is to be conducted on the general principles applicable to those
diseases; for a consideration of which the reader is referred to the
appropriate articles of this work. We have here to consider general
prophylaxis and local measures. The proper management of the child
during the period of the first dentition is a matter of great
importance, and may avert serious complications. The child should be as
much as possible in the open air whenever the weather is favorable. The
head may be daily sponged with cold water, and caps and warm
head-coverings of all kinds should {377} be forbidden.[78] Frequent
rubbing of the gums with a crust or other hard substance, or with the
finger, is advisable; and something for the child to bite on,
preferably a silver piece, should be provided. Orris-root, calamus, and
other vegetable substances frequently given to children for this
purpose are objectionable; their fermentation is apt to lead to thrush.
The secretions must be kept active. The diet should be carefully
regulated, and cooling drinks be freely given in order that the child
may not overload its stomach by too frequent suckling in its efforts to
relieve the local heat by moisture. The mother should be warned not to
put it too frequently to the breast. Weaned children will often be
found unable to digest their ordinary food, and in that case still
greater care will be required. Slight diarrhoea does not call for
interference, and is often beneficial in relieving nervous tension and
thus averting a tendency to convulsions. Indeed, when the bowels are
not relaxed gentle aperients should be given, especially in plethoric
subjects or in those with cutaneous eruptions (Clarke). Cutaneous
eruptions do not call for treatment, and there seems to be ground for
the popular fear that they may be driven inward; at least, cases are on
record in which their disappearance under treatment, and even
spontaneously, has been followed by more or less severe convulsions.
[Footnote 78: Tanner after Clarke.]
In cases where bronchitis can be traced wholly or in part to soaking of
the clothing, due protection of the chest by an oil-cloth or waterproof
bib may be prophylactic against future attacks. In children who have
suffered from any special set of morbid manifestations during the
eruption of one pair of teeth, similar disturbances may be expected,
and should be guarded against, in the future.
Aphthous ulcerations are usually associated with disorders of
digestion, the relief of which must be the main object of treatment.
Locally, the treatment does not differ from that of aphthous stomatitis
in general. Obstinate ulceration of the tongue may require the use of
silver nitrate. In that form of ulceration called odontitis infantum,
in addition to proper attention to the diet and secretions and mild
antiphlogistic medication, local depletion by leeches, preferably at
the angle of the jaw, is often beneficial. Some writers advise the
application of leeches directly to the gum. Potassium chlorate
internally, two grains every four hours to a child twelve months old,
is curative in the majority of cases. It may be given dissolved in
sweetened water. Solutions of borax, and, in severe cases, of silver
nitrate, may be applied locally. The use of the lancet is
contraindicated, for the cut surfaces would be liable to ulceration.
[Illustration: FIG. 17. Incision for a cuspid (White).]
[Illustration: FIG. 18. Incision for a molar (White).]
The propriety of resort to the lancet for cure of systemic disturbances
by obviating the source of local irritation is one which deserves
consideration. It can only be decided upon the indications presented by
the individual case. The knife is not a panacea for all the disorders
of childhood occurring during dentition, and its indiscriminate use is
to be discountenanced. Nevertheless, there can be no doubt that
engorged and inflamed gums demand incision for their relief, on the
same general principles of surgery applicable to similar conditions
elsewhere. Where it is probable that systemic disease, even if not
solely caused, is aggravated by the irritation and pain of a tooth
unable to make its way to the surface unaided, it is clearly the duty
of the physician to give his little patient that modicum of relief, if
not of cure, which will be afforded by a proper incision of {378} the
gum. It will not do merely to score the gums, but cuts should be made
deep enough to reach the presenting surface and extend even beyond its
boundaries. The developing enamel cannot be injured unless undue force
be exerted. The best instrument to employ is a curved double-edged
bistoury, so wrapped as to prevent injury to tongue, cheek, or lips.
The child should be firmly held by another person, and in such a
position that the parts may be well illuminated. The jaws can be
separated by the operator's left hand, and the fingers so disposed as
to protect the tongue and lips. Sometimes the insertion of a small cork
between the jaws will be of advantage. The cuts should be made with
special reference to the form of the presenting tooth. James W.
White[79] recommends for the incisors and cuspids a division of the gum
in the line of the arch; for the molars a crucial incision, thus X, the
centre of the crown as near as can be determined indicating the point
of decussation. A cuspid partially erupted needs severance of the
fibrous ring on the anterior and posterior as well as on the lateral
surfaces (Fig. 17). All the cups of a molar may have erupted, and yet
strong fibrous bands maintain a decided resistance. In this case White
thinks that all the boundaries of the tooth should be traced by the
lancet and all such bands completely severed, or else a crucial
incision, as in the figure (Fig. 18), should be made so as to ensure
perfect release from pressure. The only contraindication to the use of
the lancet, except in ulcerative odontitis, as before mentioned, is the
existence of a hemorrhagic diathesis.
[Footnote 79: _Op. cit._]
{379}
DISEASES OF THE TONSILS.
BY J. SOLIS COHEN, M.D.
Tonsillitis.
DEFINITION.--An acute inflammation of the tonsil or tonsils; or
inflammation of the tonsil or tonsils, with inflammation of the
peritonsillar connective tissue and of the palatine folds.
VARIETIES.--When the inflammatory process is confined to the mucous
membrane the disease is erythematous, superficial, or catarrhal
tonsillitis; when it involves the lacunæ it constitutes lacunal or
follicular tonsillitis; when it involves the gland as a whole it
constitutes parenchymatous, phlegmonous, or suppurative tonsillitis.
The two latter varieties may present in combination. When the
superficial inflammatory process is a vesicular one, eventually
sheathing the surface of the organ in whole or in part with a
membranous envelope, it constitutes herpetic or membranous tonsillitis.
This variety may complicate superficial tonsillitis. When the
inflammation of the tonsil, usually superficial, is due to the presence
of a cryptogamic growth, it is a mycotic or parasitic tonsillitis,
benign or malignant (diphtheria), as may be. When the inflammation of
the tonsil is due to rheumatism, it is rheumatic or constitutional
tonsillitis.
SYNONYMS.--Inflammation of the tonsils, Amygdalitis, Quinsy, Angina
tonsillaris, Angina phlegmonosa, Phlegmonous sore throat, Cynanche
tonsillaris. Lacunal tonsillitis is more generally known as folliculous
tonsillitis (tonsillitis follicularis). Common membranous or
pseudo-membranous sore throat (angina membranosa communis) is used as a
synonym for herpetic or membranous tonsillitis (tonsillitis herpetica
seu membranosa). Mycosis tonsillaris is a synonym for mycotic
tonsillitis (tonsillitis mycotica benigna or tonsillitis parasitica).
The tonsillitis of diphtheria is sometimes termed tonsillitis
diphtheritica, tonsillitis mycotica maligna; that of rheumatism,
tonsillitis rheumatica, angina rheumatica, rheumatic sore throat.
HISTORY.--Tonsillitis was described by Hippocrates. Of recent authors,
Sauvages, Cullen, Louis for researches on the effects of blood-letting;
Bell on the specific value of guaiacum; Velpeau as to the use of
powdered alum and nitrate of silver; Bourgeoise on the use of tartar
emetic; Maingault on paralytic sequelæ; Hering on mycosis; and the
authors of the various encyclopædias and dictionaries,--may be
mentioned as chief among the numerous observers whose contributions
have been of most value. The bibliographical references appended to the
{380} compilations last cited will guide the student in gaining access
to the more important special observations of anomalous cases.
ETIOLOGY.--Predisposing and Exciting Causes.--Tonsillitis may be
idiopathic, deuteropathic or symptomatic, or traumatic.
The predisposing cause of idiopathic tonsillitis is usually diathetic,
and is associated with congenital or inherited vulnerability of the
organ. Of diathetic causes, scrofula is undoubtedly the most
provocative, but even rheumatism and gout are likewise so considered,
though in a far more limited degree. Acute articular rheumatism is, in
fact, sometimes preceded by rather a sharp attack of tonsillitis
(rheumatic tonsillitis), which subsides spontaneously in a very few
days, sometimes within one day, sometimes suddenly and synchronously
with the onset of the ordinary manifestations of rheumatism, though the
latter are often slight and transient, as if the force of the attack
had been spent on the tonsils. Tonsillitis, non-specific in character,
is apt to be prevalent during epidemics of scarlatina, diphtheria,
rubeola, and variola. Membranous tonsillitis is common before and after
epidemics of diphtheria. Epidemics of tonsillitis have been recorded,
but in the face of their extreme rarity it becomes questionable whether
they were not extensive examples of the proclivity just alluded to.
Tonsillitis is more frequent in individuals with chronically diseased
tonsils than in individuals in whom these glands are healthy. Such
individuals, too, are more liable to recurrences; and such recurrences
often follow very slight provocations.
Idiopathic tonsillitis is rare in infancy. At the period of eruption of
the permanent teeth it is much more liable to occur than before that
period, and the liability increases progressively until the second
dentition has been completed. It is most frequent during the decennium
immediately following puberty--that is to say, in adolescents and young
adults--or from the fifteenth to the twenty-fifth year. The disposition
or predisposition to renewed attacks continues marked during the
decennium immediately succeeding; after which attacks are more and more
infrequent. Certain anatomical changes occurring in the tonsils, as the
rule about the fortieth year, may diminish their proclivity to
inflammation. Nevertheless, the disease occasionally occurs in advanced
age.[1]
[Footnote 1: Solomon Solis Cohen, "Abscess of the Tonsil in an
Octogenarian," _Med. News_, Philada., Feb. 16, 1884, p. 186.]
Deuteropathic tonsillitis is quite frequent in infancy, being excited
by the infection of scarlet fever, diphtheria, measles, and small-pox,
as discussed under these headings respectively. Under similar
circumstances it occurs in the adolescent and the adult likewise. It is
also produced in carcinoma and sarcoma of the tonsil.
Rheumatic tonsillitis, a deuteropathic variety, is most prevalent
during atmospheric changes.
Herpetic tonsillitis, often a deuteropathic variety, seems sometimes of
nervous origin exclusively. It is sometimes traceable to defective
drainage. It is sometimes prevalent during epidemics of diphtheria,
when its membranous character renders it extremely liable to be
mistaken for the tonsillitis of diphtheria.
Traumatic tonsillitis occurs occasionally. The causes are--inspiration
of irritant gases, the deglutition of chemically acrid substances, the
{381} accumulation of calcareous concretions in the crypts or in the
lacunæ, direct and indirect gunshot and other wounds, the impaction of
fish-bones, fragments of toothpicks, cherry-stones, and other foreign
bodies, and the like.
Mycotic tonsillitis is due to the development of a cryptogam upon
tonsils probably already in a state of catarrhal inflammation in
individuals with health impaired by previous disease or unfavorable
hygienic influences.
SYMPTOMATOLOGY, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND
SEQUELÆ.--The onset of tonsillitis, sometimes preceded by headache and
general malaise, is often accompanied by a chill, pyrexia following
within twenty-four hours. The temperature may reach 105° F., being at
its maximum, as a rule, about the third day. It is rarely below 101° F.
The pulse is accelerated to 120 beats per minute. Simultaneously with
the constitutional symptoms local distress is usually manifested, but
either set of disturbances may precede the other by several hours or by
an entire day. Heat and soreness of the throat are early complained of,
gradually increasing in severity to actual pain. The pain may become
intense, especially during deglutition. When the posterior palatine
fold is put upon the stretch, additional pain is referred to the ear,
for this fold encloses the staphylo-salpingeus muscle, which runs from
the palate to the pharyngeal orifice of the Eustachian tube. This pain
in the ear, sometimes the principal cause of complaint, is often
premonitory of suppuration. Noises in the ears on the one hand, and
impairment of hearing on the other, often attend extension of the
inflammation in this direction, the enlarged tonsil sometimes pressing
the posterior palatine fold against the pharyngeal orifice of the
Eustachian tube.
On inspecting the throat early in the disease, one of the tonsils will
be seen to be swollen into an irregularly tumid, much-inflamed mass,
usually of a vivid red color. Occasionally both tonsils are involved
simultaneously, but this is far less frequent than involvement of the
second tonsil a few days later or after subsidence of the process in
its fellow. In many instances the inflammation affects one tonsil only.
The inflammatory process is seldom confined to the tonsil. All the
structures of the throat, even to the base of the tongue, are often
involved, and it is rarely indeed that the anterior palatine fold,
distended over the surface of the tumefied gland, escapes inflammation.
It is this stretching of the anterior palatine fold which occasions
much of the exquisite pain that forms so prominent a subjective symptom
in severe cases. The soft palate, hanging forward in the cavity of the
pharynx, is often inflamed or intensely congested, and the uvula
tumefied, elongated, and oedematous. It may be flaccid upon the
posterior part of the tongue or hang immediately over the epiglottis or
upon it, and induce painful and tiresome efforts at deglutition and
expectoration to relieve the consequent titillation. Sometimes it
adheres by viscid secretion to the side of the swollen tonsil.
The inflamed tonsil or the tonsil and its coverings project far into
the cavity of the pharynx, often as far as the middle line, touching
its fellow when both are involved, so that ulceration sometimes ensues
at the points of contact. The posterior surface of the anterior
palatine fold sometimes becomes unfolded, as it were, in the
tumefaction of the gland, and remains {382} stretched over it in a thin
continuous layer without any line of demarcation. The swollen palate
projects upon the enlarged tonsil like a shelf, from which depends the
uvula, the latter being often oedematous, usually anteriorly, but
sometimes posteriorly.
Inflammation of the connective tissue about the lower jaw, especially
when at or near the articulation, often renders it difficult or even
impracticable to open the mouth sufficiently to permit direct
inspection of the parts; but it is rarely that sufficient space cannot
be made to allow partial protrusion of the tongue on the one hand, and
the introduction of a fore finger for exploratory purposes on the
other, though both of these acts are sometimes impossible. The
tumefaction of the parts impairs the freedom and ease of deglutition,
which may become so painful as to prevent the swallowing of the saliva,
which then may dribble from the mouth.
The pain experienced in swallowing is often manifested by convulsive
action of the muscles of deglutition and of the muscles of the face.
The swollen tonsils prevent the soft palate from being applied to the
surface of the pharynx, as usual in deglutition; and as the upper or
retro-nasal portion of the pharynx thus fails to be shut off from the
lower oesophageal portion, liquids are often forced up into the nasal
passages posteriorly, and are regurgitated through the nostrils, thus
rendering it impracticable, for the time, to slake thirst or to swallow
liquid nourishment.
At first sensations of dryness and pastiness in the throat are
complained of, but in a few hours these symptoms become relieved by a
more copious secretion of mucus or mucus and saliva. This secretion
soon becomes viscid, and so adherent to the parts as to be detached
only with difficulty, thus causing harassing efforts for its
dislodgment by hawking and expectoration, or equally distressing
efforts to swallow it. Should the inflammatory process extend to the
salivary glands, as is not infrequently the case, secondary ptyalism
often results, with increased distress from this source, and the
patient lies or sits with his head inclined upon the diseased or most
diseased side to favor the uninterrupted flow of saliva from the mouth.
Extension of the inflammatory process to the submaxillary glands, or to
the parotid, or to the connective tissue surrounding them, is indicated
by tumefaction externally, which is often exquisitively sensitive to
pressure.
The timbre or quality of the voice is often impaired in a peculiar
manner by the tumefaction of the throat and the immobility of the soft
palate. The voice is thick, throaty, or guttural, having a
characteristic harsh, rasping aspiration in enunciation, while
articulation is much impeded by impairment in the movements of the jaw,
palate, tongue, and lips. At times it is also painful. Speech is
sometimes indistinguishable or impossible, and the voice may even
become suppressed, so that signs and writing remain the sole means of
communication.
Impairment of respiration, at least to any considerable degree, does
not occur, unless both tonsils are involved and swollen to an intense
degree--conditions under which dyspnoea may become pronounced, severe,
and even urgent, and suffocation become imminent. Painful respiration
is not uncommon in rheumatic tonsillitis.
The fever is sthenic in type. There are often severe aching pains in
{383} the limbs. Headache, restlessness, insomnia, nausea, and even
vomiting, may occur. The tongue is heavily coated, the breath is fetid,
appetite is impaired, and the bowels are constipated. The urine is
diminished in quantity, high-colored, and of high specific gravity. It
usually shows slight increase of urea and great diminution of
chlorides. Albuminuria occurs in rare instances.
The symptoms are proportionate to the severity of the attack. A first
attack is usually much severer than subsequent ones, and suppurative
cases more severe than those terminating by resolution. Resolution is
the usual termination, and the parts are restored to a normal condition
at the end of ten to fourteen days, sometimes earlier; in exceptional
cases not until three or four weeks. Sometimes permanent hypertrophy of
the tonsil remains.
Where the inflammatory process fails to subside, suddenly at the end of
five or six days, or a little later, or not until ten days to a
fortnight have passed, slight rigors supervene, announcing suppuration,
and the local distress is very great, with pulsation and lancinating
pains in the tonsils, until all at once the abscess bursts and its
contents are discharged with immediate relief. Sometimes the pus or
much of it is involuntarily swallowed; sometimes it is expectorated. In
exceptional instances the pus has escaped into the larynx and
suffocated the patient, usually during sleep.[2] In rare instances the
abscess, having burrowed beneath the pharyngeal muscles, may open at
the external angle of the jaw or behind the sterno-mastoid muscle. It
may discharge into the epiglotto-pharyngeal fold, and thence reach and
distend the epiglottis. It has been known to descend along the planes
of connective tissue into the mediastinum or into the lungs. Even
ulceration into the maxillary and carotid arteries has occurred,
usually with fatal result, occasionally with an opportunity to save
life by ligating the carotid (Erhmann).[3]
[Footnote 2: Stokes, _Med. Times and Gaz._, Aug. 29, 1874, p. 251;
Littlejohn, _Brit. Med. Journ._, Jan. 2, 1875, p. 16.]
[Footnote 3: _Gaz. méd._, Paris, 1878, p. 42.]
The most frequent point of spontaneous rupture externally is at the
upper portion of the gland anteriorly, just beneath the anterior
palatine fold. Sometimes internal rupture occurs into the lacunæ.
Termination by gangrene is exceptional, and is confined to individuals
with debilitated constitutions. It is much less frequent than
formerly--as a result, perhaps, of better methods of treatment.
Metastasis is one of the methods of termination as to joints or muscles
in rheumatic tonsillitis--to lungs, brain, or gastro-intestinal
tract--as formerly occurred with much more frequency under direct
depletory treatment.
In rare cases extension of the inflammation occurs to the epiglottis,
even to the larynx, and the laryngitis may be so severe as to threaten
life from the occurrence of oedema. Diffuse inflammation of the
retro-pharyngeal connective tissue or of the connective tissue of the
neck may constitute an unpleasant complication of the disease.
In a few instances paralysis of the palate occurs as a sequel of
tonsillitis, and in exceptional cases the paralysis may also affect the
arytenoid muscles of the larynx, and even the accommodator muscles of
the eyes.
PATHOLOGY AND MORBID ANATOMY.--Tonsillitis is almost always {384}
associated with inflammation of the tissues surrounding the tonsil and
those contiguous to it, even in the mildest and most frequent
manifestations of the affection. Thus, inflammation of the palate
(staphyllitis) and uvula, and even of the pharynx (pharyngitis), are
anatomically included with tonsillitis in angina or sore throat.