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.]
[Illustration: FIG. 13. Oïdium albicans, from the Mouth in a case of
Thrush (Küchenmeister). _a_, fragment of a separated thrush-layer
implanted in a mass of epithelium; _b_, spores; _d_, thallus-threads
with partition walls; _e_, free end of a thallus somewhat swollen; _f_,
thallus with constriction, without partition walls.]
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).