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.
The disease rarely lasts longer than eight days in strong children that
can be well cared for. It may continue indefinitely, on the other hand,
in cachectic children; that is to say, for several months or until the
patient succumbs, as may be. Death occurs usually from the causal
disease, and not as a result of the morbid condition of the mouth.
DIAGNOSIS.--In the Infant.--Examination of its mouth to detect the
cause of the child's inability to nurse reveals congestion of the
mucous membrane, intense and often livid in severe cases. It is first
noticed at the extremity of the tongue. When the congestion is general
it is darkest in the tongue. This livid congestion may extend over the
entire {335} visible mucous membrane, save upon the hard palate, where
it is tightly adherent to the periosteum, and upon the gums, where it
is rendered tense by the approach of erupting teeth. The papillæ at the
tip and sides of the tongue are very prominent. Sometimes the organ is
quite dry, even sanious, while it is painful to the touch. The reaction
of the secretions of the mouth is acid instead of alkaline, and the
parts are hot and very sensitive.
Two or three days later the circular milky-white or curdy spots or
slightly prominent and irregularly-shaped flakes or patches may be seen
on the upper surface of the tongue toward the tip and inside the lips
and the cheeks, especially in the grooves connecting gums and lips and
gums and cheeks. The surrounding mucous membrane is unaltered in mild
cases, and there is no evidence of other local disorder or of any
constitutional involvement. In severe cases the entire mucous membrane
is dry and deeply congested.
The affection can be positively discriminated from all others by
microscopic examination of the deposit, which reveals the presence of
the cryptogam described.
TREATMENT.--In infants, artificial nourishment, whether with milk of
the lower animals or prepared food of whatever composition, should be
given up, if possible, and a wet-nurse be supplied. If this procedure
be impracticable, the least objectionable mode of preparation of cow's
milk should be employed (and this will vary with the practice of the
physician), and the utmost circumspection should be maintained in
securing the cleanliness of the vessels in which it is prepared, the
bottle from which it is given, and the nipple which is placed in the
child's mouth. Should the sugar and casein in the milk appear to keep
up the disease, weak soups may be substituted for the milk diet until
it has subsided. Weiderhofer advises artificial nourishment, by way of
a funnel inserted in the nasal passages, in case the child should
refuse to swallow. Deglutition is excited in a reflex manner when the
milk or other fluid reaches the pharynx.[9]
[Footnote 9: _Journ. de Méd. Bordeaux_, Juin 10, 1883.]
The local treatment should consist in careful removal of the patches
from time to time--say every two or three hours--with a moistened soft
rag. This must be done without roughness of manipulation. In addition
to this, the parts may be washed or painted every hour or so with an
alkaline solution for the purpose of neutralizing the acidity of the
fluids of the mouth. For this purpose borax is most generally used, in
the proportion of twenty grains to the ounce of water or the half ounce
of glycerin. Sodium bicarbonate or sodium salicylate may be substituted
for the sodium borate. The use of honey in connection with the drug is
calculated to promote acidity by fermentation of its glucose, and is
therefore, theoretically, contraindicated.
Adults may use washes, gargles, or sprays of solutions of sodium borate
or of sodium bicarbonate.
The constitutional treatment in each case must be adapted to the nature
of the underlying malady which has favored the local disease, with
resort in addition to the use of quinia, iron, wine, spirit, and
beef-essence. The hygienic surroundings should be made as sanitary as
possible.
{336} Stomatitis Ulcerosa.
DEFINITION.--Inflammation of the interior of the mouth, usually
unilateral, eventuating in multiple ulcerations of the mucous membrane.
SYNONYMS.--Fetid stomatitis, Phlegmonous stomatitis, Putrid sore mouth,
Stomacace, are synonymous terms for idiopathic ulcerous stomatitis.
Ulcero-membranous stomatitis, Mercurial stomatitis (Vogel), are
synonymous terms for the deuteropathic variety of the disease.
ETIOLOGY.--The principal predisposing cause of the disease is to be
found in ochlesis; the contaminating atmosphere of crowded dwellings
and apartments insufficiently ventilated; uncleanliness; insufficiency
of proper clothing; unhealthy food, and the like. It prevails
epidemically in crowded tenements, schools, prisons, asylums, and
hospitals; in garrisons and in camps; in transports and men-of-war. It
is often propagated by contagion, but whether by infection or actual
inoculation seems undetermined. Measles is an active predisposing
cause. Feeble individuals are the most liable to the disease. It occurs
at all ages. In civil life it is most frequent between the ages of four
and ten years. Sometimes more girls are affected than boys (Meigs), and
sometimes it is the more prevalent among boys (Squarrey). Autumn is the
season of greatest prevalence.
Carious teeth, fracture and necrosis of the jaw (Meigs), and protracted
catarrhal stomatitis are among the chief exciting causes. Irregular
dentition is sometimes the exciting cause; and this may occur at the
first and second dentition or at the period of eruption of the last
molars.
PATHOLOGY.--The anatomical lesion is the destructive inflammation of
portions of the mucous membrane of the mouth, leaving ulceration on
detachment of the eschars. It usually commences as a gingivitis. At two
periods of life--namely, from the fourth to the eighth year of life,
and from the eighteenth to the twenty-fifth year--it is apt to be
ulcero-membranous, a condition asserted to be altogether exceptional at
other periods (Chauffard).
A diffuse fibro-purulent infiltration of the lymph-spaces of the mucosa
is regarded as the first step in the pathological process. This
infiltration is sufficiently abundant to compress the capillary vessels
of the tissues, and thus arrest the circulation (Cornil et Ranvier).
All those localized portions of mucous membrane from which the
circulation is cut off perish and are discharged in fragments. The
ulcers thus left are grayish, granular, and sanious, with thin,
irregularly dentated borders a little undermined, through which pus can
be expressed on pressure. The usual cryptogams of the oral cavity, in
various stages of development, are in great abundance in the grayish
detritus, which likewise contains altered red and white
blood-corpuscles.
According to some observers (Caffort, Bergeron), the first evidence of
the disease is an intensely congested erythematous patch, upon which
one or more pustules present, point, and rupture promptly, leaving the
characteristic ulcerations.
For some indeterminate reason, the ulcerations are mostly unilateral,
and occur much the more frequently on the left side. The principal
{337} primal points of ulceration are upon the external borders of the
gums, more frequently those of the lower jaw, and upon the
corresponding surface of the cheek and lip--the cheek much oftener than
the lip. Thence ulceration may extend to the tongue, less frequently to
the palate. The ulcerative process follows the outline of the gums,
baring the bases of the teeth to a variable extent, so that they seem
elongated. On the cheek the patch of inflammation is generally oval,
the longest diameter being antero-posterior, and the most frequent
position is opposite to the last molar.
Each ulcer is surrounded by an intensely red areola, beyond which the
tissues are succulent and tumid from collateral inflammatory oedema,
often giving the ulcers an appearance of great depth; but when the
detritus is discharged they are seen to have been superficial.
Detachment of the necrosed segments of mucous membrane takes place by
gradual exfoliation from periphery to centre. Sometimes detachment
occurs in mass, usually in consequence of friction or suction. The
ulcers, gingival and buccal, bleed easily when disturbed. They may
remain separate, or may coalesce by confluence of interposing
ulcerations extending across the furrow between gum and cheek or lip.
The adjoining side of the tongue sometimes undergoes similar ulceration
from behind forward, inoculated, most likely, by contact with adjoining
ulceration. In rare instances, neglected cases most probably, the
ulceration may extend to the palatine folds, the tonsils, and the soft
palate.
SYMPTOMATOLOGY.--The affection usually begins without any
constitutional symptoms. Young infants sometimes present slight febrile
symptoms, with impairment of appetite and general languor. Fetid
breath, salivation, and difficulty in deglutition are usually the first
manifestations of the disease to attract attention. The mouth will be
found to be hot, painful, and sensitive to the contact of food. Infants
often refuse food altogether, though usually they can be coaxed to take
liquid aliment. Larger children and adults complain of scalding
sensations. They find mastication painful, and cannot chew at all on
the affected side. The salivation is excessive, the saliva bloody and
often extremely fetid. When swallowed, this fetid saliva causes
diarrhoea. The cheeks sometimes become swollen, and the submaxillary
connective tissue oedematous. Adenitis takes place in the submaxillary,
retro-maxillary, and sublingual glands of the affected side. Sometimes
the other side becomes affected likewise, but to a less extent. The
glands do not suppurate, but the adenitis may remain as a chronic
manifestation in scrofulous subjects.
The disease, left to itself, will often continue for a number of weeks,
or even months as may be, unmodified even by intercurrent maladies
(Bergeron). Long continuance may result in partial or complete
disruption of the teeth, or in local gangrene, or even in necrosis of
the alveoli (Damaschino). Properly managed, the ulcers become cleansed
of their detritus, and within a few days heal by granulation, their
position long remaining marked by delicate red cicatrices upon a hard
and thickened substratum. Repeated recurrences are sometimes observed.
DIAGNOSIS.--The appearances of the gums and adjoining structures
described under the head of Pathology establish the diagnosis. The
usually unilateral manifestation and the peculiar fetid odor
distinguish it from severe forms of catarrhal stomatitis. From cancrum
oris it is {338} distinguished by the absence of induration of the skin
of the cheek over the swollen membrane, and by the succulence and
diffuseness of the tumefaction. From mercurial stomatitis it is
discriminated by the history, and by the absence of the peculiar
manifestations to be discussed under the head of that disease.
PROGNOSIS.--The prognosis is good, the disease being susceptible of
cure in from eight to ten days in ordinary cases. When due nutrition is
prevented by the pain in mastication and deglutition, and in
much-reduced subjects, the disease may continue for several weeks. It
is in these cases that detachment of the teeth takes place, with
periostitis and necrosis of the alveoli. Protracted suppuration and
failure in nutrition may lead to a fatal result, but such a termination
is uncommon.
TREATMENT.--Fresh air, unirritating and easily digestible food, the
best hygienic surroundings practicable, attention to secretions from
skin and bowels by moderate and judicious use of ablutions,
diaphoretics, and laxatives, with the internal administration of
cinchona or its derivatives, with iron and cod-liver oil, comprise the
indications for constitutional treatment.
Locally, demulcent mouth-washes are called for, containing astringents,
detergents, or antiseptics. Acidulated washes are more agreeable in
some instances. For antiseptic purposes, however, sprays and douches
may be used of solutions of potassium permanganate, boric acid,
carbolic acid, or salicylic acid. Gargles of potassium chlorate, ten or
twenty grains to the ounce, are highly recommended, as well as the
internal administration of the same salt in doses of from two to five
grains three times a day for children, and of ten to twenty grains for
adults.
If the sores are slow to heal, the ulcerated surfaces may be touched
once or twice daily with some astringent, such as solution of silver
nitrate (ten grains to the ounce), or, if that be objectionable, with
alum, tincture of iodine, or iodoform.
Prompt extraction of loose teeth and of loose fragments of necrosed
bone is requisite.
Stomatitis Gangrenosa.
DEFINITION.--A non-contagious, deuteropathic inflammation of the
interior of the mouth, almost invariably unilateral, and characterized
by a peculiar gangrenous destruction of all the tissues of the cheek
from within outward.
SYNONYMS.--Gangrenous stomatitis; Gangrena oris; Grangrenopsis; Cancrum
oris; Stomato-necrosis; Necrosis infantilis; Gangrene of the mouth;
Gangrenous erosion of the cheek; Noma; Buccal anthrax; Aquatic cancer;
Water cancer; Scorbutic cancer; Sloughing phagedæna of the mouth.
HISTORY.--The most important work upon the subject was published in
1828, from the pen of Dr. A. L. Richter,[10] whose accurate historical
account of the disease was in great part reproduced, with additions
thereto, by Barthez and Rilliet in their _Treatise on the Diseases of
Infants_, Paris, 1843, and quoted by nearly all subsequent writers on
the {339} theme. From these records it appears that the first accurate
description of the affection was given in 1620 by Dr. Battus, a Dutch
physician, in his _Manual of Surgery_. The term aquatic cancer,
_water-kanker_, bestowed on it by van de Voorde, has been generally
followed by the physicians of Holland, although van Swieten (1699)
properly designated it as gangrene. J. van Lil termed it noma, as well
as stomacace and water-kanker, and cited a number of Dutch physicians
who had observed its epidemic prevalence. The majority of more recent
observers, however, deny its epidemic character.
[Footnote 10: _Der Wasserkrebs der Kinder_, Berlin, 1828; further,
_Beiträg zur Lehre vom Wasserkrebs_, Berlin, 1832; _Bemerkungen über
den Brand der Kinder_, Berlin, 1834.]
Of Swedish writers, Lund described it as gangrene of the mouth; Leutin,
under the name of ulocace. In England, Boot was the first to write of
gangrene of the mouth, and was followed by Underwood, Symmonds,
Pearson, S. Cooper, West, and others.
In France it has received great attention. Berthe[11] described it as
gangrenous scorbutis of the gums; Sauvages (1816) as necrosis
infantilis. Baron in 1816 published[12] a short but excellent account
of a gangrenous affection of the mouth peculiar to children; and Isnard
presented in 1818 his inaugural thesis on a gangrenous affection
peculiar to children, in which he described, simultaneously, gangrene
of the mouth and gangrene of the vulva. Then followed Rey, Destrees
(1821), Billard (1833), Murdoch, Taupin (1839), and others, until we
reach the admirable description by Barthez et Rilliet, from which the
present historical record has been chiefly abstracted.
[Footnote 11: _Mémoires de l'Académie royale de Chirurgie_, Paris,
1774, t. v. p. 381.]
[Footnote 12: _Bullétins de la Faculté de Médecine de Paris_, 1816, t.
v. p. 161.]
German physicians likewise have largely studied the subject. De Hilden,
A. G. Richter, C. F. Fischer, Seibert, and many others preceded A. L.
Richter, whose important contribution to the literature and description
of the disease has been so highly extolled by Barthez and Rilliet.
In America the disease has been best described by Coates, Gerhard, and
Meigs and Pepper, all of Philadelphia.
(For extensive bibliographies the following sources should be consulted
in addition to those cited: J. Tourdes, _Du Noma ou du Sphacèle de la
Bouche chez les Enfants_, Thèse, Strasbourg, 1848: A. Le Dentu,
_Nouveau Dictionnaire de Médecine et de Chirurgie pratique_, article
"Face," Paris, 1871.)
ETIOLOGY.--Almost exclusively a disease of childhood, gangrenous
stomatitis is exceedingly rare in private practice, and very infrequent
at the present day even in hospital and dispensary practice. Lack of
hygienic essentials of various kinds, impoverishment, long illnesses,
and debilitating maladies in general are the predisposing causes. It is
sometimes endemic in hospitals and public institutions, but rarely, if
at all, epidemic. It is not generally deemed contagious, though so
considered by some writers. It appears to have been more frequent in
Holland than elsewhere, to be more frequent in Europe generally than in
the United States, and now much less frequent in the United States than
formerly. To recognition of the predisposing causes and to their
abolition and avoidance may probably be attributed its diminished
frequency all over the world. Though attacking children only as a rule,
it has been observed in adults (Barthez et Rilliet, Tourdes, Vogel).
Nurslings are not liable to the disease. Though occurring occasionally
earlier in life, the greatest period of prevalence is {340} from the
third to the fifth or sixth year of age, and thence, with diminishing
frequency, to the twelfth and thirteenth years. It is probably equally
frequent in the two sexes, though the majority of authors have
described it as more frequent in females.
Healthy children are not attacked. Even in delicate children it is so
rarely idiopathic that this character is utterly denied it by many
observers. The disease which it follows, or with which it becomes
associated, may be acute or chronic. According to most writers, it
occurs with greatest frequency after measles. It follows scarlatina and
variola much less often. It is observed likewise after whooping cough,
typhus fever, malarial fever, entero-colitis, pneumonitis, and
tuberculosis. Excessive administration of mercury has been recognized
as an exciting cause, some cases of mercurial stomatitis progressing to
gangrene.
According to Barthez et Rilliet, acute pulmonary diseases, and
especially pneumonia, are the most frequent concomitant affections, and
are usually consecutive.
SYMPTOMATOLOGY, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND
SEQUELÆ.--The disease usually becoming manifested during other disease,
acute or chronic, or during convalescence therefrom, there are no
special constitutional symptoms indicating its onset. Hence
considerable progress may be made before its detection. The earliest
local characteristic symptom distinguishing gangrenous stomatitis is a
tense tumefaction of one cheek, usually in proximity to the mouth. The
lower lip is generally involved, thus rendering it a matter of
difficulty to open the mouth. This tumefaction in some instances
progresses over the entire side of the face up to the nose, the lower
eyelid, and even out to the ear in one direction, and down to the chin,
and even to the neck, in the other. Before the parts become swollen
externally, ulceration will have taken place to some extent in the
mucous membrane, but usually without having attracted special
attention, the subjective symptoms having been slight. A gangrenous
odor from the mouth, however, is almost always constant. Its presence,
therefore, should lead to careful investigation as to its seat and
cause. The gums opposite the internal ulcer become similarly affected
in most instances, and undergo destruction, so that the teeth may
become denuded and loosened, and even detached, exposing their alveoli.
The bodies of the maxillary bones suffer in addition in some instances,
and undergo partial necrosis and exfoliation.
It is maintained (Löschner, Henoch) that in some instances there is no
involvement of the mucous membrane until the ulcerative process has
reached it from the exterior.