Ulceration is at times met with do the lips and the gums, or the inside of the cheek ; in which situation aphthaa are less com mon. On the gums it is important to distinguish simple ulcera tion from that which is produced by mercury ; the correspondence of ulcers on the lips and cheeks would tend to prove that its origin was not of this specific character. One form of ulceration of the cheek is seen in childhood, which in its milder form may be called sloughing ulcer, in its more severe form has obtained the name of cancrum oris. It is characterized by foul, unhealthy secretion, and rapid tendency to spread ; in the worst cases de stroying the cheek and side of the face, and, in all, producing a large unhealthy sore. There is no doubt that this, too, is consti tutional.
§ 2. At the Entrance of the Fauces.—The morbid appearances which present themselves in this locality are those indicating inflammatory and ulcerative action : the redness and swelling occur under two very distinct forms—the acute and the chronic.
a. With some febrile disturbance, which rarely runs very high, we have general redness and swelling of all the adjacent struc tures; sometimes involving the root of the tongue, and not unfre quently the submaxillary region, accompanied by great difficulty of swallowing, especially when liquids are taken, nothing. perhaps, causing greater pain than the patient's own saliva, which for this reason he commonly spits out ; the tongue is much coated, and acquires after a time a sodden buff-leather aspect. When we can get a view of the throat, its aperture seems encroached on from all sides, and the uvula is long and large ; the mucous membrane is remarkably red and injected. These circumstances are quite sufficient to characterize quinsy : its course is usually rapid, end ing in a few days by suppuration, and occasionally by resolution. The liability to its recurrence is so great that any history of a similar attack is of value in considering the probable termination of sore-throat in any given case.
The occurrence of sore-throat is so common, while in certain circumstances it is an indication of such importance, that a few words must be said on its general bearings as a symptom of disease. In its simplest form, as a result of exposure to cold, it is the same affection which in one portion of the mucous membrane causes coryza, in another catarrh : in the pharynx slight redness is seen on inspection, very little difficulty in swallowing is experienced, and the feeling of soreness soon subsides : there is from the first very little fever, and its severity is rather proportioned to the catarrhal symptoms than to those of sore-throat. A very different state of things exists when, instead of general irritation of the mucous membrane, inflammation attacks the larynx ; the sore ness of throat and difficulty of swallowing are very much more pronounced, pyrexia is distinct, and yet on inspection little redness is seen, and that red ness has a livid aspect. In scarlatina, again, the fever generally runs high ;
but the cause of the soreness is at once discovered on inspection, in very ex tensive redness, spots of aphthous or ulcerated appearance, or even sloughing; in milder cases its true character is exhibited by the appearance of the cuta neous eruption ; in severer cases, the existence of an epidemic coupled with the occurrence of intense fever, oonsiderable prostration, great lividity of the throat and ulceration, without much swelling, enable us to assign to them their true character, even when redness of skin does not exist, or has receded.
From all of these quinsy is distinguished by its local nature, by the swell ing which goes along with it, and by the fever being only in proportion to the local action going on. And although the name be commonly restricted to those cases in which matter forms, all are to be regarded as belonging to the same class, which present such symptoms, even if the inflammation end with out suppuration.
b. In the chronic form the same structures may be implicated in a leas degree, a general dusky redness prevailing vrith no great amount of swelling; or there may be chronic enlargement of the tonsils only, or a permanently elongated condition of the uvula, which are both by no means uncommon as sequehe of acute attacks. Not only do these appearances differ greatly from those presented by quinsy; but the history is also totally dissimilar; if there have been some aggravation of the symptoms within a few days, to which the attention of the patient is especially directed, still the evidence of old standing disease is not wanting if the case have been properly investigated.
R can scarcely be necessary to add a e.antion against being deceived by the absence of any appearance of active congestion. mto the belief that the sore throat is of old standing and of small moment, when fever is present: such an error would show entire ignorance of all right principles of diagnosis. En larged tonsils are very often the effect of the scrofulous taint, and occur in early life: symptoms of cough and dyspncea, by which attention is first called to the case. may lead to a suspicion of phthisis, from the want of evidence of any other affection by which they might be accounted for, till an inspection of the throat at once explains the mystery. An elongated uvula is similarly a cause of cough ; and both may tend to excite and keep up bronchial irritation to an unusual extent.