to one side of the middle line. In their early stages they are of slow growth, and give rise to no inconvenience save from their size, are easily removed, and show no tendency to recur. Later, they grow more rapidly, tend to infiltrate their surroundings and to a.s.sume malignant characters, so that complete removal becomes difficult or impossible.

_Epithelioma_ may originate in the hard palate as a result of local irritation, or may spread from adjacent parts. When it is confined to the palate it is treated by removal of the palatal and alveolar portions of the maxilla.

#Elongation of the uvula# is usually due to a chronic inflammatory engorgement combined with glandular hypertrophy of the mucous membrane. It often occurs in children, and is a.s.sociated with a constant hacking cough, which is usually worst when the patient is lying down. By tickling the back of the tongue and pharynx it may induce vomiting after meals. The treatment consists in snipping off the redundant portion with scissors.

#Epithelioma of the floor of the mouth# frequently originates in the mucous membrane between the frenum of the tongue and the inner aspect of the gum. It develops insidiously, grows slowly, and gradually spreads to the mandible and to the substance of the tongue, tacking it down so that it cannot be protruded. The glands are early involved, and their enlargement not infrequently first draws attention to the condition. It is to be regarded as a particularly unfavourable site, as local recurrence is frequent. For the complete removal of the disease it is necessary to excise the tissues in the floor of the mouth, and a variable portion of the tongue and mandible, and to clear out the glands and fat from the submaxillary and submental regions.

THE TONSILS AND PHARYNX

#Infective Conditions.#--The majority of the infective conditions included under the popular term "sore throat" originate in the tonsils, and are due to the action of bacteria which under normal conditions are present in the crypts of the tonsils and of the mucous membrane of the naso-pharynx. The most important of these organisms are streptococci, various forms of staphylococci and of pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So long as the health is good these organisms are harmless, but when there is any lowering of the vitality they become virulent and give rise to various forms of infection.

_Catarrhal tonsillitis_--usually attributed by the laity to "catching cold"--is characterised by hyperaemia and congestion of the tonsils and mucous membrane of the pharynx, soft palate, and uvula. It is often met with in those who are much exposed to air contaminated with organisms--for example, patients who have been long in hospital, or the resident staff of hospitals (_septic_ or _hospital throat_), and particularly in persons of a "rheumatic" tendency. There is slight pain on swallowing, and a tickling sensation pa.s.ses along the Eustachian tube to the ear; the throat feels dry, and the patient has a constant desire to clear it, and there is usually a rise of temperature to 101-102 F. As a rule the symptoms pa.s.s off in three or four days, but the condition may spread along the Eustachian tube to the ear, and interfere with hearing, or it may set up chronic suppuration of the middle ear.

A similar condition of the pharynx is frequently one of the initial symptoms in acute febrile diseases, such as scarlet fever, measles, influenza, or acute rheumatism.

The _treatment_ of the throat affection consists in employing antiseptic and soothing gargles, inhalations of chloride of ammonium, or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges or pastilles containing chloride of ammonium, chlorate of potash, and cubebs may be employed. In rheumatic cases, salicin, aspirin, and salicylate of soda are indicated.

In _follicular tonsillitis_, the infection first implicates the lymphoid follicles. The crypts are distended with yellowish-white plugs, composed of inflammatory exudate, leucocytes, and desquamated epithelium, and these may project from the openings, giving the tonsil a spotted appearance. Sometimes the exudate acc.u.mulates on the surface of the tonsils and pharynx, forming a thin, greyish-white film, which is liable to be mistaken for the false membrane of diphtheria. It can, however, usually be wiped off, and when examined microscopically does not contain the typical Loffler's bacillus.

The tonsils are enlarged, and project so that they obstruct the isthmus of the fauces, sometimes even meeting in the middle line.

There is pain on swallowing, and the respiration is impeded and noisy during sleep. There is usually some degree of fever, and the glands behind the angle of the jaw are enlarged and tender and may suppurate and set up cellulitis. The acute symptoms usually subside in four or five days, but if the deeper crypts are filled with plugs of exudate the condition may prove obstinate. The patient is liable to periodic attacks, particularly if the tonsils are chronically enlarged.

The _treatment_ is carried out on the same lines as for the catarrhal form. In recurrent cases the tonsils should be removed.

#Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy.#--This is an acute suppurative inflammation of the tonsils and peritonsillar tissue, due to infection with pyogenic bacteria. It affects the whole substance of the tonsils, and the cellular tissue of the pillars of the fauces, the soft palate, and the pharynx.

_Clinical Features._--The onset is usually sudden, and the affection is ushered in by a rigor, high fever, and a feeling of malaise. There is persistent thirst and dryness of the throat, and the patient has the sensation of a foreign body being in the pharynx, with a constant desire to swallow. Swallowing is extremely painful, the pain shooting up to the ears, and the patient has difficulty in taking nourishment.

The saliva acc.u.mulates in the mouth; the voice is thick and nasal; and the respiration impeded and noisy. If the patient can open the mouth sufficiently to afford a view of the back of the throat (which, however, is seldom the case), the inflamed parts are seen to be of a dull reddish-violet colour. One tonsil is often more swollen than the other, and the corresponding anterior pillar of the fauces more prominent. The uvula is swollen and dematous, and is deviated towards the side on which there is least swelling. Suppuration occurs in from three to seven days; in adults it is usually in the peritonsillar tissue of the anterior pillar of the fauces, and extends into the soft palate. In children the pus sometimes forms in the substance of the tonsil. If left to burst, the abscess discharges itself into the mouth, and the patient experiences instant relief. The pus is always offensive, and if the abscess bursts during sleep, it may enter the air-pa.s.sages and cause septic pneumonia. The lymph glands in the neck are usually enlarged and tender, and sometimes they suppurate and give rise to a diffuse cellulitis. General infection of the blood may follow, leading to metastatic invasion of different tissues and organs, particularly one or other of the large joints.

_Treatment._--In the early stages soothing antiseptic gargles are indicated. Later, when the patient is unable to gargle, the inhalation of steam impregnated with the vapour of carbolic acid or friar's balsam, and the application of hot fomentations or a large linseed poultice to the neck may afford relief. When an abscess is formed, it should be opened by means of a fine-pointed pair of sinus forceps, thrust through the soft palate at a point opposite the base of the uvula, and in the line of the anterior pillar of the fauces. As those who suffer from quinsy are liable to have attacks coming on periodically, if the tonsils remain permanently enlarged they should be removed between attacks.

#Hypertrophy of the tonsils# is most commonly met with in children between five and ten years of age, and is often a.s.sociated with adenoid vegetations in the naso-pharynx and chronic thickening of the pharyngeal mucous membrane.

The whole tonsil is enlarged, the mucous membrane thickened, and the connective tissue more or less sclerosed. The crypts appear on the surface as deep clefts or fissures, and the lymph follicles are enlarged and prominent. Secretion acc.u.mulates in the crypts, and a calculus may form from the deposit of lime salts. Sometimes food particles lodge in the crypts, and they may collect and form acc.u.mulations of considerable size, requiring the use of a scoop to dislodge them.

_Clinical Features._--The hypertrophy is bilateral, but not always symmetrical. Sometimes the tonsils project to such an extent as almost to meet in the middle line; sometimes they scarcely pa.s.s beyond the level of the pillars of the fauces. They are usually sessile, but sometimes the base is so narrow as almost to form a pedicle. During childhood they are usually soft and spongy, but when they persist into adolescence or adult life they become firm and indurated. This sclerotic change is due to the repeated attacks of catarrhal or suppurative tonsillitis to which the patient is subject. The lymph glands behind the angle of the jaw are frequently enlarged. Swallowing is sometimes interfered with, and the patient is liable to attacks of nausea and vomiting. Respiration is always more or less impeded; the patient breathes through the open mouth, and snores loudly during sleep; and the hindrance to respiration interferes with the development of the chest. In some cases alarming suffocative attacks occasionally supervene during sleep, but the difficulty in breathing disappears as soon as the child is wakened. The voice is characteristically thick and nasal, especially when adenoids are present, and in many cases the patient has a vacant and stupid expression. Hearing is often impaired from obstruction of the Eustachian tube.

_Treatment._--In early and mild cases, the tonsils should be painted with glycerine of tannic acid, or some other astringent, and an antiseptic mouth-wash, or spray of hydrogen peroxide, should be used several times a day. When the condition is interfering with the general health or with the development of the chest, or when there is deafness or disturbance of sleep, the tonsils should be removed.

#Calculi# composed of phosphate or carbonate of lime are sometimes formed in the crypts of enlarged tonsils; as a rule they are about the size of a pea, but they may be much larger. They cause a sharp stabbing pain on swallowing, and sometimes a persistent hacking cough.

They are easily sh.e.l.led out through a small incision into the tonsil.

#Syphilis.#--The fauces and tonsils are occasionally the seat of a hard chancre, and the condition may simulate malignant disease. The submaxillary glands, however, become enlarged sooner and increase more rapidly than in cancer, and they are tender. The secondary manifestations of the disease usually appear before the chancre has healed.

Early in secondary syphilis, mucous patches and superficial ulcers are frequently met with. Later, severe phagedaenic ulceration sometimes occurs, especially in alcoholic subjects, and may rapidly eat through the soft palate, leading to marked deformity from contraction when cicatrisation takes place.

In the tertiary stage, a diffuse gummatous infiltration occurs, and is liable to be followed by ulceration, which spreads to the pharyngeal wall and soft palate, and, by causing cicatricial contraction and adhesions, may lead to narrowing or even complete occlusion of the communication between the pharynx and the naso-pharynx.

#Tuberculous# lesions of the fauces and tonsils are almost invariably secondary to tubercle of the larynx or lungs, or to lupus of the face or naso-pharynx. They are attended with more pain than syphilitic lesions; are less p.r.o.ne to spread to the palate and cause perforation; but, when cicatrisation takes place, they are equally liable to produce contraction and deformity.

#Tumours.#--_Innocent tumours_--fibroma, lipoma, myoma--are comparatively rare. When sessile they cause inconvenience only by their bulk; when pedunculated they may hang down into the pharynx and interfere with swallowing and breathing. They may be sh.e.l.led out, or ligated at the base and cut off, according to circ.u.mstances.

_Malignant Disease._--The _tonsil_ is frequently the primary seat of _lympho-sarcoma_, a very malignant form of round-celled sarcoma. The tumour is at first confined to the tonsil, which differs in appearance from simple hypertrophy only in being paler and more nodular. The growth rapidly infiltrates the peritonsillar connective tissue and adjacent palatal mucous membrane, which becomes pale and dematous, and the condition at this stage may simulate a suppurative tonsillitis. As it increases, the tumour encroaches upon the cavity of the pharynx, causing interference with swallowing and breathing; the mucous membrane soon gives way, and widespread ulceration and sloughing of the tumour substance occurs, sometimes leading to serious and even fatal haemorrhage. The patient emaciates rapidly. The adjacent lymph glands are early infected.

Removal by operation is seldom practicable, but the introduction of a tube containing radium for several days has in some cases proved beneficial.

_Carcinoma_ is more common than sarcoma. It may take the form of _squamous epithelioma_ or of _medullary cancer_, and may originate in the tonsil, in the groove between the tonsil and the tongue, or in the soft palate. By the time the patient seeks advice it has usually implicated the fauces, soft palate, and pharyngeal wall as well as the tonsil.

Males suffer more frequently than females. The disease may exist for a considerable time before giving rise to marked symptoms, and attention may first be drawn to it by pain and difficulty in swallowing, or by pain shooting towards the ear. In some cases enlargement of the glands behind the angle of the jaw is the first thing to attract the patient's attention. The other symptoms are very like those of cancer of the tongue--pain during eating or drinking, salivation and ftid breath. Sometimes fluids regurgitate through the nose, and the voice may become nasal and indistinct. As the patient is usually unable to open the mouth widely, it is seldom possible to learn much by inspection, but a digital examination may reveal an irregular, hard, and ulcerated growth. The swelling is sometimes palpable from the outside, filling up the hollow behind the angle of the jaw, and in this situation also the enlarged lymph glands may be felt. These are often enlarged out of all proportion to the size of the primary growth. The disease tends to spread locally, causing increasing difficulty in swallowing and breathing. The patient gradually loses strength, and may die from exhaustion induced by pain and insomnia, from haemorrhage, or from septic pneumonia.

In early cases an attempt may be made to remove the disease by operation. In our experience radium has proved less efficacious in cancer than in sarcoma.

In advanced cases, it is only possible to relieve the patient's suffering by palliative measures. Antiseptic mouth-washes are used to diminish the ftor of the breath and the risk of pneumonia, and heroin or morphin to relieve pain. The use of the nasal tube, or even a gastrostomy, may be necessary to enable the patient to take sufficient food, and tracheotomy may be called for to relieve dyspna.

#Retro-pharyngeal Abscess.#--The _chronic_ retro-pharyngeal abscess a.s.sociated with tuberculous disease of the cervical vertebrae, in which the pus acc.u.mulates behind the prevertebral fascia, has already been described (p. 441).

The _acute_ abscess occurs in the s.p.a.ce between the prevertebral fascia and the wall of the pharynx. The infection usually begins in one of the lymph glands that occupy this s.p.a.ce, and rapidly ends in suppuration, which spreads to the surrounding cellular tissue. It is most common in children during the first and second years, and the patient may be convalescent after one of the eruptive fevers attended with inflammation of the bucco-pharyngeal mucous membrane--such as scarlet fever, measles, or chicken-pox--or may suffer from nasal excoriations or coryza. In some cases the irritation of dent.i.tion is the only discoverable cause.

In infants, the condition is usually very acute, and is attended with fever, rigors, vomiting, and often with convulsions. The head is held rigid, and usually twisted to one side, and there is pain on attempting to move it. The child has great pain on swallowing, there is regurgitation of food, and the saliva dribbles from the mouth.

There is marked dyspna and a short, dry cough. The back of the throat is red and swollen, and a localised projection, which is soft and fluctuating, and is usually asymmetrical, may be recognised by digital examination. Sometimes the voice is lost, and the patient has severe attacks of choking--symptoms which have led to the disease being mistaken for membranous laryngitis. In some cases a soft swelling is palpable on one or on both sides of the neck. Unless the abscess is promptly opened the condition usually proves fatal. The mouth is opened by means of a gag, the head allowed to hang over the end of the table, and the abscess incised, with a guarded bistoury, through the wall of the pharynx. The dangers a.s.sociated with opening the abscess from the mouth appear to have been exaggerated.

A _less acute_ form of retro-pharyngeal abscess sometimes develops in the course of chronic middle ear disease, the inflammatory process spreading along the Eustachian tube, in the wall of which an abscess forms and burrows into the retro-pharyngeal s.p.a.ce.