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.