Chapter XX: Front Matter (20)

Dwarfed permanent median upper incisors, broader at the top than at the cutting edge, which is crescentically notched, separated by an undue interval and converging toward each other.

Evidence of past or present interstitial keratitis--a dusky and thin sclerotic in the ciliary region and slight clouds here and there in the corneal substance, there being no scars on its surface--or of disseminated choroiditis; patches of absorption especially around the periphery.

{314} A radiating series of narrow cicatricial scars extending right across the mucous membrane of the lips, or a network of linear cicatrices on the upper lip and around the nostrils, as well as at the corners of the mouth and on the lower lip.

Periosteal nodes on one or many of the long bones; sudden, symmetrical, and complete deafness, without otorrhoea and unattended by pain or other subjective symptoms.[213]

[Footnote 213: In a few instances there has been noticed an arrest of sexual development; in one case of Hughlings Jackson's there was such an entire absence of all sexual characteristics that it was supposed that the ovaries had been destroyed by syphilitic inflammation in early life.]

Late or tardy hereditary syphilis is rarely dangerous to life. The prognosis is almost unvaryingly favorable unless some grave visceral complication, such as interstitial pneumonia, gummata of the brain, liver, or kidney, or meningeal and periosteal inflammation within the cranium, should occur.

TREATMENT.--The prophylactic treatment, or that directed to the health and sexual relations of the parents previous to conception, has already been sufficiently considered. That of the mother during pregnancy, after having conceived from a syphilitic husband, or having had antecedent syphilis, or having contracted it by direct contagion subsequent to impregnation, is simply that of acquired syphilis in either adult or child. Mercury in its full physiological dose is the drug indicated. It may not be amiss to combine with it iodide of potassium in moderate doses, but the practice of employing the latter to the exclusion of the former is both theoretically and clinically unsound. Care should especially be taken to give it in such a manner, either by inunction or vaporization or so guarded with opium, that it will not produce any irritating effect on the intestinal canal, the sympathy between which and the uterus may, in the event of a strong purgative action being set up, lead to an abortion.[214]

[Footnote 214: "In respect to prophylaxis as applied to infants, all chances of infection should be entirely removed whenever constitutional symptoms exist or the nature of the primary symptoms renders them probable. Our caution should be carried still farther, and in the absence of all appreciable symptoms we should assure ourselves by the antecedents, so far as possible, that the parents are not under the influence of a syphilitic diathesis; in which case they may give birth to infected infants until appropriate treatment shields the latter from infection. With still stronger reasons, when the mother during pregnancy is affected with primary syphilitic symptoms of such a character as to give rise to secondary symptoms, or if the latter already exist, we should hasten to cope with them, and, far from regarding pregnancy as a contra-indication to treatment, should recollect that it generally prevents the disease in the infant, and when skilfully administered obviates the frequent abortions which syphilis excites. When primary symptoms have been contracted by the mother a short time before delivery, since the infant may be infected in its passage into the world, the same course should be followed with it as with a person who has just exposed himself to an impure connection" (Ricord, note on prophylaxis of venereal disease appended to his edition of John Hunter's _Treatise on Venereal_, Philada., 1853, p. 481).]

As we have seen that the pathology, the stages, and the general course of hereditary syphilis are all closely related to or identical with the same phenomena in the acquired disease, and so know that they both depend upon the same ultimate cause, whatever that may be--a virus, a fungus, or a degraded cell--it follows that the same principles should govern us in the treatment of the one as in that of the other.

We know from clinical experience that mercury exercises an almost {315} controlling influence over the secondary manifestations of acquired syphilis, whether by acting as a true antidote or as a tonic, or by virtue of its property of hastening destructive metamorphosis and thereby facilitating the absorption or elimination of new cell-growths. We know also that iodide of potassium, probably by virtue of its powerful stimulating influence on the lymphatic system, has an equal power over the tertiary growths, which by their pressure upon or situation in important tissues or organs may be so destructive. There is no reason, therefore, by analogy why these drugs should not, comparatively speaking, be equally beneficial in hereditary syphilis; and such is, indeed, found to be the case. In the latter affection, however, there are two elements which should modify the treatment somewhat, and must be taken into consideration. These are--1st. The existence of a more or less profound cachexia influencing all the nutritive and formative processes, and in itself, entirely apart from any definite specific involvement of vital organs, threatening life. 2d. The not infrequent occurrence during the secondary period of symptoms--notably gummata--belonging to the tertiary stage.

The first indication is met by making the treatment from first to last not only antisyphilitic, but also supporting or even stimulating; and with this object in view especial attention should be paid to nutrition. It may be stated, axiomatically, that for every reason, whenever it is within the bounds of possibility, the nurse of a syphilitic child should be its mother. To her it is harmless--to every other woman, not already syphilized, it is in the highest degree dangerous. Space will not permit me here to discuss the medico-legal aspect of the interesting question as to relations between such children and the outside world, especially as represented in their nurses. It will suffice to say that it is criminal and legally punishable to induce any healthy woman to act as wet-nurse to a syphilitic child unless she does so with a full knowledge of the risks she runs in undertaking that function. In the rare cases where with such information she still consents to suckle the child a written statement of the facts of the case should be signed by her, with the proper legal formalities, for the protection of the physician and the family.

If the mother has died or on account of ill-health is unable to nurse her child, and if no wet-nurse willing to enter the above agreement can be obtained, the possibility and propriety of obtaining one who has already had syphilis must next be considered. This idea to many parents seems revolting, but will naturally be less so to those who have themselves had the disease, and is, besides, so almost vitally important to the child that no hesitation should be felt about making the suggestion. If it is accepted, and if there is any opportunity for making a selection, it may be said that the more robust the present condition of such a nurse, and the more remote the date of her syphilis, the better will be the chances of the child.

If neither mother nor wet-nurse can be had to suckle the child, it must be fed by cow's, goat's, or ass's milk or by artificial alimentation; but its prospect of life will be greatly, immeasurably, reduced. In addition to careful feeding a little careful tonic treatment should from the first be employed in conjunction with the specific remedies, iodide of iron, cod-liver oil, and preparations of the phosphates being the most useful drugs.

The existence of the second condition, which, as I have stated, exercises a modifying influence upon treatment--the early appearance of tertiary {316} symptoms--is probably due in many cases at least to an overwhelming of the lymphatic system by the new cell-growth, which not only greatly increases the amount of material to be transported by the lymphatics, but at the same time, by invading their walls and diminishing their lumen, greatly cripples them. Accumulations of nutritive matter and of these new cells then take place, forming the characteristic new growths or deposits which we call gummata. This leads us to combine with the mercury from the beginning, at least in all cases where bony or periosteal involvement, suppuration, or the existence of gummata points to this condition, small doses of iodide of potassium or of some other soluble and easily decomposed iodine salt.

The principle of treatment being thus recognized, the routine procedure may be thus described: Give mercury as soon as the diagnosis of syphilis is assured--preferably by inunction. Sir Benjamin Brodie's opinion, expressed many years ago, still represents that of the profession:[215] "I have tried different ways of treating such cases. I have given the child gray powder internally and given mercury to the wet-nurse. But mercury exhibited to a child by the mouth generally gripes and purges, seldom doing any good, and given to the wet-nurse it does not answer very well, and certainly is a very cruel practice.[216] The mode in which I have treated cases for some years past has been this: I have spread mercurial ointment, made in the proportion of a drachm to an ounce, over a flannel roller and bound it around the child once a day. The child kicks about, and, the cuticle being thin, the mercury is absorbed. It does not either gripe or purge, nor does it make the gums sore, but it cures the disease. I have adopted this practice in a great many cases with signal success. Very few children recover in whom mercury is given internally, but I have not seen a case where this method of treatment has failed."

[Footnote 215: _Clinical Lectures on Surgery_, Philada., 1846, p. 230.]

[Footnote 216: This, the so-called indirect method, is altogether unreliable, and should only be employed as a forlorn hope in those cases where in every other way mercury sets up gastro-intestinal irritation.]

When, for any reason, as irritation of the skin, this cannot be employed, probably the best form of giving mercury by the mouth is in the following formula:

Rx. Hydrarg. cum Creta, gr. j to vj.
Sacch. alb. gr. xij.
In M. ft. chart No. xij.

S. One powder three times a day, to be taken soon after nursing.

Iodide of potassium may be given separately in a syrupy solution in doses of a half-grain to a grain, or if there are any marked tertiary symptoms even in much larger doses, three or four times daily.[217] {317} Treatment should, of course, be continued long after the disappearance of syphilitic symptoms, and it would probably be well to continue the mixed treatment intermittently until after puberty.

[Footnote 217: Wm. Campbell of Edinburgh was in the habit of commencing with doses of a quarter of a grain of calomel and two grains of creta præparata, once daily for the first ten days. He afterward progressively increased the calomel to a quarter of a grain twice each day. Sir John Rose Cormack says (_Clinical Studies_, vol. ii. pp. 423, 424, London, 1876) that an infant six weeks old will generally bear these doses well. In cases where they do not, he was in the habit of ordering a solution of half a grain of the bichloride in three ounces of distilled water and one ounce of syrup--one to two teaspoonfuls every six, eight, or twelve hours. When he used mercurial "swabbing" he employed from one to four drachms of unguent, hydrargyri to the ounce of lard. He alternated this treatment with short courses of the syrup of the iodide of iron, and continued the treatment up to the period of dentition. He says he has generally obtained excellent results by these methods.]

With the treatment of special symptoms the general practitioner has little concern. The cases of visceral syphilis in very young children are generally fatal. Those that recover do so in response to the active use of the above remedies. Later, the prognosis is more favorable, the treatment the same. Of course moist eruptions should be dusted with some astringent or absorbent powder; mucous patches should be cauterized; and great attention should be paid to avoidance of sources of cutaneous irritation--frequent changing of diapers, etc.--but the general methods are the same as in the adult.

{319}

DISEASES OF THE DIGESTIVE SYSTEM.

DISEASES OF THE MOUTH AND TONGUE.
DISEASES OF THE TONSILS.
DISEASES OF THE PHARYNX.
DISEASES OF THE OESOPHAGUS.
FUNCTIONAL AND INFLAMMATORY DISEASES OF THE STOMACH.
SIMPLE ULCER OF THE STOMACH.
CANCER OF THE STOMACH.
HEMORRHAGE FROM THE STOMACH.
DILATATION OF THE STOMACH.
MINOR ORGANIC AFFECTIONS OF THE STOMACH.
INTESTINAL INDIGESTION.
CONSTIPATION.
ENTERALGIA (INTESTINAL COLIC).
ACUTE INTESTINAL CATARRH (DUODENITIS, JEJUNITIS, ILEITIS, COLITIS,
PROCTITIS).
CHRONIC INTESTINAL CATARRH.
CHOLERA MORBUS.
INTESTINAL AFFECTIONS OF CHILDREN IN HOT WEATHER.
PSEUDO-MEMBRANOUS ENTERITIS.
DYSENTERY.
TYPHLITIS, PERITYPHLITIS, AND PARATYPHLITIS.
INTESTINAL ULCER.
HEMORRHAGE OF THE BOWELS.
INTESTINAL OBSTRUCTION.
CANCER AND LARDACEOUS DEGENERATION OF THE INTESTINES.
DISEASES OF THE RECTUM AND ANUS.
INTESTINAL WORMS.
DISEASES OF THE LIVER.
DISEASES OF THE PANCREAS.
PERITONITIS.
DISEASES OF THE ABDOMINAL GLANDS (TABES MESENTERICA).

{321}

DISEASES OF THE MOUTH AND TONGUE.

BY J. SOLIS COHEN, M.D.

Stomatitis.

DEFINITION.--Inflammation of the interior of the mouth.

The term Stomatitis is used to designate inflammatory affections of the mucous membranes of the structures of the interior of the mouth, including thus the mucous membrane of the lips, gums, tongue, cheek, palate, and anatomical adnexes. Inflammatory affections of the mucous membrane of the palate, palatine folds, and tonsils are usually described more particularly under the heads of angina, sore throat, and tonsillitis.

Stomatitis occurs idiopathically, deuteropathically, and traumatically.

Several varieties of stomatitis occur, sufficiently characteristic to require separate description: viz. erythematous or catarrhal, aphthous or vesicular, folliculous or glandular, pseudo-membranous or diphtheritic, ulcerous, gangrenous, cryptogamous or parasitic, and toxic.

Stomatitis Catarrhalis.

Simple, superficial, erythematous, or catarrhal stomatitis; pultaceous stomatitis.

DEFINITION.--A simple inflammation or erythema, general or partial, of the mucous membrane of the interior of the mouth.

It occurs both in adults and in children, and may be primary or secondary, acute or chronic. In adults and adolescents it accompanies catarrhal and ulcerous affections of the throat, and is described, therefore, to a certain extent, in connection with these affections.

SYNONYMS.--Ordinary or common diffuse Inflammation of the mouth; Erythema of the mouth; Oral catarrh.

ETIOLOGY.--In many cases of catarrhal stomatitis, both in adults and in children, the affection is of obscure origin and the cause eludes detection. In the great majority of instances the cause lies in some irritation of the alimentary tract, whether local or at a distance.

The local causes, which are by far the more frequent, include every variety of topical irritation to which the oral mucous membrane is in itself liable or to which it may be subjected. Thus, irritating foreign substances taken into the mouth; unduly heated, unduly iced, or unduly spiced food and drink; the excessive use or abuse of tobacco and of stimulants; contact of acrid and corrosive acid and alkaline mixtures; {322} the constitutional action of certain medicines, particularly mercury, but likewise bromine, iodine, arsenic, antimony, and, to a slighter extent, other medicinal substances also; inspiration of irritating dust, gases, vapors, steam, and smoke; even hare-lip, cleft palate, and congenital or acquired deformities of the mouth generally,--may all be included in this category.

In the newly-born a special hyperæmia of the mucous membrane has been cited (Billard) as the cause.

Morbid dentition is the most frequent local cause of catarrhal stomatitis in children, but it is an occasional cause in adults likewise. Hence it is frequent from the sixth to the thirtieth month of life; again, between the ages of six and fifteen years, the period of second dentition; and likewise between the eighteenth and twenty-second years, the period for the eruption of the last molars. Deformed, carious, and broken teeth, improper dentistry, wounds and ulcerations of the gums, negligence in cleansing the teeth,--all these contribute their quota as exciting causes. Nurslings occasionally contract the affection from the sore nipples of their nurses. In some instances they acquire it by protracted sucking at an exhausted breast. Protracted crying, from whatever cause, sometimes induces catarrhal stomatitis, not only in nursing children, but in older ones. Prolonged or too frequent use of the voice, whether in talking, reading, singing, or shouting, may be the exciting cause.

Distant irritations of the alimentary tract, exciting catarrhal stomatitis, include stomachic and intestinal derangements of all sorts. Poor food and lack of hygiene on the one hand, and over-feeding, excess of spices, alcohol, and tobacco on the other, are not infrequent exciting causes. Undue excitement, excessive mental emotion, unrestrained passion, deranged menstruation, normal and abnormal pregnancy and lactation, sometimes incite the affection. Slight colds from cold feet or wet clothing give rise to catarrhal stomatitis. It likewise presents as an extension from coryza, sore throat, glossitis, tonsillitis, pharyngitis, and laryngitis.

Deuteropathic or secondary catarrhal stomatitis occurs in various febrile diseases, especially the acute exanthemata--measles, scarlet fever, small-pox; in syphilis, in pulmonary tuberculosis, and in long-continued chronic pneumonia.

Infantile stomatitis is most frequent between the ages of two and twelve months; the stomatitis of adolescents at the periods of dentition; and that of adults when local sources of irritation predominate.

SYMPTOMATOLOGY.--The symptoms in catarrhal stomatitis vary in severity with the intensity and extent of the inflammatory processes.

In the infant the subjective symptoms usually commence with restlessness, fretfulness, and crying. Unwillingness to nurse or inability to do so soon becomes manifest. The child may seize the nipple eagerly with a firm grasp of the lips, but at the first suction lets it drop away with a cry of pain and disappointment. The cause of the pain is made evident on inspection and palpation of the interior of the mouth. The parts are dry, glazed, hot, and tender. So hot is the mouth at times that its heat, conveyed to the nipple in suckling, is sometimes the first intimation of the existence of the malady. Similar conditions often prompt an older {323} child to refuse the teaspoon. This sensitiveness is observed in the tongue and on the inner surface of the cheeks. It increases during movements of the tongue and jaw. Deglutition becomes painful, especially when the food tendered is rather hot or rather cold. There is a grayish-white accumulation of partially detached epithelium on the tongue, sometimes in longitudinal strips, sometimes in a continuous layer. Should the stomatitis be due to dentition, the affected gums will be swollen, hot, and painful. There is usually an augmentation of the secretions in the mouth. Sometimes they flow from the mouth in great quantity, inflaming the lips. These secretions acquire an increased viscidity, so that they become adherent in clammy masses to the tongue, the gums, and the lips. Taste thus becomes impaired, while decomposition of these masses in sitû imparts fetor to the breath; the odor being especially pronounced when the child awakens from a night's sleep, the secretions having accumulated meanwhile more rapidly than they could be discharged. When the secretions of the mouth are not excessive there may be merely a faint mawkish odor to the breath, sweetish in some instances, sour in others. Loss of appetite is usual. Diarrhoea sometimes exists to a moderate degree, attended at times by gaseous distension of the intestines.

In severe cases dependent on morbid dentition swelling of the submaxillary glands and infiltration of the connective tissue may take place. More or less pyrexia becomes evident. In some instances convulsions supervene; either directly from cerebral hyperæmia, or in reflex manner from irritation of the sensitive gingival nerves.

In the adult impairment of taste is one of the earliest subjective symptoms. This symptom is usually accompanied or else closely followed by peculiar viscid and sticky sensations about the tongue, gums, and palate--sensations that excite vermicular motions of the lips and tongue to get rid of the foreign material by expectoration or by deglutition. The taste is usually a bitter one, and the viscid sensations are usually due to accumulations of desquamated epithelium upon the tongue and other structures. An unpleasant odor is sometimes exhaled, the result of decomposition of the excessive secretions.

In the chronic form of the affection, especially as it occurs in the adult, the alterations of taste, the saburral coatings of the tongue, and the fetor of the breath are more marked than in the acute form.

The mucus accumulating during sleep often awakens the patient in efforts at hawking and spitting to detach and expectorate it. These movements are occasionally so violent as to provoke emesis. The disagreeable odor from the mouth is almost continuous.

In uncomplicated cases there is no loss of appetite or impairment of digestion. The presence of these symptoms is presumptively indicative of gastric disease, usually ulcerous or carcinomatous.

The course of the disease varies according to the causes which have given rise to it. When these subside, the stomatitis soon ceases; when they are irremediable, the stomatitis remains incurable. No special period can be mentioned, therefore, for its duration. It terminates, when cured, in complete restoration of the parts to their normal condition. There are no special complications or sequelæ.

PATHOLOGY AND MORBID ANATOMY.--The hyperæmia of the {324} tissues, physiological during the entire process of dentition, is readily provoked into a pathological hyperæmia. Whatever the origin, however, acute catarrhal stomatitis begins, usually, with congestion and tumefaction of the oral mucous membrane. The congestion is sometimes preceded by pallor, as though anæmia from constriction of the capillaries were the initial step in the phenomena. The congestion and swelling are more rarely diffuse than circumscribed; _i.e._ confined to certain portions of the tissues, especially the gums, which become swollen and painful to contact. The surface is dry and glistening, and the secretion diminished. The mucous membrane is raised in patches here and there where the submucous tissues are the most lax. These patches, irregular in size and configuration, are seen on the tips and edges of the tongue, on the inner surface of the cheeks, at the gingival junctions of the jaws, around the dental margins of the gums, about the angle of the mouth, and on the palate. Sometimes the patches coalesce--to such an extent in rare instances as to cover the entire mucous membrane even of the palate and the gums. Their margins are bright red, their centres yellowish. These elevated patches are due to local accumulation of new-formed cellular elements, perhaps determined by the distribution of capillaries or lymphatics. Intensification of the inflammatory process around or upon them, giving rise to a more abundant cell-proliferation, sometimes occurs; the results presenting macroscopically in ridges or welts of a vivid red, surrounding the patches or traversing them.

The tongue undergoes engorgement, and becomes increased in bulk; exhibiting dentated facets along its edges and around its tip, due to the pressure sustained from the adjoining teeth. Opposite the lines of junction of the two rows of teeth the impression is double. The dividing lines separating the facets project a little, and are opalescent, grayish, or whitish, owing to increased proliferation of epithelium. Similar dentate impressions from a like cause may be seen on the inner surfaces of the cheeks.

The hyperæmia of the parts is soon followed by excessive production of new cellular elements, rendering the now increased secretions turbid; so that the surfaces of the tongue and cheeks become moist again, and covered with a grayish-white, pultaceous form of desquamated epithelium, but slightly adherent, and therefore readily detached by movements of the tongue, lips, and cheeks. In some instances the epithelium becomes raised into minute vesicles, and chiefly on the edges of the tongue, thus presenting a sort of lingual herpes. Excoriations, and even shallow ulcerations, may follow.

Isolated lesions occur. There may be congestion of the palate without tumefaction, its epithelium undergoing detachment in shreds. The congested patches at the dental margins of the gums may become overlaid by opalescent masses of desquamated epithelium, followed by their actual ulceration, and even by detachment of the teeth.

In children the lips may be swollen and excoriated or surrounded by an eruption of herpes. Profuse salivation may occur in a child a few months old when the affection becomes protracted. Febrile movement is rare before the fifth or sixth month.

In chronic stomatitis the tumefaction is usually greater, with distension of the capillaries and hypertrophy of some of the mucous follicles, {325} especially those upon the cheeks and palate. There is also hypertrophy of the lingual papillæ, especially those at the tip of the tongue. Adherent to the gums and the tongue is a yellowish tenacious mucus, composed of squamous epithelia, fat-globules, bacteria, and the usual débris of disorganization. The saliva is secreted in unusual quantities, and sometimes dribbles more or less continuously.

DIAGNOSIS.--Recognition of the conditions described under the head of Pathology and Morbid Anatomy, in the presence of the symptoms described under Symptomatology, renders the diagnosis easy.

Chronic stomatitis may be mistaken for mere indication of gastric catarrh, which is likewise attended with loss of appetite, fetor of breath, and coating of the tongue.

PROGNOSIS.--The prognosis is favorable in almost every instance, recovery being almost universal in the acute form. Stomatitis of dentition subsides with the physiological completion of that process; stomatitis of exanthematic origin ceases with the evolution of the eruptive disorder. In the chronic form ultimate recovery will depend upon the permanency of the existing cause and the extent of the inflammatory new formations.

TREATMENT.--The first indication, as a matter of course, is to obviate the cause, whatever that may be. This, when practicable, usually suffices to bring the malady promptly to a favorable termination.

Intestinal disturbances, whether causative or incidental, must be duly corrected, and the administration of a saline purge is almost always desirable. In addition, resort is made to frequent ablutions with fresh water, warm or tepid, in sprays, gargles, or washes, as may be most convenient or practicable. Emollients (gum-water, barley-water, quinceseed-water), astringents (alum, tannin), and detergents (borax, sodium bicarbonate), may be added, with opiates to relieve pain if need be.

Frequent or continuous suction of fragments of ice usually affords prompt relief to local pain and heat. The anæsthetic properties of salicylic acid have been utilized,[1] one part to two hundred and fifty of water containing sufficient alcohol for its solution.

[Footnote 1: Berthold, cited by Ringer, _Handbook of Therapeutics_, 10th ed., London, 1883, p. 612.]

Aphthous Stomatitis.

DEFINITION.--Inflammation of the mucous membrane of the interior of the mouth, characterized by small superficial ulcers. These ulcers are irregularly circular or oval, are not depressed below the general surface of the mucous membrane, and support a creamy sebum or exudation. They occupy positions known to be normally supplied with mucous glands.

The classical description of this affection includes the initial eruption of vesicles or groups of vesicles which rupture within a day or two of their appearance, leaving, upon discharge of their contents, the little superficial characteristic ulcers. Modern investigation, however, casts some doubt upon the vesicular character of the initial lesion, and renders it extremely probable that the reiterated expression of this opinion has {326} been a simple deference by writer after writer to the descriptions given by his predecessors. This subject will receive further elucidation more appropriately in describing the pathology and morbid anatomy of the disease.

Aphthous stomatitis may be either idiopathic or symptomatic, discrete or confluent. It is often recurrent, and is sometimes epidemic.

SYNONYMS.--Aphthæ; Vesicular stomatitis; Follicular stomatitis (Billard); Canker sore mouth.

ETIOLOGY.--Aphthous stomatitis occurs at all ages, and is most prevalent during summer heat. In children it is most frequent from the period of the commencement of dentition to the completion of the eruption of the temporary teeth. It is infrequent during the fourth year of life, and is rare after the fifth. It is most apt to appear in pale, delicate, and scrofulous children, especially in such as are predisposed to catarrhal and cutaneous diseases (Billard, Barthez and Rilliet). Sometimes it seems to be hereditary (Barthez). Some individuals are subject to frequent recurrences. Poor food, insufficient clothing, want of due ventilation, lack of cleanliness, and similar deprivations act as predisposing causes. Hence the disease is apt to occur in the crowded wards of hospitals and asylums for children.

Anything that exhausts the physical forces of the adult, such as excessive heat, overwork, anxiety, hardship and privation as in shipwreck, and the drains of menstruation, pregnancy, and lactation, excessive sexual intercourse, etc., may predispose to the disease.

Long-continued debility from severe constitutional maladies, with chronic febrile conditions, such as chronic phthisis, chronic syphilis, chronic enteritis, chronic gastritis, and from diabetes and carcinoma, likewise acts as a predisposing cause, giving rise, during the final stages of the systemic disease, to symptomatic aphthæ, often of the confluent variety. Aphthous stomatitis sometimes accompanies certain of the continued fevers, exanthematous and non-exanthematous.

As exciting causes the following may be cited: gingivitis, from morbid dentition in children, and from neglect of the teeth, dental caries, and dental necrosis in adults; tobacco-smoking; the local contact of acrid substances in food or otherwise; acute gastro-intestinal disorder from improper or tainted food. Excessive humidity of the atmosphere is assigned as a prominent exciting cause of the disease in some countries. This is especially the case in Holland, where it often exists epidemically. The confluent form at these times is said to attack parturient women principally (Ketslaer). Inundations, not only in Holland, but in Hayti, Porto Rico, and in the United States, are sometimes followed by an endemic of aphthous stomatitis. It is believed that the emanations from decayed animal and vegetable matters left ashore on the reflux of the water, produce the morbid conditions which constitute the predisposing cause under such circumstances.

The use of certain drugs--preparations of antimony, for example--sometimes produces a vesicular stomatitis sufficiently analogous to aphthæ to be mentioned in this connection, and only to be distinguished therefrom by the history of the case.

PATHOLOGY AND MORBID ANATOMY.--As has been intimated, the morbid anatomy of aphthæ has long been described as a series of initial {327} vesicles[2] upon the buccal, labial, gingival, or lingual mucous membrane. Their variance from analogous cutaneous vesicles--herpes, for instance--is attributed to anatomical differences in the constitution of the mucous membrane and the skin. The rarity of their detection has been accounted for by the rapid maceration of the epithelium.

[Footnote 2: Tardieu, Hardy and Behier, Barthez and Rilliet, Meigs and Pepper, and many others.]

The general opinion at present, however, is that the apparent vesicle is an inflamed mucous follicle.[3] Some observers contend that it is an inflammation of the mucous membrane pure and simple (Taupin); others consider it an inflammation, sometimes in a follicle, sometimes in the mucous membrane (Grisolle); others, a fibrinous exudation in the uppermost layer of the mucous membrane (Henoch). Some have described it as the analogue of a miliary eruption (Van Swieten, Sauvage, Willan and Bateman); others, of herpes (Gubler, Simonet, Hardy and Behier); others, of ecthyma (Trousseau) and of acne (Worms).

[Footnote 3: Bichat, Callisen and Plenck, Billard, Worms, and others.]

The vesicle of the primary stage, though generally vouched for, is rarely seen by the practitioner, so rapid is the metamorphosis into the aphthous ulcer. Its very existence is positively denied by several authorities (Vogel, Henoch), and Vogel states that he has never, even upon the most careful examination, discovered a real vesicle upon the mucous membrane of the mouth--one which, upon puncture, discharged thin fluid contents and then collapsed.

Beginning in a few instances, only, in a simple stomatitis, the initial anatomical lesion presents as a red, hemispherical elevation of epithelium one to two millimeters in diameter, and barely perceptible to the touch of the finger, though described by the patient as positively appreciable to the touch of the tongue. Believed to have been transparent or semi-transparent at first, its summit is usually opaque when first seen by the medical attendant, appearing as a little white papule. Billard describes a central dark spot or depression--the orifice of the duct of the inflamed follicle, as he considers it. Worms and others, however, who likewise attribute the little tumor to an inflamed follicle, have failed to recognize any such central depression. There may be but four or five of these papules; rarely are there more than twenty. Diffuse inflammation between them is rare. A few new papules are seen on the second day, perhaps a few fresh ones on the third day. Eventually, contiguous desquamations coalesce into an irregular excoriated or ulcerated surface. These appearances and processes may be summed up as hyperæmia, increased cell-proliferation into circumscribed portions of the mucous structures, with distension of the epithelium (dropsical degeneration?), rupture, and ulceration.

This is the stage at which the local lesion usually comes under professional notice as a superficial circular or ovoidal ulceration or patch, with irregularly rounded edges and an undermined border of shreddy epithelium. It is level with the surface or but slightly tumefied, and is usually surrounded by an inflammatory areola that gives it a slightly excavated aspect. Sometimes this is a narrow red rim, and sometimes it is a delicate radiating arborescence of several millimeters. Adjacent ulcerations coalesce and produce irregularly elongated losses of substance. The floor {328} of the ulcer is covered with an adherent semi-opaque or opaque lardaceous mass, sometimes grayish-white, sometimes creamy or yellowish-white when unadmixed with other matters; the color depending more or less upon the number of oil-globules present, the result of fatty degeneration of the epithelium.

For a few days, three to five or more, the surface of the ulcer increases slightly by detachment of its ragged edges, eventually leaving a clean-cut sore, gradually reddening in color, with an inflammatory margin indicative of the reparative process. Repair steadily progresses by the reproduction of healthy epithelium from periphery to centre, so that within a day or two the size of the ulcer becomes diminished to that of a pinhead; and this is promptly covered over, leaving a red spot to mark its site, until, in a few days more, the color fades in its turn, and no trace of the lesion remains. The period of ulceration is prolonged to one or more weeks in some subjects, chiefly those of depraved constitution.

It was the uniform configuration of the initial lesions, their invariable seat, and the central depression which he detected, that led Billard to the opinion that the so-called eruption or vesicle was an inflamed mucous follicle. This view was further supported by the fact that the disease does not occur in the new-born subject, in whom the lymphatic glands and follicles of the digestive tract are barely developed, while it does occur after the fifth or sixth month of life, up to which time these structures are growing rapidly, and thus predisposing the infant to this peculiar disease by reason of the physiological nutritive hyperæmia.

Discrete aphthæ are found principally in the sides of the frenum and on the tip and sides of the tongue; on the internal face of the lips, the lower lip particularly, near their junction with the gums; on the internal face of the cheeks, far back, near the ramus of the jaw; upon the sides of the gums, externally and internally; on the summit of the gums of edentulous children (Billard); exceptionally upon the soft palate; in rare instances upon the pharynx.

Confluent aphthæ appear in the same localities as are mentioned above, and are much more frequent in the pharynx and oesophagus than are discrete aphthæ. They are said to be found occasionally in the stomach and in the intestinal canal.

In the confluent form of the disease the aphthæ are much more numerous, and the individual ulcerations run into each other; coalescing into elongated ulcers, especially upon the lower lip and at the tip of the tongue.

SYMPTOMATOLOGY, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND SEQUELÆ.--The discrete form of the affection is rarely attended by constitutional disturbance of any gravity, and such disturbance, slight as it may be, is much more frequent in children than in adults. The local manifestation gradually wanes from periphery to centre in from eight to ten days, the patches changing in color from grayish to yellow, becoming translucent, and losing their red areola, until nothing but dark-red spots remain to mark their site. These spots fade in time, removing all trace of lesion.

Aphthous stomatitis of secondary origin attends conditions of serious constitutional disturbance--circumstances under which it is incidental and not causal.

The confluent form, unless exceedingly mild, is attended by symptoms {329} of gastric or intestinal derangement--viz. coated tongue, thirst, salivation, acid or acrid eructations, nausea, perhaps vomiting, indigestion, and constipation or diarrhoea, as may be. The vomiting in these instances is usually attributed to the presence of aphthæ in the oesophagus and stomach, and the diarrhoea to their presence in the intestines.

Severer cases present, in addition, febrile phenomena, restlessness, loss of appetite, and unhealthy fecal discharges.

The constitutional symptoms precede the local manifestations in some instances by a number of days.

Confluent epidemic aphthous stomatitis, as it occurs in parturient women, is described (Guersant) as commencing with rigors, headache, and fever. The local symptoms are very severe. Pustules form upon the palate and pharynx. Deglutition becomes painful and difficult. Vomiting and painful diarrhoea occur, indicating extension of the disease to the stomach and the intestines. Typhoid conditions may supervene, and continue as long as three weeks, even terminating fatally.

The earliest local symptoms consist in some degree of discomfort and heat, to which severe smarting becomes added at the period of ulceration. The little sores, no matter how minute they may be, are exceedingly painful to the touch, even to the contact of the tongue. Mastication thus becomes painful, and even impracticable, in the adult; and suction at the breast or the bottle difficult and painful in the infant. The mouth of the infant is so hot that its heat is imparted to the nipple of the nurse, whose sensations in nursing sometimes furnish the earliest indication of the disease. Indeed, the heat of the child's mouth at this time, and the acridity of the buccal secretions, are often sufficient to irritate and inflame the nipple, and even to produce superficial excoriation. The general mucous secretions of the mouth are usually augmented. Hypersalivation is much less frequent.

The course of the disease is mild as a rule. The chief inconvenience is the difficulty in alimentation consequent on the pain in mastication and in swallowing.

The duration of the affection in idiopathic cases varies, as the rule, from four to seven days, counting from the first appearance of the local lesion to the complete repair of the succeeding ulceration. Individual cases are often more protracted. Successive crops of aphthæ may prolong the disease for many days. In confluent aphthæ the course is slower and the disease less amenable to treatment; ulceration often continuing longer than a week, and recovery requiring twelve or fifteen days. The duration in consecutive cases varies with the nature of the underlying malady. In individuals seriously debilitated by protracted constitutional disease, as in the subjects of phthisis, the affection may continue, with intermissions and exacerbations, as long as the patient lives. The termination of the individual ulcerations is in repair.

There are no special complications. The accompanying stomatitis is usually a gingivitis simply, and is apt to be circumscribed when more extensive.

There are no sequelæ. Sometimes labial herpes or similar ulcerations follow, which are likewise sore and painful.

DIAGNOSIS.--The isolated patches of the discrete form are usually sufficiently characteristic to establish the diagnosis.

{330} In children the gums are usually seen to be congested, swollen, moist, and glistening. Sometimes they are even sanious. This condition is deemed of great importance in cases of small, solitary aphthæ concealed in the sinus between gums and lips (Rilliet).

Confluent aphthæ may be mistaken for ulcerative or ulcero-membranous stomatitis, especially when the emanations from a coated tongue exhale a disagreeable or fetorous odor.

From thrush--with which it is most frequently confounded--it is to be discriminated by the absence, upon naked-eye inspection, of the peculiar curdy-like exudations to be described under the appropriate section, and under microscopic inspection by the lack of the peculiar thrush-fungus (Oïdium albicans).

PROGNOSIS.--Recovery is usually prompt in discrete cases, but relapses are not infrequent. In confluent cases recovery is dependent upon the character of the constitutional disorder by which the local disease has been caused or with which it is associated, and is therefore much slower.

The disease is grave in certain epidemic confluent forms, such as are described as occurring in Holland and elsewhere under conditions alluded to. Parturient women under such circumstances occasionally succumb to the typhoid condition into which they are thrown. When following measles there is some danger of laryngitis, and the case becomes grave. Oedema of the larynx is sometimes produced.

TREATMENT.--Very simple treatment suffices in the discrete form of the disease. A mild antacid, or even an emetic, may be indicated when there is gastric derangement or disturbance; or a mild laxative when the patient is costive. Castor oil, rhubarb, or magnesia may be given, followed, if need be, by an astringent if diarrhoea should occur. A little opium may be administered if requisite. The diet should be quite simple and unirritating. Cold milk is often the very best diet, especially while the mouth remains quite sore.

Topical treatment in the milder cases may be limited to simple ablutions, by rinsing or by spray, with water, cold or tepid as may be most agreeable to the patient. A little opium may be added when the parts are painful or tender. In severer cases an antiseptic wash may be substituted, as the sodium sulphite or hyposulphite, thirty grains to the ounce, creasote-water, or the like.

Demulcent washes of elm, sassafras-pith, or flaxseed are often more soothing than simple water. Pellets of ice from time to time are quite refreshing and agreeable. Occasional topical use of borax or alum, applied several times a day by means of a hair pencil, soft cotton wad, or the like, is often useful, care being taken to touch the sores lightly, and not to rub them. If the course toward repair is retarded, the parts may be touched lightly with silver nitrate in stick or in strong solution (60 grains), or washed more freely, two or three times a day, with a weaker solution, five or ten grains to the ounce of distilled water. Cupric sulphate, ten grains to the ounce, zinc sulphate, twenty grains to the ounce, mercuric chloride, one grain to the ounce, or potassium chlorate, twenty grains to the ounce, may be used as local applications, repeated at intervals of four or five hours. Iodoform has been highly recommended of late.

{331} The confluent variety requires constitutional treatment adapted to the underlying malady. Nutritious diet is often demanded, together with tonics, such as iron and quinia, or even stimulants, wine or brandy. Topically, cauterization with silver nitrate is more apt to be indicated, and to be indicated more promptly than in the discrete form. Potassium chlorate in doses of one or more grains may often be given with advantage, at intervals of from four to two hours.

Stomatitis Parasitica.

DEFINITION.--An exudative inflammation of the interior of the mouth, due to the development upon the mucous membrane of a parasitic vegetable confervoid growth, the Oïdium albicans (Robin).

SYNONYMS.--Stomatitis cremosa; Stomatitis pseudo-membranosa; Thrush; Muguet of the French; Schwämmchen of the Germans.

HISTORY.--Thrush was long regarded as a pseudo-membranous variety of stomatitis, and was likewise confounded with other varieties of stomatitis, especially aphthæ, its differentiation from which will be rendered apparent by a study of its etiology and morbid anatomy.

The microscopic researches of Berg[4] of Stockholm upon the minute structure of the supposed pseudo-membrane developed the fact that it was largely composed of certain cryptogams. This growth was named Oïdium albicans by Prof. Ch. Robin,[5] by whom it had been subjected to minute study.

[Footnote 4: _Ueber die Schwämmchen bei Kindern_, 1842--Van der Busch's translation from the Swedish, Bremen, 1848.]

[Footnote 5: _Histoire naturelle des Végétaux parasites_, Paris, 1853.]

Later observers consider the oïdia in general simply transitional forms in the life-history of fungi otherwise classified. According to Grawitz, the O. albicans is a stage of the Mycoderma vini, his experiments having shown that on cultivation the filaments germinate like Torula and Mycoderma, and that the latter can be grown in the epithelium of the mucous membrane.[6]

[Footnote 6: Ziegler, _A Text-book of Pathological Anatomy and Pathogenesis_, translated by Macalister, vol. i. p. 319, London, 1883.]

ETIOLOGY.--Thrush is usually a symptomatic disease, secondary to an {332} acid condition of the fluids of the mouth. Athrepsia (Parrot, Meigs and Pepper), or innutrition, is the presumable predisposing cause. Negligence in maintaining cleanliness of the mouth and of the articles which are placed in it is regarded as the main exciting cause. It occurs both in the adult and in the infant, but it is much more frequent in infancy and in early childhood. It is most frequently encountered in asylums and hospitals for children, being often transmitted from child to child by the nurse or by means of the feeding-bottle. The poor health of the child seeming less accountable for the disease than the unsanitary condition of the wards, buildings, and surroundings, it is consequently much less frequent in private than in public practice. It is more frequent in the first two weeks of life than later. Seux observed it within the first eight days in 394 cases out of 402 (Simon). It is much more frequent during summer than at any other season, more than half the cases (Valleix) occurring at that portion of the year.

In senile subjects, in adults, and in children more than two years of age it is cachectic, and observed chiefly toward the close of some fatal and exhausting disease, such as diabetes, carcinoma, tuberculosis, chronic pneumonia, enteric fever, puerperal fever, erysipelas, chronic entero-colitis and recto-colitis, and pseudo-membranous sore throat. It is sometimes observed in the early stage of enteric fever.

Meigs and Pepper, apparently following Parrot, deem the central cause to lie in a certain failure of nutrition under which the general vitality slowly ebbs away. They are inclined[7] to recognize a causal factor in a deficiency in the supply of water in much of the artificial food administered to young subjects. The normal acidity of the fluids of the mouth of the newly-born (Guillot, Seux) is not sufficiently counteracted until saliva becomes abundant. Premature weaning, entailing, as it often does, the use of improper foods, renders the child liable to gastro-intestinal disorders. To this add want of care of the bottle and nipples, of the teaspoon or pap-boat, and of the mouth itself, and the conditions are fulfilled in fermentations of remnants of milk taking place without and within, which produce the acid condition of the fluids and secretions of the mouth said always to accompany and precede the development of the disease (Gubler).

[Footnote 7: _A Practical Treatise on the Diseases of Children_, 7th ed., Philada., 1882.]

The theory of contagiousness seems established (Guillot, Berg, Gubler, Robin, Trousseau). This has been further demonstrated by experiments upon sheep (Delafeud), in which thrush has been implanted whenever the animals were unhealthy, but not otherwise.

PATHOLOGY AND MORBID ANATOMY.--The mucous membrane of the mouth within a few hours after its invasion by thrush is seen to be covered to some extent by minute masses of a granular curdy substance adherent to the tissues, which often bleed slightly when the substance is forcibly removed.

In children much reduced by inanition or severe disease, much of the deposit soon coalesces into a membraniform product, grayish or yellowish from rarefaction by the air, or even brownish from admixture of blood. By the same time the general congestion of the mucous membrane will have subsided into the pallor of anæmia. Though tolerably adherent when fresh, the deposit when older often becomes loosened {333} spontaneously, so that it may be removed by the finger in large flakes without producing any hemorrhage whatever.

The characteristic masses present both as delicate roundish flakes, isolated, not larger than a pinhead, and as confluent patches several times as large and more irregular in outline. These masses under microscopic inspection are seen to be composed of the filaments and spores of a confervoid parasitic plant, the Oïdium albicans, enclosing altered epithelia in various conditions. This parasitic growth does not become developed upon healthy mucous membrane with normal secretory products. Acidity of the fluids and exuberance of epithelium are the requisites for its production, whatever be the cause. The acidity of the fluids irritates the mucous membrane upon which they lie. This irritation induces abnormal proliferation of epithelium, upon which the spores of the cryptogam then germinate. Dissociated epithelial cells become proliferated at the surface of the mucous membrane, between which and upon which both free and agglutinated spores accumulate. From these spores sprout out simple and ramified filaments in compartments containing moving granular elements. (For the minute detailed anatomy of these filaments and spores the reader is best referred to Robin's work on _Vegetable Parasites_.)

It may suffice here to mention that the filaments are sharply-defined tubercles, slightly amber-tinted, of a mean diameter of between four and three millimeters, simple while immature and branched when fully developed. These tubules are filled with link-like groups of elongated cells in compartments, giving them an appearance of regular constriction at the junctions of adjoining groups of cells. Surrounding these tubules are groups of spheroid or slightly ovoid spores from five to four millimeters in diameter. Each spore contains one or two granules and a quantity of fine dust. This cryptogamic growth is developed in the proliferated cells of epithelium. The filaments in their further growth separate the epithelia, and even penetrate them. Thence they penetrate the mucous membrane and the submucosa (Parrot).

The mucous membrane beneath the growth is red, smooth, and glistening. Papillæ are sometimes prominent. It is not excoriated unless the growth has been removed with some violence, when, as noted, it may bleed slightly. Duguet and Damaschino have recently encountered cases associated with a special ulceration of one of the palatine folds; the former in enteric fever, the latter in a primitive case. The growth is quickly reproduced after removal--even within a few minutes when the secretions are very acid.

The glossal mucous membrane is usually the tissue first involved, the specks being more numerous at the tip and edges of the tongue than at its central portion. The glands at the base of the tongue may become invaded. From the tongue extension takes place to the lips, the cheeks, the gums, and the palate, hard and soft. The growth is especially prolific in the folds between lips and gums and between cheeks and gums. Sometimes the parts mentioned become involved successively without actual extension. In several recently reported instances occurring during enteric fever,[8] the affection began on the soft palate, tonsils, and pharynx, and then progressed anteriorly toward the tongue, the cheeks, and the lips.

[Footnote 8: Duguet, _Soc. Méd. des. Hôp._, Mai 11, 1883; _Rev. mens._, Juin 1, 1883, p. 187.]

{334} But there is no limitation of the disease to these structures. The growth may cover the entire mucous membrane of the mouth. From the mouth it may reach the lateral walls of the pharynx, and in rare instances the posterior wall of the pharynx. The product is said to be more adherent on the pharynx (Reubold) than in the mouth. From the pharynx it may reach the epiglottis, and even the larynx (Lelut), in which organ it has been seen upon the vocal bands (Parrot). It has never been observed in the posterior nares or at the pharyngeal orifice of the Eustachian tube. It flourishes best, therefore, upon squamous epithelium. In infants much reduced, Parrot has seen ulceration in the neighborhood of the pterygoid apophyses, but attributable to the cachectic state of the child, and not to the disease in the mouth.

In many cases--in as large a proportion as two-thirds, according to some observers--the oesophagus becomes invaded, either in irregular longitudinal strips or in rings, in all instances (Simon) terminating a little above the cardia. In exceptional cases the entire mucous surface of the oesophagus may be covered with the product (Seux). It has been seen in the stomach (Lelut, Valleix), and is even said to be developed there (Parrot), presenting as little yellow projections, isolated or contiguous, from the size of millet-seeds to that of peas, and usually located along the curvatures, especially the smaller curvature and cardia (Simon).

In instances still more rare it is found in the intestinal canal (Seux), even at the anus (Bouchut, Robin), and thence upon the genitalia. In a child thirteen days old, Parrot found it in the pulmonary parenchyma at the summit of the right lung, where it had probably been drawn by efforts of inspiration.

The nipple of the nurse often becomes covered with the growth (Gubler, Robin, Trousseau, Simon).

SYMPTOMATOLOGY.--In infants the earliest symptom is distress during nursing, the nipple being seized repeatedly, and as frequently released with cries of pain and disappointment. This cry is hoarse when the vocal bands are involved.

The constitutional symptoms depend upon the underlying malady, and may of course vary with its character. Thus we may have the symptoms of simple diarrhoea, gastro-enteritis, or entero-colitis on the one hand, and of tuberculosis and other diseases elsewhere enumerated on the other. Cachectic children, especially in asylum and hospital practice, lose flesh, and their skins become harsh, dry, and inelastic from loss of fluids (Meigs and Pepper). The genitalia, the anus, and the adjacent parts become eroded by the acridity of the discharges, and then become covered with the growth.