SYPHILIS OF THE LINGUAL TONSIL. BY JAMES E. NEWCOMB, M.D., ATTENDING LARYNGOLOGIST, DEMILT DISPENSARY ; ASSISTANT IN THE ROOSEVELT OUT-PATIENT (THROAT) DEPARTMENT, NEW YORK CITY. FROM THE MEDICAL NEWS, July 2? 1892. [Reprinted from The Medical News, July 2,1892.] SYPHILIS OF THE LINGUAL TONSIL.1 BY JAMES E. NEWCOMB, M.D., ATTENDING LARYNGOLOGIST, DEMILT DISPENSARY ; ASSISTANT IN THE ROOSEVELT OUT-PATIENT (THROAT) DEPARTMENT, NEW YORK CITY. Although the past decade has witnessed marvel- lous progress in every department of that branch of medical science that specially interests the members of this Section, in none, perhaps, has greater interest been felt than in the one that concerns the pathol- ogy and treatment of the various conditions that beset the adenoid tissue of the mouth and naso- pharynx. The introduction, by Waldeyer, of the term "tonsillar ring" into medical literature has led to a more accurate understanding of the relation of the various adenoid deposits to each other, both in structure and in function. Nor, moreover, is this term merely a fanciful one. There is almost a cir- cular continuity of adenoid tissue from the naso- pharyngeal vault to the tubal deposits, to those on the posterior surface of the soft palate, to the faucial tonsils, and to those at the base of the tongue. Modern histologists have greatly differed as to what constitutes a typical tonsil. It seems to me 1 A paper read before the Laryngological Section of the New York Academy of Medicine, April 27, 1892. 2 NEWCOMB, that the recent paper of Harrison Allen Q is at present the best exposition of the subject. Accord- ing to this writer, a tonsil is essentially an associa- tion of diverticula developed from the epithelial layer of the mucous membrane. In the walls of these diverticula are grouped muciparous glands and lymph-follicles ; and the mouths of the diverti- cula open in a uniform manner on the surface of the mass. The various tonsillar masses differ only in the arrangement of these anatomic units, so to speak. In the lingual or fourth tonsil they are single. In spite of all we know regarding the structure of this tissue, however, we are still in the dark as to its physiology. Kingston Fox's theory {Lancet, 1888) of absorption has been discarded. Scanes Spicer's views as to their share in the blood forma- tion (2), " nurseries for young leukocytes, planted by the waterside and drawing their sustenance from the streams nutrient," afford opportunity for pleasing phrases, but do not recognize certain obscure points in our knowledge. The fascinating doctrine of phagocytosis, advanced by Metschni- koff, caused many to think that the problem had been solved, but further investigations, carried on in a calmer frame of mind, have caused the pro- fession to bring in the Scotch verdict of "not proven." Yet this doctrine is certainly worthy of consideration, for it fulfils, better perhaps than any other, the condition of a scientific theory, viz., it best explains observed phenomena. Hodenpyl, in a recent article, regards the functions of the tonsils as unknown. SYPHILITIC LINGUAL TONSIL. 3 The latest portion of the tonsillar ring to receive attention has been that localized thickening and broadening of the adenoid tissue at the base of the tongue. That we call the fourth or lingual tonsil. It is situated behind the circumvallate papillae, and extends a varying distance toward the anterior sur- face of the epiglottis. It consists of closed follicles surrounded by irregular masses of adenoid tisse, the whole bound up in connective tissue. Our great advance in knowledge has come in the realization of this fact: that we have here, both in structure and in function, a tonsil, modified, it is true, by its situation, but subject to all of the mutations of ton- sillar life. Stoerck, in 1877, first called attention to the trouble that its enlargement may produce by irritation of the epiglottis. Since then many ob- servers Have reported various reflex neuroses arising therefrom. Curtiss has shown its effects upon the singing voice ; Joal (3), how it may cause esophageal spasm and be a factor in globus hystericus; Hey- man, Michael, Bentz, Rice, Swain, and others, have discussed the general question. Attention has also recently been called by Ruaulb(4) to the fact that we may have a peri-amygdalar cellulitis here, as in the fauces. He reports five cases of this affection : once in the median line, three times to the right, and once to the left. It is worthy of note that ton- sillar hypertrophy here is generally confined to the middle period of life, while in faucial and retro- nasal situations the hypertrophy is characteristic of adolescence. Furthermore, we have learned that the fourth tonsil is not merely a servile imitator of those patho- 4 NEWCOMB, logic processes that precede it in other segments of the tonsillar ring. It may present conditions en- tirely independent of those of its neighbors. These may be involved while it escapes. Natier(5) has noted that in syphilis of the faucial tonsils we may have a thickening of the ary-epiglottidean folds, with a tumefaction of the epiglottis by an abundant vascularization, while the fourth tonsil escapes in- tact. Schaede (6) has seen enlargement of the latter, while the other adenoid deposits have been in an atrophic condition. The lingual tonsil, however, can lay claim to being the site at which diathetic influences may frequently localize themselves. Little attention has, until recently, been directed to its relation to the syphilitic virus. That such a relation exists is be- yond dispute. We have heard much about chancre of the lip, of the anterior part of the tongue, and of the faucial tonsils with their pillars. From the shel- tered position of the lingual tonsil, it can rarely, if ever, be the seat of primary infection. In fact, in a careful review of the literature, no such case has come to my notice. It is often the seat of secondary trouble, more rarely of the gummatous deposit, with its subsequent breaking down. This would be a logical deduction from the law of identity in struc- ture and function, and one corroborated by clinical experience. Yet it is somewhat remarkable that the syphilographers, who go into such details in regard to specific lesions of other parts of the mouth, should have passed over the matter in silence, especially as now over thirty years have elapsed since the exist- ence of true lingual chancre was demonstrated by SYPHILITIC LINGUAL TONSIL. 5 Le Gendre. The causes of this condition and the circumstances that determine the localization of the lesion are, as far as we know, referable entirely to various forms of irritation. It is more common in men, and generally in young adult life. It is more common in those addicted to excesses in tobacco and alcohol; also, in those whose occupations require prolonged straining of the vocal organs. Further than this, the lesion offers no exception to the gen- eral rules of syphilis. The condition is frequently overlooked because the symptoms do not differ from those observed when the pharyngeal walls bear the brunt of the trouble. When the localization is at the base of the tongue, in the median line, there is the sensation as of a foreign body. When it is confined, as it sometimes is, to the lateral portions, the function of the pharynx in deglutition causes more or less pain- ful swallowing, the pain radiating toward the ears The voice is frequently husky, and becomes quickly fatigued. Cough is frequently present, and not rarely asthmatic breathing. In other words, the syphilitic lesion occasions no other distinctive symp- toms than may arise from simple hypertrophy. It is in the pathologic appearances, perhaps, that the greatest interest centers. These may manifest themselves either in the median line or on either side thereof. Two different pictures present them- selves-as best described by Moure and Raulin : (7) i. Nipple-shaped protuberances, grayish-red in color, and separated by furrows. Their summits are ulcerated and crowned with the typical mucous plaque, clean-cut, and clearly differentiated from 6 NEWCOMB, the surrounding surface. Each protuberance cor- responds to a group of closed and inflamed follicles. The neighboring tissues are not at all involved. 2. There is at times a single tumefaction, median or lateral; a compact mass with slightly projecting swellings, the top of each of which is covered with mucous plaques, varying in size, diffuse and gener- ally ulcerated. The whole mass is of ovoid or spherical shape, and the area involved is much greater than in the first variety. Here, while the closed follicles are infiltrated, the tissue between them is also infiltrated, and this interstitial infiltra- tion is what goes to make up the mass. The epi- thelial layer of the mucous membrane and the sub- mucous connective tissue both participate in the morbid process. There is not only a folliculitis, as in the first variety, but a peri-folliculitis as well- a folliculo-interstitial process. The transformation of the first type into the second is very rare. Of course, we must bear in mind that in any case the exact picture varies according to the normal distri- bution of the follicles and their size before infiltra- tion, which in turn depends upon the preexistence of simple hypertrophy. The clinical history of a case that has recently come under observation, is as follows : W. D., a colored man, thirty-one years old, was first seen in the Roosevelt Out-patient Department (in the service of Dr. Jonathan Wright), January 23, 1892. The man was a porter, stout, and of rugged physique. His family history was good. He was a moderate drinker of malt liquors, and had used tobacco to excess. Last fall he had a slight SYPHILITIC LINGUAL TONSIL. 7 attack of rheumatism, that did not compel him to give up work. In September, 1891, he had the initial lesion of syphilis. No alopecia or rash fol- lowed, but in December (about six weeks before coming under observation) he began to complain of sore-throat, with pain in swallowing. Examina- tion revealed a normal nose. The faucial tonsils were swollen, and their surface more or less convo- luted. The inside of the cheeks was sprinkled with mucous plaques, and the anterior surface of the tongue as well. A few superficial ulcerations existed in the naso-pharynx. At the base of the tongue, on either side of the median line, were situated lesions of the first variety, previously described. Labit (8) has recently described a somewhat similar case. His patient was a male, twenty-nine years old, who had contracted syphilis six months before. No rash had been observed. Three months before the man was first seen he had begun to have painful spots in the mouth, with hoarseness and difficulty in swallowing. There was a general red- ness of the faucial tonsils and of the palatine vaults. The latter showed whitish patches, elliptical in shape, with uneven edges. There was an erythema- tous redness of the larynx, with slight inflammation of the ary-epiglottidean folds and vocal bands. In the region of the lingual tonsil the follicles appeared as projecting nipples, red, varying in size and separated by furrows of varying depth. The sum- mits of some of these projections were covered with grayish ulcerations, contrasting strongly with the surrounding redness. The tertiary lesions are more uncommon. Natier(5), writing in 1890, had been able to find the records of only fifteen cases in French literature. The 8 NEWCOMB, diagnosis of this condition is difficult before the appearance of disintegration, and yet of the utmost importance, because the ulcerations may extend deeply and reach important bloodvessels. A few words may be said concerning the differen- tial diagnosis. This, as in doubtful specific cases, must be made from the history, the local appearance, and other evidences in neighboring parts. Schu- macher (9) has called attention to one clinical mani- festation that might give rise to some confusion. It is a local appearance met with, independently of mercurial stomatitis, in the pharynx of those patients who are being treated by inunctions. It begins among the circumvallate papillae, and spreads back- ward to the epiglottis, attacking especially the edges of the pharyngeal and epiglottidean mucous mem- brane, passing down at times to the entrance of the larynx, seldom to the posterior laryngeal wall. At first there is only a slight dulness of color, but in a few days there are visible snow-white deposits, from one-half to one centimeter in circumference, surrounded by a zone of intense redness. If the condition be severe, the cervical and submaxillary glands may swell. Such manifestations generally precede the cutaneous eruption. Concerning the early diagnosis of the gumma, we are aided by the induration of the surrounding area, the center of which will, if the evolution of the de- posit be not checked, eventually support the deep cone-shaped ulcer characteristic of the fully-devel- oped lesion. A suspicious sign is a slight thicken- ing of the palate and the same side of the uvula. The absence of adenopathy is negative evidence. Its presence also does not greatly help us, because a SYPHILITIC LINGUAL TONSIL. 9 unilateral glandular enlargement is characteristic of several affections. Moreover, carcinoma, chronic abscess, and diphtheria may all be attended with the radiating pains already alluded to. Here, as elsewhere, the grouping of features must decide the diagnosis. Concerning the treatment of this condition, we are fortunately in a position to do much. The in- ternal medication with the various mercurials generally yields prompt and satisfactory results. For local relief, we may at first need sedative appli- cations. Natier has suggested a spray of potassic bromide with cocaine, in cherry-laurel water; Moure and Raulin, a gargle of Sydenham's laudanum in glycerin. For an alterative effect probably nothing exceeds in efficacy Mandi's solution of iodine, potassium iodide, and carbolic acid in glycerin. There is some danger in too irritant applications, as the epiglottis and larynx might be injured. Spasm of the glottis, and even edema, are not mere fanciful dangers. In the acute stage, the applications of dilute acid nitrate of mercury stimulate to healthy action. This, in my own case, with a sublimate gargle and mixed treatment, led to a cure in about five weeks. For inveterate cases, light applications of the cautery have served as a useful adjunct to other treatment. References. i. Amer. Journ. Med. Sci , Jan., 1892. 2. Ibid. 3. Revue de Laryngol., 1890, p. 521 4. Archiv. Internal, de Laryngol., vol. v., No. 1. 5. Annal. de Polycl. de Paris, 1890, p. 109. 6. Berl. klin. Wochenschr., 1891, No. 13. 7. Revue de Laryngol., 1891, p. 171. 8. Ibid., p. 710. 9. Medical Chronicle, 1887. 131 West Sixty-first Street. 2 The Medical News. Established in 1847. A WEEKLY MEDICAL NEWSPAPER. Subscription, $7 00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. CO MM VTA TION RA TE, $7 jo PER ANNUM. LEA BROTHERS &- CO. PHILADELPHIA.