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a sound. The expired air passed through a hole in the palate. A gutta-percha
obturator was put into the perforation ; the symptoms immediately disappeared.
In this case, too, the perforation supervened suddenly in the course of syphilitic
rhinitis.

The following case also presents many interesting points :

" For the last seventeen years," said my patient, ** I have gone about with a hole
in my mouth. I have made obturators in caoutchouc and in gutta-percha as well as
I could, but they are very imperfect. What can you do for me ?" At the same
time he removed the so-called obturator. His speech was at once transformed into
a kind of unintelligible mumbling. I examined his mouth, cknd saw on the roof of
the palate an enormous hole, large enough to take in a hazel-nut. The perforation
had commenced seventeen years before as a small opening in the course of syphiHtic
rhinitis. The ulceration had gradually destroyed a part of the roof of the mouth, and
yet during this long time the general health was not interfered with, and the syphilis
did not manifest itself elsewhere. The necrosis was arrested by means of oily injections
of biniodide of mercury. Berger made an obturator, and since then phonation,
mastication, and deglutition have been performed to perfection.



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DISEASES OF THE MOUTH 553

Description. — The necrotic process shows itself first on the floor of the
nasal fossae, and the general rule is that syphilitic rhinitis almost always
precedes the perforation of the roof of the palate (I am speaking of the
roof, and not of the velum). It was believed for a long time that perforation
of the roof proceeded from the mouth towards the nose. This is an error.
The perforation proceeds from the nose towards the mouth. This view is
held by Fournier and Duplay, and I agree with them entirely.

Besides, if we consider syphiUs of the nasal fossae as a whole, we see that
it is the centre from which syphiUtic lesions of the neighbouring parts start
out. In one patient, syphilitic rhinitis ends in necrosis of the nasal bones,
and the bony framework collapses. In another, nasal syphiUs attacks the
lachrymal bone and the nasal process of the superior maxilla. Dacryo-
cystitis, with or without abscess, is the result. In a few, happily rare, cases
nasal syphiUs attacks more dangerous regions — the upper wall of the nasal
fossae and the cribriform plate of the ethmoid and the sphenoid bones.
Syphilitic osteo-periostitis readily spreads into the cranial cavity, and may
cause meningo-encephaUtis, abscess of the brain, phlebitis of the sinuses,
or '* naso-cranial syphiUs," as Fournier calls it.

Perforation of the roof of the palate is also a consequence of nasal
syphilis. " In consequence of tuberculo-ulcerous syphiUdes, or of gum-
matous periostitis of the floor of the nasal fossae,'* says Fournier, " a larger
or smaller segment of th^ superior maxilla is denuded, and becomes necrosed.
An eUminative peripheral phlegmasia occurs, and an abscess is formed under
the mucous membrane Uning the inferior surface of the diseased bone. This
abscess points in the mouth as a small hemispherical tumour. At a given
moment it opens spontaneously, or is opened by the surgeon. The orifice
soon enlarges, and then a part of the necrosed segment appears bare on the
roof of the palate. Lastly, the necrosed portion separates, and in a moment,
to the great surprise of the patient, a more or less extensive perforation of
the palate is formed, with two major troubles, which are its necessary conse-
quence — alteration of the voice and reflux of soUd and Uquid foods introduced
into the mouth."

Two distinct phases then occur in this sjrphiUtic process. In the first
phase, which is often slow and insidious, the process is nasal. The lesion
betrays itself by the symptoms of chronic coryza, with ozaena, crusts, muco-
purulent secretion, and the formation of sequestra, easily distinguishable
with the probe. This phase is followed by the phase of perforation. This
perforation usually occupies the median Une of the roof of the palate a Uttle
in front of the palate bones. It foUows " the partial necrosis of the maxilla,
or of the two maxillae and the vomer at their point of meeting." The perfora-
tion may be round or oval. At first it is the size of a pin's head ; later it
may be as large as a florin or more, because it may invade a portion of the



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554 TEXT-BOOK OP MEDICINE

roof of tlie palate. On the side of the mouth the lesion in the palate is
also very indolent. My patient noticed nothing until the smoke from his
cigarette came out of his nose, and revealed the perforation. The cornet-
player felt no pain in his mouth when the perforation suddenly occurred.

At the moment of its formation the perforation does not always look
like a hole ; it may be only a simple fissure, as in the second case. " The
hole " only exists when the sequestrum has been eliminated. This elimina-
tion may be slow, the fragment crumbling gradually ; it may be sudden, the
fragment being evicted as a whole, as in the comet-player. The elimination
of the sequestrum usually leaves but a small perforation, which is at this
time perfectly curable, either spontaneously or by specific treatment.

As a rule, a syphilitic perforation left to itself tends to enlarge. The
ulcero-necrosing process, which is slow in its course, recalls both rarefying
osteitis and phagedaena. In two or three years the perforation attains the
size of a halfpenny ; in four or five years it is as large as a florin. It is
somewhat surprising that syphilis persists in a certain region, and slowly
pursues its ravages for ten or fifteen years, whilst it leaves the rest of the
organism free. The same process is seen in other regions. We are not
suflSciently familiar with these elective locaUzations of syphilis, and we too
often make mistakes, because we believe sjrphilis to be incapable of
lasting for ever in one spot, and of respecting the remainder of the
economy.

The symptoms vary according to the size of the perforation. If the
perforation is a simple fissure or a small opening, reflux of a few drops of
fluid through the nose and slightly nasal timbre of the voice are its only
symptoms ; if the perforation is larger, nasal voice, defective pronunciation,
and reflux of drink and food through the nose are the consequences. These
symptoms recall paralysis of the velum palati ; in both cases we find the
same diflBculties of deglutition and pronunciation.

Besides the nasal sound which renders the voice unnatural, certain words
or letters cannot be pronounced. Thus *' b " and " p " are pronounced
" m," for the following reasons : Under normal conditions the letters " b "
and " p " are formed by the colunm of expired air, which suddenly separates
the lips and makes them vibrate. When the roof of the palate is perforated,
the colunm of expired air loses its strength, because it is divided into two
parts : one part separates the lips, and only succeeds in pronouncing " m,"
while the other passes into the nasal fossse, and renders the voice nasal.
The patient can partially remedy this condition by pinching his nose.
Deglutition is rendered very diflScult by the perforation of the palate, because
the solids and liquids which are passing between the tongue and the palate,
and are being pushed from before backwards, enter the hole and come back
through the nose. Perforation of the roof of the palate betrays itself by



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DISEASES OP THE MOUTH 555

other symptoms, such as the impossibility or diflSculty of sucking, of
whistling, of blowing, or of inhaling the smoke of a cigarette.

Pathogenic Diagnosis. — Perforation may be also caused by tubercu-
losis and by lupus, but it is extremely rare. " Out of twenty palatine per-
forations," says Fournier, " nineteen may be ascribed to syphilis." I go
even further, and I believe that out of forty perforations sypliilis can claim
thirty-nine. Yet this considerable disproportion, notwithstanding, the
diagnosis, must be made. Tubercular perforations of the velum palati are
more conmion than those of the roof. The latter alone demand our attention
here.

Case observed by Quenu :

A patient suffering from phthisis complained of the passage of liquids through his
nose. On examining the mouth, an antero-posterior ulcer was observed on the
middle line of the roof of the palate, behind the incisors. The surface was covered with
a yellowish -grey detritus. In the centre there was a small perforation. On the posterior
part of the roof of the palate the swollen mucous membrane was covered with the tuber-
cular granulations. Post mortem, the roof and the velum of the palate were removed.
The mucous membrane was destroyed ; the bone formed the bottom of the ulcer. The
perforation was due to the destruction of the fibro-mucous tissue which closed the
anterior palatine canal. This perforation, like the bony canal, which is single on the
side of the mouth, bifurcated into the two tubes which opened on either side of the
nasal septum. On the nasal side the perforations were rounded.

Caussade has sent me the following case :

He had under his care a tubercular patient who complained of a smarting in the
roof of the palate and of sharp pains on contact with food. On examining the mouth,
the general pallor so frequent in tuberculosis was noticed. On the roof of the palate,
to the left of the middle line, and, as it were, grafted on to the cicatrix of old lupus,
there existed an irregular ulcer of the siz« of a florin. Around this ulcer, which
had a sanious floor and loose edges, wete some yellowish granulations. A probe
readily entered the nasal fossse, proving the existence of a small perforation. Tubercle
bacilli were found in the purulent liquid bathing the ulcer ; they were also present
in the yellow granules.

To sum up : the jagged, loose edges of the ulceration, the sanious floor, the yellow
peripheral granules, and the presence of the bacilli in the pus, distinguished the tuber-
cular from the syphilitic ulceration. '

There is a perforating disease of the mouth which must be distinguished
from syphilitic perforations. What is to be understood by perforating
disease of the mouth ? Fournier thus names the trophic lesion, which is
especially seen in tabetics ; it is comparable with perforating ulcer of the
foot. Baudet has collected seven cases. This trophic trouble, which as a
rule causes no pain, runs the following coarse : progressive absorption of
the alveolar arches causes the teeth to fall out spontaneously. The falling
out of the teeth is followed by absorption of the alveolar border. " Per-
forating disease " follows this bony absorption ; it commences with ulceration
of the mucous membrane, and burrows down into the tissues until it per-
forates the bone. This perforation only affects the superior mr.xilla (though



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556 TEXT-BOOK OF MEDICINE

trophic troubles are met with in both maxillse). It may be unilateral or
bilateral ; it never occupies the centre of the roof of the palate, but the peri-
phery, especially at the site of the first molars which have fallen out. The
perforation is elongated in its antero-posterior direction, and may allow
insertion of the finger ; it establishes communication between the mouth
and the nasal fossae or the maxillary sinus.

Perforating disease differs from syphilitic perforations of the palate in
the trophic troubles which precede it — viz., ccwting of the teeth and absorp-
tion of the alveolar borders of both maxillsB. As I have just stated, it never
occupies the centre, but the periphery of the roof of the palate ; the edges are
usually insensitive. It is a trophic trouble almost always accompanied by
positive or aberrant symptoms of tabes.

Treatment. — Treatment is in part prophylactic. As the perforation is
preceded by syphilitic rhinitis, we should recognize and treat the rhinitis.
In a syphilitic patient chronic coryza is always open to suspicion. Anyone
tainted with syphilis who catches " a persistent cold in the head," with
purulent mucus and crusts, must be watched closely, because the rhinitis
may end, for want of specific treatment, in ozsena, in destruction of the
cartilages and the bones, and in perforation of the palate. With all the more
reason must treatment be commenced without loss of time in a sj^hilitic
patient who, during a chronic coryza, feels a swelling in the roof of the
palate. This swelling is the prelude of a process which will terminate in
perforation ; the lesion, if taken in time, may be confined within limits.

The perforation at its commencement is always of small size, perhaps as
large as a pin's head. At this moment it is sometimes curable by mercury,
with or without the addition of iodides. When the perforation is large, we
have only two means of remedying it — surgical intervention or a well-made
obturator. In either case the patient must be at first put on specific treat-
ment to limit the necrotic process if it is still active. This treatment con-
sists in mercury, with or without iodide of potassium. As regards mercurial
preparations, I give the preference to injections of an oily solution of bin-
iodide of mercury.

X. TUBERCULOSIS OF THE MOUTH.

Some years ago tuberculosis of the digestive canal was practically
unknown ; tubercular lesions and ulcers of the intestine had alone been
described, but the other parts of the digestive tube had not been explored.
Bayle had seen tubercular ulcerations of the mouth without giving them
their real significance. This question, first studied by Ricord, was at his
inspiration undertaken by Buzenet, and was clearly stated by JuUiard ; since
these early researches of French origin, numerous investigations, both in



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DISEASES OF THE MOUTH 557

France and abroad, have rendered the question of bucco-pharyngeal tuber-
culosis classical.

The ulcerations of the mouth and the throat, which are sometimes met
with in tubercular subjects, are not ulcerations of a cachectic nature, as was
at first believed ; they are really tubercular ulcerations, resulting from
tuberculosis in situ (Trelat). By choice their seat is on the tongue, the
pharjmx, and the isthmus of the gullet. They may be solitary or multiple,
and show the most varied forms. I shall study them separately in the
mouth and in the throat. This distinction is, furthermore, necessary, because
the ulcerations of these different regions have a somewhat different course.

Tongue. — Tuberculosis of the tongue shows two chief forms — ^tumour
and ulcer. The tumour, called also tubercular gumma, lingual tubercu-
loma, or tubercular intramuscular abscess, is a soft tumour which is not
painful, projects from the surface of the tongue, and may be as large as a
cherry-stone or a nut.

Tubercular ulcers of the tongue are more common ; they occupy, in order
of frequency, the tip, upper, and lower surfaces of that organ. They develop
in the following manner : A rounded yellowish spot, about 2 lines in diameter,
is seen on the mucous membrane. The epithelium falls off, and the result is
an ulceration, which increases in size and depth. The ulcer sometimes com-
mences as a fissure, and brings about hypertrophy of the papillae. When the
ulcer has formed the edges are scalloped and clean-cut ; the floor is covered
with a layer of mucus and saliva, which on removal leaves a yellowish uneven
surface exposed. Around the ulcer a bed of yellowish points is frequently
seen ; they were incorrectly considered to be follicular orifices, but they are
really small subepithelial abscesses, or masses of tubercular follicles, having
the structure of tubercular tissue, ulcerating in their turn, and becoming
part of the principal ulcer.

Histological examination reveals the following characteristics : A section
through an ulcer of the tongue shows that the granulating portions of the
ulcer are formed of embryonic tissue. The surface of the ulcer is likewise
infiltrated with embryonic tissue, and, deeper still, bundles of muscular fibres
are seen, between and around which the embryonic connective tissue shows
here^and there little islands of more or less developed tubercular granula-
tions. The granulations, or rather the tubercular follicles (giant cells,
embryonic cells, and bacilli), invisible to the naked eye, are deeply seated in
the muscular tissue of the tongue ; they are found as much as j inch or more
beyond the ulcerated surface.

The tubercular ulcer of the tongue is almost always solitary at its onset,
thus differing from ulcers of the pharynx, the isthmus and the velum,
which are often multiple. As the ulcer grows older, it becomes deeper, an-
fractuous, and deeply excavated, in distinction to the ulcers of the pharynx.



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558 TEXT-BOOK OF MEDICINE

which are generally superficial. On the tongue the ulcers make slow progress,
and coincide with the chronic forms of pulmonary phthisis, whilst the tuber-
cular ulcers of the pharynx coincide rather with the rapid and general forms
of tuberculosis. The ulcers in the mo ith in some cases seem to precede the
lesions in the lung ; they may heal and cicatrize. The ulcers of the tongue
are very painful upon contact with liquids or food, and patients have much
pain in the acts of mastication and deglutition.

These pains are, however, not so acute as those occasioned by ulceration
of the pharynx. Contrary to what might be supposed, tubercular ulcers
of the tongue are rarely followed by adenopathy.

The tubercular ulcer of the tongue must not be confounded with
chancre. The chancre has not a greyish and granular surface ; it is not sur-
rounded by a bed of yellowish points ; its floor is more in relief, and it is not
painful on pressure. Its base is much more indurated ; the adenitis which
it provokes is painless. Tubercular ulceration of the tongue is distinguished
from epithelioma by the following signs : The surface of the epithelioma
shows more vegetations ; it bleeds easily, and gives rise to an oozing of
foetid liquid. Its edges are very much raised and, as it were, everted. It
it often the seat of spontaneous lancinating pains. It produces painful
adenitis of slow course.

Tubercular ulcers are very rare on the lips and gums. They are some-
times consecutive to tubercular idcers of the mucous membrane of the
cheeks. Reclus records a case in which ulcers on the gums led to faUing out
of the teeth. Giraudeau cites a case in which osteo-periostitis, falling out of
the teeth, and necrosis of the maxilla occurred.

Roof of the Palate. — Tubercular ulcers of the roof of the palate are
inore common than was formerly supposed. Hcrmandier has collected
eight cases. One or more ulcers may be foimd ; they are situated indiscrimi-
nately on all parts of the roof, and, as a rule, the velum palati, the pillars of
the fauces, and the lips present at the same time ulcers of a like nature.
Here, as elsewhere, the outlines are well defined when the ulcer is solitary; but
when several ulcers unite, as frequently happens, the ulcerated surface
presents a sinuous outline, and may be some inches in extent. The edges of
the ulcers are reddish, puffed, and clean-cut ; they are rarely indurated.
Tubercular ulceration of the roof, like that of the tongue, is frequently
surrounded by projecting yellowish points, which are tubercular nodules.

The formation of the ulcers is accompanied by smarting and pain, par-
ticularly on contact with food. In some cases (Qu6nu, Caussade)* the ulcers
end in perforation of the roof of the palate. The ulcer is rarely cured.

Painting with a solution of lactic acid (1 in 10) gives good results.

* This question has been treated in the section dealing with perforation of the
roof of the palate, as regards differential di agnosia.



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CHAPTER II
DISEASES OF THE THROAT AND PHARYNX

Ik studying the diseases of the throat and pharynx we shall at every
moment meet with the word angina. This word angina (from a7;^a), I
strangle) was formerly employed to designate every disease which was
accompanied by troubles of deglutition and respiration and was seated
above the lung and the stomach. Though the word angina does not
answer to-day to the ideas which created it, it has, nevertheless, been
retained, and writers have essayed to make it comprehensible by associating
with it certain adjectives which give it species and varieties.

I. ACUTE CATARRHAL ANGINA— ACUTE ERYTHEMATOUS

ANGINA.

Under the name of erythematous angina and acute anginal catarrh,
we describe inflammation of the mucous membrane of the posterior portion
of the mouth and the pharynx, which is superficial, sometimes limited to a
difFuse redness, as the name " erythematous " indicates, and sometimes
accompanied by a pultaceous covering. The localization of the angina is
somewhat variable : sometimes it is diffuse, and occupies both the pharynx
and the posterior portion of the mouth ; at other times it affects certain
points, as the isthmus of the gullet, the tonsils, or the pharynx.

Description. — Acute catarrhal angina commences with shivering,
fever, lassitude, headache, and loss of appetite, which are slight in some
subjects, but in others (in children especially) become so severe that we are
liable to suspect the onset of some serious disease. The general troubles,
which may be accompanied or not by gastric disturbance, precede the angina
by a day or so ; they may appear simultaneously. The angina is ushered in by
a sensation of dryness and smarting in the throat. Deglutition is painful ;
the mucous membrane is red, dry, sniny, and close set with projections due
to swelling of the muciparous glands ; while the serous infiltration of the sub-
mucous tissue produces swelling of parts rich in loose cellular tissue, such as
the uvula and isthmus of the gullet. The angina may remain simply
erythematous, but sometimes as early as the second or third day the hyp ^r-

559



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560 TEXT-BOOK OF MEDICINE

secretion of the mucous membrane is shown by mucus on the pharynx and
by caseous concretions, or pultaceous layers on the tonsils. These products,
which are not adherent, do not resemble the membranes of diphtheria, and
yet they may be associated with the diphtheria bacillus, as bacteriology
has proved.

Acute angina is most frequently accompanied by a gastric or biUous
condition. The tongue is white and coated, the anorexia is complete,
attacks of nausea are frequent, and constipation is the rule. The fever falls
from the second to the fifth day. The submaxillary glands are but slightly
enlarged. Acute catarrhal angina does not last more than a week ; it gener-
ally ends in resolution, but relapses and passage into the chronic state may
occur in patients predisposed by some diathetic condition. Paralysis of the
velum, and even general muscular paralysis have been described (Gubler) ;
these cases are obviously diphtheria.

etiology, diagnosis, and treatment will be studied in the following
chapter. For the time being let me remark that the better prepared the
soil, the more important the role of the micro-organisms.

Mouth-washes and antiseptic gargles are indicated. I generally employ
very weak solutions of boric acid (6 per cent.).



II. ACUTE TONSILLITIS— SIMPLE TONSILLITIS— SUPPURATIVE
TONSILLITIS— ULCERO-MEMBRANOUS TONSILLITIS-
VINCENT'S ANGINA.

Inflammation of the tonsils, or amygdalitis, is also called tonsillar angina.
In order to faciUtate description I shall describe three varieties— simple,
suppurative, and infectious amygdalitis— but these three varieties have
common characteristics which are often blended clinically.

1. Simple Acute Tonsillitis.
Description. — Acute tonsiUitis constitutes an important variety, and is
the most common form of catarrhal angina. When the tonsiUitis is slight,
its description blends in part with the sjrmptoms enumerated in the previous
section. When it is severe, it may commence with a sharp rigor; the
temperature^ particularly in children, rises to 104° F., and the face becomes
red and feverish. Deglutition soon becomes very painful, and its every move-
ment is accompanied by contortions and grimaces. Liquids often regurgitate
through the nose, and the patient refrains from swallowing his saliva.
The voice becomes tonsillar ; the opening of the mouth and the move-
ments of the jaw are very painful. The exterior and lateral regions of the
neck are painful and brawny, and the tonsils become so swollen that respira-



Online LibraryGeorges DieulafoyA text-book of medicine, Volume 1 → online text (page 68 of 129)