Part 58

In cases of chorea or epilepsy, of eye or ear troubles, or of any morbid condition not otherwise accounted for, occurring during the period of the second dentition, especially at the sixth, twelfth, and seventeenth years, or until the wisdom teeth are fully erupted, it is well to inspect the mouth and to think of dentition as the possible cause.

PROGNOSIS.--The prognosis will depend upon the character and gravity of the associated symptoms, the presence or absence of diathesis, and the etiological importance attached to dentition. It is impossible to lay down a general law.

TREATMENT.--The treatment of the deuteropathic or associated disorders 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. 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.

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.

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 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.

{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.

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.