Chapter XIV

.) These enlargements are seldom seen alone in the tonsils.

Similar involvement of the lymphoid or adenoid tissue in the vault of the pharynx, and even at the base of the tongue, is quite common, the entire original lymphoid ring being more or less involved.

The consequences of chronic enlargement of the tonsils have much to do with the subsequent welfare of patients. Not only is speech interfered with and made peculiarly “throaty,” but, owing to encroachment upon the natural breathing space, children suffering in this way contract a habit of carrying the head forward and stooping the shoulders, in order thereby to increase the dimensions of the nasopharynx; thus they become “mouth-breathers” and hard of hearing, which is deleterious to their intelligence as well as to their physical well-being. Such children, in time, become stupid, unintelligent, and defective in many ways. There is, then, every reason for removing these obstructions to respiration and for doing it early.

Children thus suffering will present such peculiarity of voice as to suggest immediate examination of the oropharynx, while the posture above described and the existence of the mouth-breathing habit should also prompt investigation. An instant inspection through the widely open mouth should permit the detection of this condition. Should it be desired to estimate it more thoroughly it may be done with the finger, although it will provoke the act of coughing or vomiting and be resisted by most children. Frequently the enlargements can be felt from the outside. There is but one suitable treatment for such a case, _i. e._, _tonsillotomy_.

Tonsillotomy may be effected with any one of several different patterns of tonsillotomes on sale in the instrument stores, most of which are neat and speedy in their work, but the surgeon need not refrain from the purpose of removal because of the lack of such an instrument, as it may be easily accomplished without one. Young and timid children are probably best anesthetized, although if one can establish perfect confidence it may be possible to do it by the aid of local anesthesia. In adults the latter will always be sufficient.

An anesthetized patient should be placed in a chair or semi-upright, and the mouth widely opened. The circular loop of the instrument should be fitted over the tonsil, this, if necessary, being drawn into its grasp by a small hook or forceps, after which by a quick motion of the cutting blade the projecting mass is removed. All instruments are made to be used with either hand and to cut on either side. The practised operator will, therefore, use his left hand when operating on the right tonsil of the patient, and _vice versa_, it being best to adopt this order, for should he be a little clumsy with his left hand and the patient be thereby somewhat disturbed, the right hand may more dexterously perform the excision on the other side. The surgeon should be thoroughly familiar with his tonsillotome before using it. It is not, however, necessary to employ such an instrument, and it will often be more satisfactory to grasp the projecting tonsil in the bite of a suitably constructed tenaculum forceps, or even hold it with a common tenaculum, while with blunt scissors, long handled and curved upon the flat, the tonsil itself is cut away.

None of these methods gives promise of complete extirpation of the tissue, which is often chronically diseased, and it is often well, therefore, to complete the extirpation with the sharp spoon or even to use the finger-nail as a curette. Hemorrhage will be active for a few moments, but is nearly always controlled with either iced water or water as hot as can be borne. Only rarely does it give rise to serious trouble. In such cases adrenalin may be used. Cases are on record where it has been necessary even to tie the carotid, but such instances are mostly bugbears which need not deter one of good judgment from a properly devised operation. Antiseptic gargles, and avoidance of speech and swallowing of hard food, will be all that are needed in the after-management.

The young and the timid will need complete anesthesia, which should be complete in order to abolish reflexes, and cocaine locally to ensure this condition. Many of these subjects are, however, those presenting minor degrees of the _status lymphaticus, to whom anesthetics should be administered with caution_. In such children tonsillotomy should be combined with the erasion and removal of other involved adenoid tissue in the nasopharynx. Inquiry should be made as to whether the patient bleeds unduly freely after minor injuries. In a bleeder it would be well to proceed with caution or abstain from operating.

_Foreign bodies in the tonsil_ are as often fish-bones as any kind; they all give rise to serious irritation. True _calculous formation_ in the tonsil is known. Every foreign body which can be detected and exposed should be removed.

_Tumors of the tonsil_ are usually of the malignant type, either epitheliomatous or sarcomatous. A cancer of the tonsil should be recognized as such very early if operative or other relief is to be effectually afforded, and if operation is made it should be done more thoroughly than can be done through the mouth.

_External pharyngotomy_ is the measure usually required for this purpose. This is usually performed by making a long incision along the anterior border of the sternomastoid muscle, and, after retracting it, making careful and blunt dissection down in the direction of the tonsil, separating tissues which are evidently not involved, but excising everything in which infiltration can be recognized. An extensive operation of this kind would justify preliminary or provisional ligation of the common or at least the external carotid artery. Care should be taken to avoid wounding the nerve trunks, especially the hypoglossal.

_Subhyoid pharyngotomy_ is performed by a transverse incision just below the hyoid bone, with division of the platysma, the omohyoid, the sternohyoid, and the thyrohyoid muscles, leaving enough of their insertion into the bone to permit of subsequent reunion by suture. The thyrohyoid membrane is then divided in such a way as to also permit of its reunion by sutures. Then the mucous membrane, which will probably now protrude into the wound, is caught and divided, retraction sutures being inserted in the edges of the wound. The epiglottis may be retracted or a suture may be passed through it, to be used as a retractor. The lower portion of the pharynx is now exposed and through this opening the tonsil may be removed. After completion of the deeper work the different layers of the tissues are reunited with chromic gut and the deep wound is drained.

_Transhyoid pharyngotomy._ Vallas has suggested a central method of approach to the pharynx by a median incision, through which the mylohyoid muscles are separated, the body of the hyoid exposed, and its division effected with stout scissors or with cutting forceps. When its two halves are retracted a space over an inch long is made, through which the mucous membrane of the pharynx may be opened, this being done by making it protrude with the finger passed into the throat, which shall thus serve as a guide. In closing the wound it is not necessary to make suture of the hyoid bone.

THE TEETH, THE ALVEOLAR PROCESS, AND THE GUMS.

The alveolar process, which furnishes the actual sockets for the teeth, and which carries that peculiar fibrous texture with its mucous covering known as the gum, is a frequent site of ulcerative disease and fertile source of infection. While the toilet of the mouth is much more generally attended to at present than in times past, the majority of people are extremely inattentive and indifferent to the condition of the teeth and the gingival borders. As elsewhere stated the mouth is the habitat of an extensive flora and fauna, and deposits of tartar along the gingival border afford excellent hot-beds for their development and growth. This accounts for the marginal ulceration of the gum, or _ulcerative gingivitis_, seen in so many mouths, and it may be regarded as the beginning of a disease process, _pyorrhea alveolaris_ (Rigg’s disease), that will eventually cause the loss of the teeth and extensive infection of the lymphatics in the neck. In almost every mouth where such accumulations of tartar have taken place the expressions of local infection may be traced by a bluish or purplish line along the gingival border, with some degree of sponginess and mild ulceration.

The enamel covering the teeth is extremely resistant, but when the dentine is exposed below the enamel line, as happens in such instances as those just described, bacteria may easily enter the dental tubules, and _dental caries_ or _alveolar suppuration_ is the result. In order to prevent such disease the services of the dentist should be secured at least as often as every six months, in order that all tartar may be removed and the gums placed in a healthy and resistant condition.

For the marginal ulcerations thus produced there is no better treatment, after removing tartar, than the local application of zinc iodide, either in fine crystalline form or in saturated solution. It is not so much the visible surfaces which need such application as does the gingival tissue in concealed locations and between the teeth. Zinc iodide is not only an excellent antiseptic, but a powerful astringent, and meets a double indication. It may be applied once a week or oftener.

The dental enamel is the protective medium which, being once injured, exposes the dentine beneath to the possibility of infection. Such injuries are mechanical, but usually minute. The practice of putting hot food into the mouth and immediately following it with a drink of iced water is calculated to crack the enamel on a tooth as it would on any other material. Such a crack, although microscopic in dimensions, permits the entrance of bacteria into the dentine, in whose tubules they multiply and produce minute amounts of lactic acid. The enamel will resist this acid almost indefinitely, but the softer dentine is dissolved by it, and in this way cavities are formed within the teeth, and the condition known as _dental caries_ is engendered. While it requires the special art and training of the dentist to cope with such conditions, every general practitioner should be familiar with the circumstances under which these lesions are produced. Congenital defects of the enamel afford also the same opportunities for infection.

When infection has extended to the delicate pulp cavity and when one of the terminal fibers becomes exposed the condition is accompanied by more or less distress, and when the alveolar socket becomes involved the tooth is loosened, either temporarily or permanently, according as the condition is treated. Thus a small _alveolar abscess_, referred to as “gum-boil,” may result. In the former case there is usually a small sinus which leads down to the root of the tooth, either through the spongy bone or alongside the tooth itself.

Plate III illustrates the conditions in teeth undergoing various forms of caries, there being numerous bacterial forms responsible for different types of the disease.

_Treatment_ here does not differ in principle from that for treatment of caries in bone. Its essential feature is actual removal of all infected dental tissue, with a combination of protection against further infection, and that substitution for lost tissue which is effected by the use of gold, amalgam, or some of the other fillings in common use among dentists. American ingenuity has reached its acme in the discovery of means and methods for atonement of tissue thus lost by disease, and American dentists certainly lead the world in the mechanics of their art. They go much beyond the mere filling of diseased teeth, but have devised substitutes for teeth actually lost, and much of the plate work of the past is now substituted by what is known as _crown and bridge work_.

Dentistry as a part of oral surgery has now become a specialty by itself. A competent dentist, therefore, is a necessary coöperator in the treatment of all diseases of the teeth.

It is mainly when disease has spread from the teeth to the surrounding bone and tissues that the surgeon as such intervenes. _Caries and necrosis_ of a small or large part of either jaw may be the result of extension of disease processes having their beginnings as above. In the chapter on the Neck, when dealing with the subject of tuberculosis of the lymphatics, it is stated that a large proportion of such cases due to the propagation of infection from the oral cavity and often from the teeth.

There are two substances used in medicine and in the arts which have a proclivity for the tissues of the mouth and jaws. These are _phosphorus_ and _mercury_, the former usually affecting the bone and the latter the softer tissues. Before legislation had been enacted by which the young were prevented from working in match factories phosphorus necrosis of the lower jaw was not uncommon. Today it is rarely seen. Again, in the older days when mercury was given in large amounts, and its effects were not as well guarded against as now, _mercurial stomatitis proceeding to ulceration_ and even loss of teeth was not an uncommon event. Now it is seen only in those who have an idiosyncrasy which makes them peculiarly liable to its effects. The mechanism of phosphorus necrosis is supposed to be an ossifying periostitis, with formation of small osteophytes in the alveolar periosteum, which lower tissue resistance and permit easier invasion of bacteria from the mouth. (See p. 428.)

The extension of disease from the teeth, especially of the upper jaw, upward into the _antrum of Highmore_, with its consequent infection, is elsewhere discussed, and the reader will find the treatment of _empyema of the antrum_ considered in