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 passes 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 deg.-102 deg. F. As a rule the symptoms pass 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 accumulates 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 Loeffler'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 accumulates 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 oedematous, 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-passages 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 associated 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 accumulates 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 accumulations 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 pass 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 shelled 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 prone 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 shelled out, or ligated at the base and cut off, according to circumstances.

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 oedematous, 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 foetid 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 foetor 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 dyspnoea.

Retro-pharyngeal Abscess.—The chronic retro-pharyngeal abscess associated with tuberculous disease of the cervical vertebrae, in which the pus accumulates behind the prevertebral fascia, has already been described (p. 441).

The acute abscess occurs in the space between the prevertebral fascia and the wall of the pharynx. The infection usually begins in one of the lymph glands that occupy this space, 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 dentition 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 dyspnoea 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 associated 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 space.



CHAPTER XXI

THE JAWS, INCLUDING THE TEETH AND GUMS

TEETH: Dental caries—Impacted wisdom tooth. GUMS: Gingivitis; Pyorrhoea alveolaris; Hypertrophy; Epithelioma. JAWS: Pyogenic affections: Periostitis; Osteomyelitis; Tuberculosis; Syphilis; Actinomycosis—Tumours: Of alveolar process; Of maxilla; Of mandible—Fracture of maxilla—Fracture of mandible—Affections of the temporo-mandibular articulation: Dislocation of the mandible; Acute arthritis; Tuberculous arthritis; Arthritis deformans; Closure of the jaws.

Dental caries is a process of disintegration which begins in the enamel of a tooth—usually in the region of its neck—and gradually extends through the dentine till the pulp cavity is reached.

Infection of the exposed pulp cavity may set up an acute purulent pulpitis. This is associated with severe pain, which is not confined to the diseased tooth, but may spread to adjacent teeth, and sometimes to all the branches of the trigeminal nerve on the same side of the face.

The infection may spread from the tooth to the alveolo-dental periosteum, and set up a periodontitis. In the affected tooth there is at first a feeling of uneasiness, which is relieved by the patient biting against it. Later there is severe lancinating or throbbing pain. The affected tooth usually projects beyond its neighbours, and is excessively tender when the opposing tooth comes in contact with it in mastication. The gum becomes red and swollen, and the cheek is oedematous.

Periodontitis is usually followed by the formation of an alveolar abscess. The pus, which forms at the root of the tooth, in most cases works its way through the bone and into the gum, constituting a "gum-boil." The pus may then burst through the gum, or may spread underneath the external periosteum of the jaw and lead to necrosis.

In some cases the cheek becomes adherent to the gum and to the jaw before the abscess bursts, and the pus escapes through the skin, leaving a sinus which leads down to the defaulting tooth, and which is slow to heal, usually because there is a small sequestrum at the bottom of it. The opening of the sinus is most commonly situated at the under margin of the mandible a little in front of the masseter muscle. An alveolar abscess deeply seated in the maxilla may open into the maxillary antrum and set up suppuration in that cavity. To avoid a scar on the face, the abscess should be opened from the mouth. A periodontal abscess of one of the upper central incisors spreads backwards between the muco-periosteum and the bony palate, causing an elongated swelling in the roof of the mouth.

In all cases the extraction of the carious tooth is necessary before the abscess will cease discharging and the sinus heal. If a sequestrum is present it must be removed, and the bone scraped with a sharp spoon. Among the other effects of dental caries may be mentioned localised necrosis of the alveolar margin, cellulitis of the neck, and enlargement of the cervical lymph glands.

A cyst is frequently found attached to the root of a decayed tooth. It is lined with epithelium, and is probably derived from a belated portion of the enamel organ which has been stimulated to active growth by infective processes in the pulp cavity. It is seldom larger than a pea, and contains a pultaceous mass like inspissated pus. It gives rise to no symptoms, and is only recognised after extraction of the root.

Odontomas have already been described (Volume I., p. 192).

A localised swelling of the mandible, associated with pain referred to the ear and neck, and in some cases with spasmodic contraction of the muscles of mastication, may be due to impaction of the wisdom tooth (lower third molar). If the tooth is merely embedded in the gum, incision may allow of its eruption; if the X-rays show that it is wedged under the second molar it must be extracted, and this may prove a difficult dental operation.

Affections of the Gums.—Inflammation of the gums—gingivitis—usually occurs in association with a general stomatitis. The gums are swollen and spongy, and may show superficial ulceration, associated with bleeding and extreme foetor of the breath. The teeth become loose, project from the alveoli, and sometimes fall out. These symptoms are prominent in cases of scurvy, and of chronic mercurial poisoning. In chronic lead-poisoning a characteristic blue line is seen on the gums near the dental margin. The treatment consists in removing the cause, improving the hygienic and dietetic conditions of the patient, and administering lime-juice, iodide of potash, quinine, or cod-liver oil, according to the cause. Antiseptic mouth-washes and dentifrices are also indicated. Chlorate of potash, being excreted in the saliva, is particularly useful.

Pyorrhoea alveolaris is a chronic form of gingivitis, met with after middle life, which begins in relation to the necks of the teeth and the alveolo-dental periosteum. It is due to bacterial infection, and is associated with an accumulation of tartar between the gums and the teeth. A muco-purulent discharge escapes from within the free edge of the gum and alveolus. The alveolar borders and the gum subsequently undergo atrophy, so that the roots are exposed, and the teeth are liable to become loose and eventually to fall out. The condition may only affect a few teeth, or it may spread to them all, in which case the patient may in the course of some years become edentulous. Gastro-intestinal disturbances, chronic joint affections of the nature of arthritis deformans, a form of pernicious anaemia, and other general conditions have been attributed to the absorption of toxic products. The treatment consists in removing the tartar from the teeth, applying strong antiseptics to the groove between the teeth and the gums, and employing mouth-washes and dentifrices. Massage of the gums night and morning, and rubbing in a paste of chlorate of potash and menthol, is often of great value. Good results have followed the use of vaccines and improvement of the general health.

Hypertrophy of the gums is occasionally met with in children and young adults who are mentally defective, and the teeth appear early and are abnormally large. The gum almost buries the teeth, and large polypoid masses form which tend to fungate. The treatment consists in removing not only the hypertrophied gums, but also the affected alveolus (Heath).

A localised hypertrophy—polypus of the gum—sometimes results from the irritation of a carious tooth, or from the pressure of an artificial denture, and may simulate an epulis (p. 513). The swelling is usually pedunculated, and if cut away close to the alveolar margin does not tend to recur.

Epithelioma sometimes originates in the gum in relation to a carious tooth or to an artificial tooth-plate. The growth tends to invade the bone and to spread to the cheek or buccal mucous membrane, or to the maxillary antrum, and its malignant nature is suggested by its persisting after the removal of the irritation. The only treatment is early and complete removal of the growth and the adjacent segment of bone.

Other tumours of the gums, such as angioma and papilloma, are rare.

THE JAWS

Pyogenic Infections.—The jaws may be infected in fractures communicating with the mouth or as a result of the unskilful extraction of teeth, but the majority of pyogenic infections originate in relation to carious teeth, beginning as a periodontitis which is followed by diffuse periostitis that may lead to necrosis of considerable portions of bone. In workers exposed to the fumes of yellow phosphorus, the bone may be so devitalised that it readily becomes infected with pyogenic organisms and undergoes a process of cario-necrosis—the phosphorus necrosis of the older writers.



Acute osteomyelitis occasionally attacks the mandible, less frequently the maxilla. Pus rapidly forms under the periosteum, and a considerable area of bone may undergo necrosis.

In cancrum oris, also, the bones are frequently attacked and may undergo necrosis.

The treatment is to let out the pus, and, whenever possible, this should be done from the mouth to avoid a cicatrix on the face. When the angle or the ascending ramus of the mandible or the facial portion of the maxilla is involved, it is not possible to avoid making an external opening. Drainage is secured, and the mouth kept sweet by the frequent use of antiseptic washes. When the condition is due to a carious stump or to an unerupted tooth, this should be extracted at the same time as the abscess is opened.

The separation of a sequestrum is usually slow, taking from two to four months according to the acuteness of the infection and the extent of the necrosis. In the mandible the sequestrum becomes surrounded by a sheath of new periosteal bone, so that, even if the greater part of the jaw undergoes necrosis, the arch is reproduced, and after removal of the sequestrum little or no deformity results. The sequestrum can usually be removed after dividing the mucous membrane and gouging away a portion of the outer aspect of the new sheath. The cavity is packed with iodoform or bismuth gauze. When the ascending ramus is involved, precautions must be taken to prevent fixation of the jaw taking place during the healing process. In the maxilla no new case is formed, and deformity results from sinking in of the cheek, unless this is prevented by wearing a plate made by the dentist.

Tuberculous disease is comparatively rare. It is occasionally met with on the orbital margin of the maxilla and in the region of the zygomatic (malar) bone. In the mandible it usually occurs near the angle. Stockman isolated the tubercle bacillus from a series of cases of "phosphorus necrosis" investigated by him. The sinuses that form when a cold abscess bursts on the surface are peculiarly intractable and only heal after the diseased bone has been removed, leaving a characteristically depressed scar, which is adherent to the bone.

Syphilitic affections are also rare. A localised gumma may develop in the neighbourhood of the angle of the mandible, or the whole of the body of that bone may be the seat of a diffuse gummatous infiltration (Fig. 248). In either case the clinical importance of the condition lies in the fact that it is liable to be mistaken for a new growth, such as an osteo-sarcoma, or for actinomycosis.



Actinomycosis.—This condition is met with in the jaws more frequently than in any other part, and the mandible is attacked oftener than the maxilla. The actinomyces gain access to the bone through a carious tooth or through the gum.

At the outset the patient complains of pain and tenderness referred to one or more carious teeth. Within a few weeks a swelling forms—in the mandible near the angle as a rule, and in the maxilla in some part of the cheek. The swelling, which varies in consistence, implicates the bone and cannot be moved apart from it. The skin over it becomes red, suppuration occurs, and sinuses form and give exit to a sero-purulent fluid in which the characteristic yellow "sulphur grains" may be detected. The surrounding soft tissues are infiltrated, and the part becomes riddled with sinuses, which lead down to bare bone. The disease usually runs a chronic course, lasting for one or two years, and, unless pyogenic infection is superadded, is not attended with fever.

In the absence of the characteristic yellow granules, actinomycosis may readily be mistaken for tuberculous or syphilitic disease, or for sarcoma.

The treatment consists in removing the diseased tissue with the knife or sharp spoon, and in the administration of large doses of potassium iodide. The insertion of tubes of radium has a beneficial effect.

Tumours of the Alveolar Process.—Epulis.—The tumours that grow from the alveolar processes of the jaws appear at first sight to spring from the gums, hence the term epulis, generally applied to them. They really originate in the periosteum of the alveolus or in the periodontal membrane, and are essentially of the nature of fibro-sarcoma. In some, the fibrous element predominates, but the frequency with which they recur after removal, unless the segment of bone from which they spring is also excised, indicates their malignant tendency. In most cases the tumour is of the myeloid type—myeloma; in others new bone is formed in its substance—osteo-sarcoma.

An epulis usually begins in the gap between two teeth, and grows slowly, either towards the cavity of the mouth, or more frequently towards the lip or cheek, where it appears as a bright red, smooth, firm, rounded swelling, which is adherent to the jaw, and may be sessile or pedunculated (Fig. 249). It causes little pain, but is liable to interfere with mastication. As it increases in size it spreads over the alveoli of several teeth, becomes softer, and assumes a dark violet colour, and if subjected to pressure or irritation may ulcerate and bleed.



The true alveolar tumour is to be diagnosed from a mass of redundant granulations such as may form in relation to a carious tooth, from a polypus or an epithelioma of the gum, a tumour of the body of the jaw, or an angioma.

The treatment consists in removing the tumour together with a wedge-shaped or quadrilateral portion of the alveolar process from which it grows. A dental plate should be fitted to fill up the gap in the alveolus. After such free removal these tumours show little tendency to recur and metastases are rare.

Malignant Tumours of the Maxilla.—All varieties of sarcoma and carcinoma are met with; of the former, the round and spindle-celled are the most common. Carcinoma occurs chiefly in two forms, less commonly a columnar epithelioma arising from glandular epithelium, much more commonly a squamous epithelioma either originating within the antrum and causing its expansion, or spreading to the maxilla from the mucous membrane of the nose or mouth. Clinically it is practically impossible to differentiate sarcoma from carcinoma; in the later stages the infection of the glands below the mandible is more marked in carcinoma. An important point to determine is whether the growth arises within the maxilla or has spread to it from adjacent parts, such as the base of the skull, the nose, or the palate. In this the X-rays are helpful. Their malignancy is evidenced by the rapidity of their growth, the manner in which they infiltrate adjacent parts, and the frequency with which they recur after removal. They occur at all ages, and have been met with even in children.

The clinical features vary according to whether the tumour originates on the anterior aspect of the bone, in the maxillary antrum, or on the posterior aspect.

When the tumour originates in the periosteum covering the front of the bone, it forms a swelling under the cheek, usually in the vicinity of the zygomatic (malar) bone, and grows towards the mouth as well as towards the surface. The cheek is gradually invaded, and in some cases the growth extends into the maxillary sinus.

The typical malignant tumour of the upper jaw originates in the lining membrane of the antrum; it first fills the cavity and then bulges its walls in every direction, so that, on pressure being made over the swelling, the osseous shell of the sinus dimples and crackles under the finger. The sinus is dark on trans-illumination. The tumour may obstruct the nostril on the same side, and, by pressing on the tear duct, may cause the tears to flow over the cheek. It may be seen through the anterior nares, and may be attended with a sanious discharge from the nose. The eyeball is liable to be displaced upward, and if the ethmoid cells are invaded, it is also pushed outward; the palate may be depressed and the cheek projected (Figs. 250, 251).



When the tumour grows from the periosteum of the posterior aspect of the bone, and extends into the spheno-maxillary or pterygo-maxillary fossa, the eyeball is usually protruded by the invasion of the orbit from behind, and a swelling appears in the temporal region. If the sinus is invaded, the tumour spreads in the various directions already indicated. Not infrequently a tumour, which appears to have its seat in the maxilla, is really a downward prolongation of a growth originating in the base of the skull, a point on which the X-rays may yield valuable information.

In all cases the tumour tends to infiltrate the surrounding tissues indiscriminately. There is severe pain referred to the distribution of the maxillary division of the trigeminal nerve. Haemorrhage is liable to occur when exposed portions of the tumour ulcerate—for example in the nasal fossae. Sarcoma is to be distinguished from the solid and cystic forms of odontoma, which also may distend the bone, bulging the hard palate and projecting on the face.

Treatment of Malignant Disease.—Without the help of radiation the results of operative treatment of malignant disease of the maxilla are far from encouraging. Probably the best line to follow is to embed several tubes of radium in different parts of the tumour for several days, and when the resulting shrinkage of the growth appears to have attained its limits, the maxilla should be excised. If on microscopic examination it is found to be a carcinoma, the glands on the same side of the neck should be removed at a second operation on lines similar to those in Butlin's operation in cancer of the tongue. The aid of the dentist is required to fit a denture which will at least restore the hard palate and alveolar margin. The operation of excising the upper jaw is not a dangerous one, especially if the risk of broncho-pneumonia is minimised by the intra-tracheal administration of ether. The final illness in cases of malignant disease of the upper jaw left to nature, or when it has recurred after operation, is a terrible one; the growth displaces and destroys the globe, blocks the nose and fungating on the face, causes hideous disfigurement.

Simple tumours are rare. Fibroma may originate in the periosteum or in the lining membrane of the maxillary sinus. It usually tends to assume the characters of sarcoma. Chondroma usually begins either on the nasal surface of the bone or in the maxillary sinus. Osteoma occurs in two forms: the exostosis, which may be composed of cancellated or of compact tissue, and the diffuse osteoma or leontiasis ossea (Volume I., p. 485). All intermediate forms are met with, and when confined to the maxilla, the resulting disfigurement may be improved or remedied by operation; the cheek is raised or reflected and the bone shaved away with a strong knife or osteotome.

Tumours of the Mandible.—The same varieties are met with as in the maxilla. The non-malignant forms—osteoma, chondroma, and fibroma—are rare.

A dentigerous cyst appears as a smooth, rounded, and painless swelling, usually in the region of the molar teeth. The bone gradually becomes expanded and crackles on pressure. The cyst is filled with a glairy mucoid fluid, and may contain one or more unerupted teeth (Fig. 252). The X-ray appearances are characteristic. The treatment consists in removing the anterior wall of the cyst, scraping the interior, and packing the cavity with iodoform or bismuth gauze.



The myeloid tumour or myeloma is comparatively common. It develops in the interior of the bone and expands the affected segment (Fig. 253). It grows slowly, is more or less encapsulated, and therefore does not infiltrate the surrounding tissues. Sometimes it so weakens the bone that pathological fracture occurs. There is no glandular involvement, and the tumour shows little evidence of malignancy.



The periosteal sarcoma is the most malignant form. It grows rapidly, and infiltrates the surrounding tissues. The submaxillary salivary glands and the cervical lymph glands are usually implicated, and the disease tends to spread by metastasis to distant parts.

Epithelioma is the commonest new growth affecting the mandible; it usually involves the central portion of the bone, being a direct spread from the lower lip, tongue, or floor of the mouth. When it originates in the pillars of the fauces it implicates the ascending ramus. In all cases the infection of the cervical lymph glands is a serious factor both in prognosis and treatment.

Treatment.—Partial removal of the mandible may be undertaken for myeloma, and in cases of sarcoma and epithelioma in which the tumour is limited to a small area of the bone—for example, to the alveolar process, the angle, the horizontal ramus, or the symphysis; in other cases, the whole bone must be removed.

INJURIES OF THE JAWS

Fracture of the Maxilla.—Fractures of the maxilla are nearly always due to direct violence, such as a blow on the face, a stab, or a gun-shot wound. They are often rendered compound by opening into the mouth, into the maxillary sinus, or on to the skin of the cheek. The alveolar process, in whole or in part, may be separated from the body of the bone by a severe blow, such as the kick of a horse, and when the whole alveolus is detached, it may carry with it the hard palate. Limited portions of the alveolus are frequently broken in the extraction of teeth. The main trouble after severe alveolar fractures is that the upper teeth do not accurately oppose the lower ones, and mastication is thereby interfered with.

When the frontal (nasal) portion of the maxilla is broken, the lachrymal sac and nasal duct may be damaged and the flow of the tears obstructed. In such cases emphysema is also liable to develop. Fractures of the facial portion are frequently complicated by haemorrhage from the infra-orbital vessels, and anaesthesia of the area supplied by the infra-orbital nerve. Suppuration may occur in the maxillary sinus. In some cases the maxilla is driven in as a whole, and in others the fracture radiates to the base of the skull and cerebral symptoms develop.

The treatment consists in reducing any deformity that may be present, ensuring efficient drainage, and keeping the mouth as aseptic as possible. Union takes place rapidly, and owing to the vascularity of the parts necrosis is rare, even when suppuration ensues. When the alveolar portion is comminuted, the fragments may be kept in position by fixing the mandible against the maxilla by means of a four-tailed bandage (Fig. 255), or by adjusting a moulded lead or gutta-percha splint to the alveolus and palate.

The zygomatic (malar) bone is sometimes fractured by direct violence, along with the adjacent portion of the maxilla. It may be possible to manipulate the displaced fragments into position with the fingers introduced between the cheek and the gum; if this fails, a small incision should be made in the mucous membrane anterior to the masseter, and the bone levered into position with an elevator.

The zygomatic arch is occasionally fractured by a direct blow. As the depressed fragments are liable to interfere with the movement of the mandible, they should be elevated either by manipulation or through an incision.

Fractures of the Mandible.—The most common situation for fracture of the mandible is through the body of the bone in the vicinity of the canine tooth (Fig. 254). The depth of the socket of this tooth, and the comparative narrowness of the jaw at this level, render it the weakest part of the arch. The fracture is usually due to direct violence, such as a blow with the fist, the kick of a horse, or a fall from a height. It is sometimes bilateral, the bone giving way at the canine fossa on one side and just in front of the masseter on the other; or both fractures may be at the canine fossae. The fracture is usually oblique from above downwards and outwards, and is nearly always rendered compound by tearing of the mucous membrane of the mouth.



When only one side is broken, the smaller fragment is usually displaced outwards and forwards by the masseter and temporal muscles, so that it overlaps the larger fragment. In bilateral fractures the central loose segment is driven downwards and backwards towards the hyoid bone by the force causing the fracture, and is held in this position by the muscles attached to the chin, while both lateral fragments are tilted outwards and forwards by the masseters and temporals. The amount of displacement is best recognised by observing the degree of irregularity in the line of the teeth. Abnormal mobility and crepitus are readily elicited, and there is severe pain, particularly if the inferior dental nerve is stretched or crushed. The patient's attitude is characteristic; he supports the broken jaw with his hands, and keeps it as steady as possible when he attempts to speak or swallow. Saliva dribbles from the open mouth, and the speech is indistinct.

In adults, the bone may be broken at the symphysis as a result of lateral compression of the jaw—for example, pressing together of the angles. The general characters of the fracture are the same as those of fracture of the body, but the displacement is inconsiderable.

Fractures of the angle and through the ramus are less common, and are not attended with deformity, as the fragments are retained in position by the masseter and internal pterygoid muscles. Fracture of the coronoid process is rare.

The condyle is usually fractured just below the insertion of the external pterygoid muscle (Fig. 254) by a fall on the chin or by a severe blow on the side of the face. When the fracture is unilateral, the broken condyle is tilted inwards and forwards by the external pterygoid, and can be palpated from the mouth, while the rest of the jaw is displaced towards the affected side, and not away from it, as happens in unilateral dislocation. When the fracture is bilateral, the mandible falls backwards, so that the lower teeth lie behind those of the maxilla.

In a few cases the condyle has been driven through the floor of the glenoid cavity, causing fracture of the base of the skull. The diagnosis may be established by means of the X-rays.

Complications.—As the majority of these fractures are compound, suppuration is comparatively common during the process of repair, but if means are taken to keep the mouth clean it can usually be kept in check, and seldom leads to necrosis. The teeth adjacent to the fracture are liable to be loosened or displaced. If merely loosened they should be left in place, as they usually become firmly fixed in the course of a few days. Care must be taken that a displaced tooth does not pass between the fragments, as this has been the cause of difficulty in reducing a fracture and of its failure to unite. Irregular union, by destroying the alignment of the teeth, leads to interference with mastication. The bone usually unites in from four to six weeks. Want of union is a rare event.

Treatment.—In the majority of cases of unilateral fracture after reduction, the fragments can be kept in apposition by closing the mouth and keeping the lower jaw fixed against the upper by means of a four-tailed bandage (Fig. 255). Care must be taken that the posterior tails of the bandage do not pull the mandible backward. Additional security may be given by a light poroplastic or gutta-percha splint fitted to the chin, the vertical portion passing well up the ramus of the jaw. After a few days the apparatus is removed, the patient is encouraged to move the jaw, and massage is employed. The mouth must be regularly cleansed by an antiseptic mouth-wash, or by a spray of hydrogen peroxide.



In certain fractures implicating the body of the jaw, and particularly when bilateral, the co-operation of the dentist is necessary to obtain the best results. After the fragments have been coapted, a plaster impression is taken of the jaw and teeth, and from this a silver frame is cast which surrounds but does not envelop the teeth. This frame is then applied to the fractured jaw, and restrains movement of the fragments without interfering with the action of the jaw (W. Guy). The use of an intra-oral frame obviates the necessity of wiring the fragments.

Even in badly united fractures the original contour of the bone is eventually restored by the movements of the tongue moulding it into shape.

AFFECTIONS OF THE TEMPORO-MANDIBULAR ARTICULATION

Dislocation of the Mandible.—Dislocation of the lower jaw may be unilateral or bilateral. The bilateral form is the more common, and is met with most frequently in middle life, and in females. The liability to dislocation is greatest when the mouth is widely open—for example, in yawning, laughing, or vomiting—as under these conditions the condyle, accompanied by the meniscus, passes forwards out of the glenoid cavity and rests on the summit of the articular eminence. If, while the bone is in this position, the external pterygoid muscle is thrown into contraction, it pulls the condyle forward over the eminence into the hollow beneath the root of the zygoma, and the contraction of the masseter and temporal muscles retains it there. Muscular contraction is therefore an important factor in its production.

Dislocation may be produced also by a downward blow on the chin, by the unskilful introduction of a mouth gag, particularly while the patient is anaesthetised, or even in the attempt to take a big bite—say, of an apple. The dislocation that results from such causes is usually unilateral.

In some persons the ligaments of the joint are unnaturally lax, and dislocation is liable to occur repeatedly from comparatively slight causes—recurrent dislocation.

Clinical Features.—The appearance of a patient suffering from bilateral dislocation is characteristic. The mouth is open, the jaw fixed, and the chin protruded so that the lower teeth project beyond the upper. The patient has difficulty in swallowing, and the saliva dribbles from the mouth. As the lips cannot be approximated, the speech is indistinct and guttural. Just in front of the auditory meatus a deep hollow can be felt, and in front of this the condyle forms an undue projection. The coronoid process is displaced below and behind the zygomatic (malar) bone, and may be felt through the mouth. The contracted temporal muscle forms a prominence above the zygoma.

In unilateral dislocation the deformity is the same in character, but is less marked, and in mild cases its cause is liable to be overlooked. In most cases the chin deviates towards the sound side.

Treatment.—In recent cases, reduction is usually easily effected. The patient should be seated on a low chair or stool, an assistant supporting the head from behind. The surgeon, standing in front, places his thumbs, well protected by a roll of lint, far back on the molar teeth, and with his other fingers grasps the body of the jaw. Pressure is now made downwards and backwards to free the condyles from the articular eminence, and to overcome the tension of the temporal and masseter muscles, and as this is effected the tip of the chin is carried upward, while the whole jaw is pushed directly backward. The condyle slips into position, sometimes with a distinct snap. When difficulty is experienced in levering the condyle from its abnormal position, a cork may be placed between the molar teeth on each side to act as a fulcrum. After reduction the jaw is fixed by means of a four-tailed bandage for a few days. The patient is warned to avoid for some weeks opening the mouth widely.

Old-standing Dislocation.—It sometimes happens that, from having been overlooked or neglected, the dislocation remains unreduced. In such cases the movement of the jaw is in time partly restored, and the patient acquires sufficient control of the lips to be able to articulate intelligibly and to prevent dribbling of saliva. The power of masticating the food, however, remains impaired. The hollow behind the condyle and the projection of the chin persist. Reduction by manipulation is seldom possible after the dislocation has existed for more than three months, but it has been effected as long as ten months after the accident. Several attempts at reduction should be made at intervals of two or three days, and if these fail recourse may be had to operation. As the masseter and internal pterygoid muscles have assumed a vertical position and become shortened, they form an obstacle to reduction, and to overcome their action it is necessary to separate them from their insertion to the ascending ramus of the bone through an incision carried round the angle. If the adhesions about the dislocated condyle are then separated, reduction can be effected (Samter). In some cases it is necessary to excise the condyle to restore movement.

Internal Derangements of the Temporo-mandibular Joint.—The intra-articular cartilage is liable to be displaced by excessive traction exerted on it by the external pterygoid muscle during some sudden movement of the joint, particularly in closing the mouth. There is acute pain in the region of the joint, the teeth on the affected side cannot be brought into apposition, so that mastication is interfered with, and the patient is conscious of something locking inside the joint. The joint is tender to the touch, but there is no external swelling. Replacement is effected by keeping up firm pressure at the back of the condyle with the mouth open, and slowly closing the jaw. If recurrence takes place repeatedly, the disc may be sutured to the periosteum (Annandale), or excised (Hogarth Pringle).

Arthritis of the temporo-mandibular joint occurs in two forms, non-suppurative and suppurative.

The non-suppurative form is usually due to gonorrhoeal infection, and as a rule is bilateral. The patient complains of neuralgic pains shooting towards the ears and temples, and of pain in the joint on movement. The jaw is therefore kept fixed, usually with the mouth slightly open and the chin protruded. Mastication is impossible, and the speech is indistinct. There is effusion into the joint, and a swelling may be detected in front of the ear. The inflammation may subside and movement restored, or fibrous ankylosis may ensue.

The suppurative form may be due either to direct spread of infection from adjacent parts, as, for example, in middle ear disease, suppurative parotitis, or pyogenic affections of the mandible, or it may be part of a general pyaemic infection, as sometimes occurs after exanthematous fevers and in gonorrhoea. The clinical features are similar to those of the non-suppurative form, but the signs referable to the joint are often masked by those of the primary lesion. When the pus originates in the joint, it may point either towards the skin or into the external auditory meatus through the petro-tympanic (Glaserian) fissure. The joint is usually completely disorganised and ankylosis results.

Tuberculous arthritis is rare, and is usually secondary to disease of the mandible, the temporal bone, or the middle ear. It leads to destruction of the joint and ankylosis. It is treated by incision and scraping, or by excision of the condyle.

Arthritis deformans is a comparatively common affection, and is generally bilateral. In the earlier stages the condyle is usually hypertrophied and distorted, and the glenoid cavity is correspondingly broadened and flattened, and in time may be filled up by new bone. Osteophytic outgrowths form around the joint and lead to fixation or locking. The enlarged condyle may be felt in front of the ear, and there is pain and cracking on movement; the pain is worst at night and in wet weather. The jaw is usually depressed and the chin protruded. The disease runs a chronic course, with occasional acute exacerbations. Excision of the condyle may be advisable when non-operative measures have failed to give relief. In the later stages, the condyle, together with the meniscus, may be worn away and completely disappear.

Closure or Fixation of the Mandible.—Temporary fixation is due to spasmodic contraction of the muscles of mastication, particularly the masseter. This may be symptomatic of some inflammatory condition in the vicinity, such as a pyogenic affection of the lower jaw—for example, that associated with a carious root or an unerupted wisdom tooth, or with parotitis or tonsillitis. In such cases the spasm passes off on the removal of the cause. It is occasionally a manifestation of hysteria. The administration of a general anaesthetic and the introduction of a wedge or separator is usually necessary to confirm the diagnosis and, it may be, to permit of operative measures, such as the extraction of a wisdom tooth.

Muscular fixation may be due to rheumatic or syphilitic myositis, and this is sometimes followed by fibroid degeneration of the muscles, rendering the fixation permanent.

Permanent fixation may be due to a variety of causes. Fibroid degeneration of muscles following myositis has already been mentioned. Much more frequently it results from cicatricial contraction of the soft parts of the face or mouth following such conditions as cancrum oris, ulceration, or burns. Fixation following upon prolonged immobilisation after fracture or dislocation, or any of the forms of arthritis or suppurative or tuberculous disease of the adjacent portions of the mandible, is also met with. The ankylosis may be fibrous or osseous, and may be intra- or extra-articular.

The clinical features vary with the degree of separation of the jaws. There is always some deformity, and more or less interference with mastication and speech. The patient usually feeds himself by pushing small portions of bread or meat with the fingers through some gap between the badly opposed and badly formed and preserved teeth. As the patient is unable to keep the mouth clean, particles of food lodge and decompose there, causing irritation of the mucous membrane, caries of the teeth, and foetor of the saliva and breath. When osseous ankylosis occurs in childhood, it leads to arrest of development of the mandible, which is small and markedly receding, so that the teeth do not oppose those of the maxilla (Fig. 256).



Treatment.—When the cause of the fixation is in the joint itself, the best treatment is to resect one or both condyles.

When the fixation is due to cicatricial contraction of the soft parts, mobility is best restored by forming an artificial joint well in front of the cicatricial tissue, as suggested by Esmarch.



CHAPTER XXII

THE TONGUE

Surgical Anatomy—Wounds—Dental ulcer—Inflammatory affections: Acute parenchymatous glossitis and hemi-glossitis; Mercurial glossitis; Chronic superficial glossitis; Leucoplakia; Smoker's patch—Tuberculous disease; Syphilitic affections; Sclerosing glossitis; Gummas; Ulcers and fissures—Tumours: Carcinoma; Sarcoma; Innocent tumours; Cysts—Thyreo-glossal tumours and cysts—Malformations: Absence; bifid tongue; Tongue-tie; Excessive length of frenum; Macroglossia; Atrophy—Nervous affections.

Surgical Anatomy.—The tongue is composed of interlaced, striped muscle fibres, partly consisting of the terminations of the extrinsic muscles, and partly of the intrinsic muscles. A median fibrous septum divides it into two lateral halves so completely that but little communication takes place between the blood vessels and lymphatics of the two sides. It is covered by stratified squamous epithelium. For practical purposes it is described as consisting of an anterior or oral part, and a posterior or pharyngeal part.

The oral part, which includes the anterior two-thirds of the organ, is mobile, and the epithelium on its dorsal aspect is modified so as to form several varieties of papillae. A slight median depression is recognisable on the dorsum as far back as the vallate (circumvallate) papillae, which mark the boundary between the oral and pharyngeal parts. A double fold of mucous membrane—the frenum—connects the under aspect of the tip with the floor of the mouth and the mandible. On each side of the frenum, under the mucous membrane of the tip, are mucous glands—apical glands—in which cysts sometimes form. On the lateral border of the tongue, just in front of the anterior palatine arch, are several vertical folds of mucous membrane—the folia linguae, or foliate papillae.

The pharyngeal part, or base of the tongue, forms the anterior wall of the pharynx, and is attached to the hyoid bone. Its mucous membrane is devoid of papillae, but contains numerous lymphoid follicles—the lingual tonsil. The foramen caecum lies just behind the apex of the vallate papillae in the middle line.

The chief artery, the lingual, a branch of the external carotid, passes forward beneath the hyoglossus muscle, and is continued to the apex as the ranine, lying nearer the under than the upper aspect of the tongue. The pharyngeal part is supplied by the dorsalis linguae branch. The blood is returned to the internal jugular by the ranine vein, which can be seen under the mucous membrane on the inferior aspect near the frenum, and by the venae comites of the lingual artery and its branches.

The hypoglossal is the motor nerve of the tongue. The lingual branch of the mandibular (inferior maxillary) supplies the anterior two-thirds with common sensation. It is accompanied by the chorda tympani branch of the facial, which probably carries the taste fibres. The glosso-pharyngeal supplies the posterior third of the tongue with both common and gustatory sensation.

The lymph vessels of the anterior two-thirds of the tongue drain into the submental and submaxillary glands, and these in turn into the deep cervical group which accompany the internal jugular vein. The vessels of the base converge into several large trunks which pass out behind the tonsils and drain directly into the deep cervical glands. One of these, which lies in the angle between the internal jugular and common facial veins, is frequently infected in cancer of the tongue.

Wounds are commonly produced by the teeth, as, for instance, when a child falls on the chin with the tongue protruded, or when an epileptic bites his tongue during a fit. Less frequently a foreign body, such as a pipe-stem, a bullet, or a displaced tooth, is driven into the tongue. The immediate risk is haemorrhage, particularly when the posterior part of the tongue is implicated and the wound penetrates deeply. Of the later complications, infections and secondary haemorrhage are the most serious, and they are most liable to occur when a foreign body is embedded in the tongue.

Treatment.—In superficial wounds near the tip the oozing is efficiently arrested by sutures, but in deeper wounds a ligature must be applied to the bleeding vessel. Secondary haemorrhage is much more difficult to arrest on account of the friable state of the tissues, and it may be necessary to ligate the lingual or even the external carotid in the neck.

To prevent infective complications any foreign body must be removed and an antiseptic mouth-wash regularly employed.

Cases have been recorded in which such a foreign body as a bullet, a needle, or a piece of a pipe-stem, has remained embedded in the substance of the tongue for a long period, and caused a firm, indolent swelling liable to be mistaken for a new growth.

Dental Ulcer.—The continuous friction of a jagged tooth, or of an ill-fitting dental plate, is liable to cause swelling and excoriation of the side of the tongue. A painful superficial ulcer forms, and if the irritation continues and infection occurs, the surrounding parts become indurated, the ulcer assumes a crater-like appearance, not unlike that of a commencing epithelioma. If such an ulcer does not promptly heal on the removal of the irritant, a portion of the margin should be removed and submitted to microscopic examination to make sure that it is not cancerous.

Inflammatory Affections.—Acute Parenchymatous Glossitis is usually due to the action of streptococci. Although it affects mainly the mucous membrane and submucous tissue, it causes a diffuse oedematous swelling of the whole organ, and this may extend to the ary-epiglottic folds and give rise to oedema of the glottis. As a rule it does not go on to suppuration.

The onset is sudden, and is marked by pain and stiffness of the tongue, particularly when the patient attempts to masticate or to speak. The tongue rapidly swells, and in the course of twenty-four or forty-eight hours may fill the mouth and protrude beyond the teeth. There is profuse salivation, and in addition to difficulty in swallowing and speaking there may be considerable interference with respiration. The salivary and lymph glands in the submaxillary space are enlarged and tender. The symptoms begin to subside in three or four days, unless suppuration occurs.

The treatment consists in administering a sharp purge and employing a mouth-wash; leeches may be applied to the submaxillary region with benefit. When the swelling is excessive, it may be necessary to make longitudinal incisions into the substance of the tongue, and dyspnoea may call for laryngotomy. If an abscess forms it must be opened.

A similar condition has been met with in patients who have contracted the "foot and mouth disease" of cattle. Vesicles form on the mucous membrane, and after bursting, ulcerate, and a mixed infection with streptococci occurs, leading to diffuse oedema. Portions of the tongue may become gangrenous, and the infection may spread to the tissues of the neck and set up one form of angina Ludovici. The condition is usually fatal.

Acute Hemi-glossitis.—An acute transitory swelling, confined to one half of the tongue, in the distribution of the lingual nerve, is occasionally met with. It is attended with great pain and high temperature, and is believed to be analogous to herpes zoster (Gueterbock).

Mercurial Glossitis may accompany mercurial stomatitis (p. 496).

Chronic Superficial Glossitis.—Several forms of chronic superficial glossitis are met with. The most important, as it is frequently followed by the development of epithelioma, is that known as leucoplakia or leucokeratosis.

The tongue is studded over with white patches, which result from overgrowth and cornification of the surface epithelium, whereby it becomes thickened and raised above the surface, and at the same time there is small-celled infiltration of the submucous tissue. The patches are irregularly lozenge-shaped, and when crowded together they present the appearance of a mosaic (Fig. 257). Similar patches are often present on the mucous membrane lining the cheek.



The disease is met with almost invariably in men between the ages of forty and fifty. Syphilis appears to be a predisposing factor, and any form of irritation—for example, the chewing or smoking of tobacco, the drinking of raw spirits, friction by a rough tooth or tooth-plate—plays an important part in inducing or in aggravating the condition.

The milder forms give rise to no discomfort, but when the condition is advanced the patient complains of dryness and hardness of the tongue, with impairment of the sense of taste and persistent thirst. When cracks, fissures, or warts develop, there is pain on chewing or speaking, or on taking hot or irritating food. The glands below the jaw may be enlarged.

The disease is most intractable and persistent, and even after disappearing for a time is liable to recur. After a variable number of years epithelioma is prone to develop, usually in one or other of the fissures which accompany the condition.

The treatment consists in removing all sources of irritation, particularly smoking, and in employing mouth-washes. Butlin recommends antiseptic ointments applied before going to bed. In some cases painting the patches with chromic acid (10 grains to the ounce) or lactic acid (20 per cent.) is useful in removing the excess of epithelium, but stronger caustics are to be avoided. Constitutional treatment is of little use even when the patient has suffered from syphilis. The best results have been attained by the use of radium.

The "smoker's patch" consists of a small oval area on the front of the tongue from which the papillae have disappeared. It is slightly raised, smooth and red, and may be covered with a yellowish-brown or yellowish-white crust. It causes no discomfort unless the crust is removed, when a raw, sensitive surface is exposed. The condition is liable to spread over the tongue if the patient persists in smoking. It may eventually assume the characters of leucoplakia. The treatment consists in stopping the use of tobacco, and painting the patches with chromic acid, tannic acid, or alum, and employing a chlorate of potash mouth-wash.

Tuberculous Disease.—The tongue is rarely the primary seat of tuberculosis. The majority of cases occur in adult males, who suffer from advanced pulmonary or laryngeal phthisis, the tongue being infected by bacilli from the sputum or through the blood stream. In other cases the infection is due to direct spread of lupus from the face or nose.

The condition may begin as a firm, painless lump, seldom larger than a hazel-nut, on one side of the tongue, or near its tip. At first the swelling is covered by epithelium; in time caseation takes place, the epithelium gives way, and an open sore is formed.

The tuberculous ulcer is the form most frequently met with. The surface of the ulcer is uneven, pale and flabby, and is covered with a yellowish-grey discharge, with here and there feeble granulations showing through. The edges are shreddy, sinuous in outline, and there is little or no induration. The surrounding parts are slightly swollen, and may be studded with small tuberculous foci. The ulcer may be quite superficial, or it may extend into the muscular substance, and the tip of the tongue may be completely eaten away so that it looks as if it had been cut off with a knife. As the disease advances there is severe pain and usually profuse salivation. The submaxillary glands may be, but are not always, enlarged. The ulcer may heal, but tends to break down again.

Unless there is advanced pulmonary disease or other contraindication to operation, the ulcer should be excised under local anaesthesia. Care must be taken to avoid reinfecting the raw surface. When excision is impracticable, it is only possible to palliate the symptoms by dusting with orthoform, or applying local anaesthetics, and by attending to the hygiene of the mouth and removing all sources of irritation.

Syphilitic Affections.—A primary lesion on the tongue is accompanied by marked enlargement and tenderness of the submaxillary lymph glands on one or on both sides. It is most common in men, infection usually taking place through the medium of tobacco pipes, or implements such as the blow-pipes of glass-blowers.

During the secondary stage—particularly in the later periods—mucous patches and ulcers are common, and they may assume a condylomatous or warty appearance.

The tertiary manifestations in the tongue are sclerosing glossitis, gummas, and gummatous ulcers.

Sclerosing glossitis is the term applied by Fournier to a condition in which there is an abundant new formation of granulation tissue in the substance of the tongue, leading to the appearance of tuberous masses on the dorsum. These tend to be oval in outline, are elevated above the normal mucous membrane, and present a dull red mammilated or lobulated surface, comparable to the surface of a cirrhotic liver. They are firm, elastic, and insensitive.

A gumma is usually situated on the dorsum and more often towards the centre than at the edges. As it seldom implicates the floor of the mouth or the base of the tongue, the tongue can usually be protruded freely. It forms an indolent swelling, which tends to break down slowly and to ulcerate. So long as it remains unbroken it does not cause pain, and there is no enlargement of the adjacent lymph glands. Two forms are met with—the superficial, and the deep or parenchymatous.

A superficial gumma appears as a small hard nodule under the mucous membrane, varying in size from a pin's head to a pea. The mucous membrane over it is redder than normal, and in the early stages retains its papillae but later becomes smooth. It tends to break down early, forming a superficial ulcer. Superficial gummas are often multiple.

The deep or parenchymatous form varies in size from a hazel-nut to a walnut, and feels like a hard body in the substance of the tongue. The mucous membrane over the swelling is of normal colour, but is usually devoid of papillae. The gumma may remain for months unchanged, or may approach the surface, soften, and break down, leaving a deep, ragged ulcer.

Syphilitic ulcers and fissures are nearly always due to the softening and breaking down of gummas. The ulcers have seldom the typically rounded or serpiginous outline of gummatous ulcers on other parts of the body. The base is ragged and unhealthy, and on it a yellowish-grey slough resembling wash-leather may be seen. The edges are steep, ragged, and often undermined, and the surrounding parts thickened and indurated. The neighbouring glands are not usually enlarged. The ulcer is extremely painful when irritated by food, hot fluids, or spirits. If untreated, the sore may remain indolent and for months show no sign either of spreading or healing, but at any time it may become the seat of cancer.

Syphilitic fissures are met with as long, narrow, deep clefts, or as stellate or sinous cracks in the substance of the tongue. After the healing of these ulcers and fissures permanent furrows and depressed scars remain.

Treatment.—The tertiary manifestations of syphilis in the tongue are treated on the same lines as other tertiary lesions. Locally, the use of mouth-washes, such as chlorate of potash or black wash diluted with lime-water, the insufflation of powdered iodoform and borax with a small quantity of morphin, or the application of mercurial ointment is useful. The sore must be thoroughly cleansed before these remedies are applied.

NEW GROWTHS

Carcinoma is by far the most common form of new growth met with in the tongue, and it is almost invariably a squamous epithelioma.

Epithelioma generally occurs between the ages of forty and sixty, and attacks males oftener than females, in the proportion of about six to one. Its development is favoured by any long-continued irritation, such as the rubbing of the tongue against a carious tooth, an ill-fitting tooth-plate, or the rough end of a short clay pipe, particularly when such irritation leads to the formation of an ulcer. Chronic superficial glossitis associated with leucoplakia, and syphilitic fissures, ulcers, or scars, also act as predisposing factors. The repeated application of strong caustics to chronic inflammatory conditions is, according to Butlin, a determining cause of cancer. The degree of malignancy appears to vary in different cases, and is probably lowest when the disease originates in a patch of leucoplakia or other pre-cancerous lesion.

The disease is usually situated in the anterior half of the tongue, and more commonly on the edge than on the dorsum. It may begin as an excoriation, ulcer, or fissure, or as a warty growth, particularly in association with a patch of leucoplakia. In all cases ulceration begins early, and the base of the ulcer and the surrounding parts become indurated. The lymph glands are, as a rule, early infected.

Clinical Features.—The clinical appearances vary widely. Sometimes the surface presents a warty growth; sometimes it is excavated, forming a deep ulcer with raised nodular edges; in other cases the ulcer is smooth, and its edges even and rounded. Extreme hardness of the edges and base of the ulcer is always a characteristic feature. The tongue tends to become fixed, especially when the disease spreads to the floor of the mouth, so that it cannot be protruded, and the restriction of its movement produces a characteristic interference with articulation, certain words being slurred, and when the fixation is extreme it may interfere with mastication and swallowing. The patient complains of a constant gnawing pain in the tongue, and of severe pain shooting along the branches of the trigeminal nerve, and especially towards the ear. In the advanced stages there is salivation and foetor of the breath.

When the disease is situated on the edge of the tongue it tends to spread to the floor of the mouth and the muco-periosteum of the mandible. If situated far back on the dorsum, it spreads on to the epiglottis, the pillars of the fauces, and the tonsil.

The neighbouring lymph glands—particularly those under the jaw and along the line of the carotid vessels—soon become infected and are palpable. The submaxillary and sublingual salivary glands are also liable to be affected. The enlarged cervical glands later undergo softening, or suppurate and burst on the skin surface, forming fungating ulcers. Metastasis to the liver, lungs, and other viscera is exceptional. If the disease is allowed to run its course, the patient usually dies in from twelve to eighteen months from repeated small haemorrhages, toxin absorption, or septic broncho-pneumonia.

Differential Diagnosis.—Cancer of the tongue has to be diagnosed from syphilitic and tuberculous affections, from papilloma, and from simple ulcer and fissure. It is to be borne in mind that any of these conditions may take on malignant characters and develop into epithelioma. The microscopic examination of a portion of the growth removed under local anaesthesia from the base of the ulcer at some distance from its epithelial core is often the only certain means of establishing the diagnosis, and should be had recourse to as early as possible. When there is still doubt as to the nature of the growth, it should be treated as if it were cancerous.

An unbroken gumma is liable to be confused only with the uncommon form of epithelioma which begins as a nodule under the mucous membrane. Gumma, however, are often multiple, and the tongue shows old scars or other evidence of syphilis.

Gummatous ulcers are usually situated on the dorsum, are frequently multiple, and have sloughy, undermined edges; the surrounding parts, although indurated, are not so densely hard as in cancer; there is not necessarily any involvement of lymph glands. The cancerous ulcer is usually single and situated on the margin of the tongue; its edges are hard, raised, and nodular; and the glands are usually enlarged and hard. Little reliance is to be placed on the therapeutic effects of anti-syphilitic drugs in the differential diagnosis, as they are often inconclusive, and their use results in loss of time.

Tuberculous ulcers usually occur in association with other and unmistakable evidences of tuberculosis. A papilloma, when sessile, may simulate cancer; these tumours show a marked tendency to become malignant. Simple ulcers and fissures are usually recognised by the history of the condition, the absence of induration and of glandular involvement, and by the fact that they heal quickly on removal of the cause.

Treatment.—The only treatment that offers any hope of cure is free removal of the disease, and experience has proved that unless this is done early the prospect of the cure being a radical one is remote. Not only must the segment of the tongue on which the growth is situated be widely excised, but all the lymphatic connections must also be removed whether the glands are palpably enlarged or not.

The chief risk after operation is pneumonia resulting from the inhaling of blood and products of infection: hence the importance of rendering the mouth as dry and as sweet as possible before operation, special attention being paid to the teeth, and precautions being taken at the operation to prevent the passage of blood down the trachea. The patient is usually able to be out of bed on the second or third day, and is well in a fortnight or three weeks. The operation, even when followed by recurrence, usually prolongs life by six or eight months, and renders the patient more comfortable by removing the foul ulcer from the mouth. The speech, although impaired by the removal of one-half or even more of the tongue, is distinct enough for ordinary purposes. When recurrence takes place it is usually in the glands, and may be attended with great suffering.

Treatment of Inoperable Cases.—The mouth must be kept as sweet as possible. The pain may be relieved to some extent by cocain or orthoform, but as a rule the free administration of morphin is called for. Pain shooting up to the ear may be relieved by resection of the lingual nerve, or the injection of alcohol into its substance. If haemorrhage takes place from the ulcerated surface and cannot be controlled by adrenalin, or other local styptics, it may be necessary to ligate the lingual, or even the external carotid artery. Interference with respiration may necessitate tracheotomy. When the patient has difficulty in taking food, recourse should be had to the use of the stomach-tube or to gastrostomy. The use of radium or of the X-rays appears to have a restraining influence on the disease in the glands, but has not proved curative.

Sarcoma of the tongue is rare, and is sometimes met with in children. The round-cell type is the most common; it grows rapidly, and tends to ulcerate and fungate, pain becoming severe when the growth has broken down. The diagnosis is always difficult, and is seldom made until a portion of the growth has been removed and examined microscopically. The more slowly growing forms, if removed before ulceration has taken place, show little tendency to recur, but those which grow rapidly and break down, not only recur locally, but are liable to give rise to metastases. The treatment is the same as for cancer; the use of radium is more likely to be beneficial than in epithelioma.

Innocent Tumour and Cysts.—Lipoma, fibroma, and various forms of angioma (Fig. 258) are occasionally met with. They are all of slow growth, and give rise to inconvenience chiefly by their bulk, and should be removed.



Papilloma may occur on any part of the tongue, and at any age. It may be single or multiple, pedunculated or sessile, and is liable to become malignant, especially when associated with leucoplakia. It should be freely removed by excising a wedge-shaped portion of the tongue.

Dermoid cyst is met with beneath the tongue, lying in the middle line, between the genio-glossi (genio-hyoglossi), and on the upper surface of the mylo-hyoid muscles. It may be noticed soon after birth, or may only attract attention during adult life. The cyst usually projects under the chin, forming a soft swelling of putty-like consistence, which varies in size from a pigeon's to a turkey's egg (Fig. 259). When it bulges towards the mouth it is liable to be mistaken for a retention cyst of one of the salivary glands. It is distinguished by its medial position, its yellow colour, and its opacity, the retention cyst being to one side of the middle line, purplish in colour, translucent and fluctuating. The cyst should be dissected out, either from the mouth or from under the chin, according to circumstances.



A sebaceous cyst may reach such dimensions as to simulate a dermoid or thyreo-glossal cyst.

Hydatid and cysticercus cysts have also been met with in the tongue.

Thyreo-glossal Tumours and Cysts.—Tumours may develop in the embryonic tract which passes from the isthmus of the thyreoid gland to the foramen caecum at the base of the tongue—the thyreo-glossal tract of His. They have the same structure as the thyreoid gland, and occupy the dorsum of the tongue, extending from the foramen caecum backwards towards the epiglottis, in some cases attaining considerable size. They are of a bluish-brown or dark red colour, and are liable to repeated attacks of haemorrhage. These tumours sometimes become cystic, the cysts being lined with ciliated epithelium and containing colloid material. Bleeding may take place into a cyst, causing it to become suddenly enlarged, or the cyst may burst and the blood escape into the mouth. These variations in size and repeated attacks of bleeding help to distinguish thyreo-glossal cysts from other swellings of the tongue. Treatment is only called for when the swelling causes interference with speech or swallowing; it consists in removing the tumour by dissection.

When the lower end of the tract becomes cystic it forms a swelling in the neck (p. 583).

Malformations.—Complete or partial absence of the tongue is exceedingly rare.

Occasionally the fore part of the tongue is bifid. The function of the organ is not interfered with, and the operation of paring and suturing the two halves is only called for on account of the disfigurement.

Congenital tongue-tie is a condition in which the tip of the tongue is bound down to the floor of the mouth by an abnormally short and narrow frenum, or by folds of mucous membrane on each side of the frenum, so that the tongue cannot be protruded. Although this deformity is rare, it is common for parents to blame an imaginary tongue-tie when a child is slow in learning to speak, or when he speaks indistinctly or stammers, and the doctor is frequently requested to divide the frenum under such circumstances. In the vast majority of cases nothing is found to be wrong with the frenum. In the rare cases of true tongue-tie the edges of the shortened bands should be snipped with scissors close behind the incisor teeth, and then torn with the finger-nail.

Excessive length of the frenum is occasionally met with, and in children may allow of the tongue falling back into the throat and causing sudden suffocative attacks, one of which may prove fatal. In some cases the patient is able voluntarily to fold the tongue back behind the soft palate.

Macroglossia is the term applied to a variety of conditions in which the tongue becomes unduly large, so that it tends to be protruded from the mouth, and to become scored by the teeth. The typical form—lymphangiomatous macroglossia—is due to a dilatation of the lymph spaces of the tongue. It is often congenital, and may affect the whole or only a part of the tongue. The enlargement may be progressive from the first, or may remain stationary for years, and then begin to develop somewhat suddenly, sometimes after an injury or as a result of some infective condition. The treatment consists in removing a wedge-shaped portion of the tongue.

In certain cases of macroglossia in children, the lesion has been found to be a fibromatosis of the nerves of the tongue, analogous to the plexiform neuroma.

Atrophy of the tongue is rare as a congenital condition. Hemi-atrophy occurs in various diseases of the central nervous system, as well as after injuries and diseases implicating the hypoglossal nerve.

Nervous Affections of the Tongue.—Neuralgia confined to the distribution of the lingual nerve is comparatively rare. It usually yields to medical treatment, but in inveterate cases it is sometimes necessary to resect the nerve.

It is more common to meet with a condition in which the patient complains of severe burning or aching pain in the region of the foliate papilla, which is situated on the edge of the tongue just in front of the anterior pillar of the fauces. The patient is usually a middle-aged, neurotic woman, and often with a gouty or rheumatic tendency. The pain, for which it is seldom possible to discover any cause, is usually worst at night, and may last for months, or even years. The practical importance of the condition is that, as the foliate papilla is prominent and red, it is liable to be mistaken on superficial examination for a commencing epithelioma. An inspection of the opposite side of the tongue, however, will reveal an exactly similar condition, which is not painful. The first and most important step in treatment is to assure the patient that the condition is not cancerous. Caustics and other irritating applications are to be avoided.

Spasm of the tongue sometimes occurs after injuries of the head implicating either the centre or the trunk of the hypoglossal nerve. It may also appear as a reflex condition in infective affections of the teeth and gums, or as a manifestation of some general disease of the central nervous system.

Paralysis of the tongue—unilateral or bilateral—may be due to injury or disease of the nerve centres of the hypoglossal nerve, more frequently to injury of or pressure on the nerve-trunk. The nerve may be bruised or divided in operations for the removal of tuberculous glands or other tumours in the neck. When the tongue is protruded it deviates towards the paralysed side, being pushed over by the active muscles of the opposite side (Fig. 260), and speech and mastication may be interfered with. The paralysed half of the tongue subsequently undergoes atrophy, but the functional disability largely disappears.



CHAPTER XXIII

THE SALIVARY GLANDS

Surgical Anatomy—Injuries—Salivary fistulae—Salivary calculi—Infective conditions: Parotitis; Inflammation of submaxillary gland; Angina Ludovici; Inflammation of sublingual gland; Tuberculous disease—Tumours: Ranula; Mixed tumours of parotid; Sarcoma; Carcinoma; Tumours of submaxillary and sublingual glands.

Surgical Anatomy.—The parotid gland lies on the side of the face below and in front of the ear, and extends deeply behind the mandible reaching almost to the side wall of the pharynx. Its deeper part lies in close relation with the internal carotid artery, the internal jugular vein, and the vagus, glosso-pharyngeal, accessory, and hypoglossal nerves. The external carotid artery passes through the substance of the parotid, and bifurcates opposite the neck of the condyle into the temporal and internal maxillary arteries. It is accompanied by the venous trunk formed by the junction of the temporal and internal maxillary veins. The facial nerve and its branches traverse the lower third of the gland from behind forwards. The facial portion of the gland lies on the surface of the masseter muscle, and the parotid duct (Stenson's duct) emerges from its anterior border. After crossing the masseter, the duct pierces the buccinator muscle and the mucous membrane obliquely, and opens into the mouth opposite the second upper molar tooth. Its course is indicated by a line passing from the upper part of the lobule of the ear to a point midway between the ala of the nose and the margin of the upper lip—that is, at a higher level than the facial nerve. Several lymph glands—pre-auricular—lie inside the capsule of the parotid just in front of the ear.

The submaxillary gland lies under the integument and fascia in the triangle formed by the lower jaw and the two bellies of the digastric muscle. Its anterior part is crossed by the facial vessels, and several lymph glands lie inside its capsule. The submaxillary duct (Wharton's duct) opens into the mouth by the side of the frenum of the tongue.

The sublingual gland lies in the floor of the mouth just beneath the mucous membrane. It has numerous ducts, some of which open directly into the mouth, others into the submaxillary duct.

Injuries.—The parotid is frequently injured by accidental wounds and in the course of operations. If the blood vessels traversing the gland are divided, such wounds are liable to bleed freely, and if the facial and auriculo-temporal nerves are damaged, motor and sensory paralysis of the parts supplied by them ensues. Wounds of the parotid heal rapidly and without complications so long as infection is prevented, but if suppuration takes place they are liable to be followed by the escape of saliva, which may go on for weeks; in some cases a salivary fistula is thus established.

The parotid duct may be divided and a salivary fistula result. If the external wound heals rapidly, a salivary cyst may develop in the substance of the cheek, forming a swelling, which fills up at meals, and may be emptied by external pressure, the saliva escaping into the mouth.

In a wound implicating the whole thickness of the cheek the skin should be accurately sutured, care being taken that the stitches do not include the duct, but in order that the saliva may readily reach the mouth, the mucous membrane should not be stitched.

Salivary Fistulae.—A salivary fistula may occur in relation to the glandular substance of the parotid or in relation to the duct. Fistula in connection with the glandular substance—parotid fistula—seldom results from a wound, made, for example, in the removal of a tumour or in an operation on the ramus of the jaw, so long as it is aseptic; but as a sequel of suppuration in the gland, and particularly of an abscess developing around a concretion, it is not uncommon. The fistulous opening is usually small, and may occur at any point over the gland. The fistula may be dry between meals, or the saliva may escape in small transparent drops, but the quantity is always greatly increased when food is taken. A parotid fistula, although it may continue to discharge for weeks, or even for months, usually closes spontaneously.

In persistent cases, the edges of the fistula may be pared and brought together with sutures, or the actual cautery may be applied to induce cicatricial contraction.

Fistula of the parotid duct is more serious. It is usually due to a wound, less frequently to abscess or impacted calculus. From the minute opening, which is most frequently situated over the buccinator muscle, there is an almost continuous flow of clear limpid saliva, which is greatly increased in quantity while the patient is eating. These fistulae show little tendency to close spontaneously. Attempts to close the opening by the external application of collodion, by cauterising the edges, or even by paring the edges and introducing sutures, usually fail. It is necessary to establish an opening into the mouth, either by opening up the original duct or by making an internal fistula in place of the external one.

Salivary Calculi.—Salivary calculi are most commonly met with in the submaxillary gland or its duct. They consist of phosphate and carbonate of lime with a small proportion of organic matter, and result from the chemical action of bacteria on the saliva. In rare cases a foreign body, such as a piece of straw, a fruit-seed, or a fish-bone, forms the nucleus of the concretion. They vary in size from a pea to a walnut, and are hard, of a whitish or grey colour, and rough on the surface. Those that form in the gland itself are usually irregular, while those met with in the duct are rounded or spindle-shaped (Fig. 261).



A calculus in the duct gives rise to sharp lancinating pain, which is aggravated when the patient takes food. The duct is seldom completely obstructed, but the flow of saliva is usually so much impeded that the gland becomes greatly swollen during meals. The swelling gradually subsides between meals, or can be made to disappear by external pressure. The calculus can usually be felt by means of a probe passed along the duct, or by puncturing the swelling with a needle; or, with one finger inside the mouth and another under the jaw, a hard lump can be detected under the mucous membrane of the floor of the mouth. It may be revealed by the X-rays. When the obstruction is complete, a retention cyst forms in which suppuration is liable to occur, causing marked aggravation of the symptoms. In some cases the wall of the duct and the surrounding tissues become thickened and indurated, forming a swelling which is liable to be mistaken for a malignant growth. The treatment consists in making an incision through the mucous membrane over the calculus and extracting it with a scoop or forceps.

INFECTIVE CONDITIONS.—Parotitis.—Inflammation of the parotid gland may be non-suppurative or suppurative.

Of the non-suppurative varieties the most common is the epidemic form known as mumps. This is an acute infective condition, which usually attacks young children, and implicates both glands, either simultaneously or consecutively. It runs a definite course, which lasts for from one to two weeks, and almost invariably ends in resolution. The parotid gland is swollen and tender, there is pain on attempting to open the mouth, difficulty in swallowing, and dribbling of saliva. The surgical interest of this disease lies in the fact that it is frequently complicated by pain and swelling of the testis, oedema of the scrotum, and occasionally by a urethral discharge, and atrophy of the testis has been observed after such an attack. In females there is sometimes pain in the ovary, tenderness and swelling of the mamma, and a vaginal discharge.



The parotid on one or both sides may suddenly become swollen and tender in patients who are taking large doses of mercury, in gouty subjects, or in patients suffering from infective conditions of the genito-urinary organs, such as orchitis, ovaritis, urethritis, or cystitis. The condition is usually transient and leads to no complications.

Recurrent enlargement of the parotid and submaxillary glands, as well as of the lachrymal glands, is occasionally met with in adults, and was first described by Mikulicz. It may be associated with salivary lithiasis, xerostomia, or organic narrowing of the ducts, but in the majority of cases no such cause can be discovered (D. M. Greig). When the parotid is affected the condition tends to be bilateral and there is some constitutional disturbance. The submaxillary form is usually unilateral and the symptoms are entirely local. The affected gland rapidly becomes swollen, painful and tender to the touch, and the swelling increases markedly while the patient is eating. Each attack lasts for a few hours to one or two weeks, and then subsides spontaneously. The intervals between attacks vary from a few weeks to a year or more. In the course of a few years there is considerable deformity, and sometimes deficiency in the glandular secretion, but the disease is not attended by other inconvenience. Benefit has followed the administration of arsenic and iodides, and the use of radium and X-rays.

The treatment of these non-suppurative forms of parotitis consists in relieving the symptoms.

Suppurative parotitis may be due to direct spread of infection from the mouth along the parotid duct, or to extension of suppurative processes from the temporo-mandibular joint, the jaw, or a lymph gland. It is liable to occur also in the course of any disease in which there is an infection of the blood with pyogenic bacteria, and has been met with in diphtheria, typhoid fever, scarlet fever, measles, and other eruptive fevers.

The post-operative form of parotitis is most frequently met with after laparotomy for such conditions as suppurative appendicitis, perforated gastric ulcer, ovarian cyst, and pyosalpinx.

These secondary forms are probably due to infection from the mouth under conditions in which the secretion of saliva is arrested or its escape from the gland interfered with.