Chronic Enlargement of the Tonsils occasionally takes place in children, but generally in persons from eighteen to twenty-four years of age, or in such adults as are subject to irritations in the neighbourhood of the organs. A delicacy of constitution is supposed to be indicated by the affection. One or both tonsils may be enlarged, usually both. The surface of the tumour is irregular; the mucous follicles are enlarged, and often filled with sebaceous matter. The swellings in each side gradually approach each other, meet, and by narrowing the isthmus, seriously interfere with the functions of the parts. Little pain is felt, and that is dull, occasionally shooting through the ear. Respiration is at all times fettered, and during sleep noisy. Occasionally the swellings exceed their usual size, from some accidental excitement of the circulation. They may subside very considerably on the removal of the cause, or abatement of its operation, for there is nothing malignant in their nature. It is true, as I have seen, that the tonsils may be involved in malignant disease spreading from the neighbouring parts; but in the affection under consideration, no mark of malignancy appears, as far as I know. There is mere enlargement and opening out of the texture, without much, if any, change in structure or consistence; the part may be cut into without the risk of exciting unhealthy action, and the divided surface cicatrises readily.
Deobstruents, and iodine, as the most efficient, may be given, with perhaps some effect. In the adult, when the affection is troublesome, permanent, and of long duration, the exuberant matter must be removed, and this is accomplished either by ligature or by incision. The former method is the more difficult, tedious, painful, inconvenient, and dangerous. It is seldom that one ligature, with a simple noose, suffices; it is necessary to transfix the tumour, and, separating the portions of the ligature, to include the upper and under halves in distinct nooses. The latter method is the preferable. It is not requisite to cut out the whole tonsil, and there is risk in attempting such a measure, but that part only is removed which projects beyond the arches of the palate and the natural level of the gland. Long curved scissors may be employed, but the straight probe-pointed bistoury is more convenient; and this, to insure security, may be blunted to within an inch and a half of its point, or rolled so far in lint. To facilitate incision, the tumour is laid hold of by a sharp hook, or, what is better, by a vulsellum. Occasionally violent attempts at retching occur during the operation; but there is little pain or hemorrhage. The complicated machines invented for this purpose are worse than useless. The healing of the sore is hastened by fomentations and mild gargles, and by either stimulating or soothing applications, as circumstances require.
Excision of the tonsils is said to produce the bad effect of changing the pitch of the voice—taking from the high, and adding to the low notes. I have performed the operation, as above described, on professional vocalists, to remedy indistinctness of articulation and constant hoarseness, with the desired effect, and without altering either the pitch, quality, or compass of the voice. No doubt, unpleasant results might follow extensive incisions of the parts, as division of the anterior fold of the palate, and removal of the whole tonsil; but by paring off the prominent parts of the glands no risk is incurred.
Ulcers of the Palate, &c., are said to have arisen almost uniformly from contamination of the system, following sores on the genital organs. Now, at least, they seldom and scarcely ever occur from this cause, unless most execrable practice has been resorted to. Foul and extensive ulcers of the membrane of the mouth, of the tongue, of the gums, and of the folds of the palate, are common in those who have used mercury recently; and those whose constitutions have been saturated with mercury, or who have taken only alterative doses for a considerable time, are for a long while liable to ulcerations of these parts on exposure to moisture and cold—one set of sores healing, but others soon breaking out. It is, indeed, very rare to meet with sores in these situations that are not thus accounted for: certainly such as are by recurrence deep, extensive, and troublesome, are not seen unless in those who have suffered from mercurial medicines. Slight excoriations are not uncommon in individuals of the soundest and most untainted systems; but even in very young subjects, if the sore is of considerable size, and slow in healing, it will generally be found that some preparation of mercury, probably calomel, had been given previously, and perhaps without precaution and care. Calomel, as well as other forms of the mineral, is too often and too freely given, and without proper consideration; the ruin of many good constitutions is attributable to this cause, and to this cause alone. How long mercurial poisons continue to exercise a prejudicial influence on the constitution, is a question not easily determined. In many, its dominion is long and powerful. Frequently its effects are developed years after its exhibition, from accidental circumstances, such as change in the mode of living, derangement of the stomach and its appendages, exposure to inclement weather, change of climate, &c.
Sores form in various situations, between the pillars of the fauces—in the site of the tonsils—on the uvula, and by its side—on the posterior and anterior surfaces of the pendulous velum; sometimes the ulceration appears to have extended from the nostrils. Often the uvula is entirely lost; it is not long since I saw two uvulæ, in one day, as black as a bit of coal, surrounded by ulceration, and just about to drop away. Ulceration of the posterior surface of the velum is marked by dark redness, and swelling of the anterior. Sometimes it happens, that by deepening of the ulcers, the velum is perforated at one or more points, and the edge of the opening healing, a permanent deficiency remains. The whole of the soft palate may be destroyed, either by one extending ulceration, or by repeated attacks. When cicatrisation takes place, the posterior nares are narrowed, deformed, or even completely closed. Along with ulceration of the fauces, abscesses frequently form in the coverings of the hard palate; they are either the consequence or the cause of necrosis of part of the bone. Whatever their origin, more or less of the bone with which the matter is in contact, dies and separates; and thus openings are established between the cavities of the mouth and nostril. This is productive of great inconvenience, the patient speaks very indistinctly and, when taking food, a part of the more fluid ingesta returns by the nostrils. During the progress of the exfoliation, the breath is intolerably fetid.
Such is an outline of mercurial products in the mouth. Eruptions and ulcers on the surface of the body often accompany or follow them; and the patient gets into a bad state of health—becomes, in short, cachectic.
The state of the system must be ameliorated if possible; and chiefly by attention to the digestive organs. These may be improved by such medicines, as ipecacuan, taraxacum, gentian, rhubarb, scammony, aloes,—given in various doses and combinations, according to the circumstances of the individual case. The first two possess many of the good qualities of calomel, in regard to the biliary secretion, and leave no evils behind them. Sarsaparilla is a most important remedy, and the form of its exhibition should be varied when its effects begin to diminish. The different applications which may be made to the sores have been mentioned formerly; of them all, the nitrate of silver is the most generally useful, either in solution or in substance. It is used at intervals of two or three days, not to destroy living texture, but to diminish irritability and dispose to heal. If there be no great loss of substance, deficiency in the soft parts may be repaired by operation after the ulcerative disposition has ceased. In deficiency of the palate—during the progress of the ulceration in the bone and the parts investing it, and for some time after it has ceased—the inconvenience is lessened by filling the opening with crumb of bread softened, and made into a paste by kneading; this must be frequently renewed, otherwise it collects discharge, and becomes offensive. After cicatrization of the margins, and contraction of the opening, a metallic plate may be fitted in.
ULCERS OF THE TONGUE.
Ulcers of the Tongue.—Such as are not of a malignant kind are readily healed on improving the state of the digestive organs and general health. The state of the organ indicates that of the chylopoietic viscera, it enjoys intimate sympathy with the other parts of the alimentary canal, and why it should suffer from derangements of them is readily understood. The sores may be continued by local irritations, as by friction on encrusted tartar, or sharp or decayed portions of teeth, or by repeated application of heat, as in smoking. In consequence of long-continued irritation, like similar ulcers of the lips, they take on malignant action. The malignant ulcer generally occurs in patients
