irregular ulcer of the tongue surmounted with grayish detritus and
surrounded by reddened edges, should suffice for the recognition of its
presumptive tuberculous character. It is most difficult perhaps to
differentiate from a small ulcerated squamous-celled carcinoma, and the
two indeed sometimes coexist, rendering the discrimination extremely
difficult until the advanced progress of the carcinoma places the
diagnosis beyond doubt.
{370} In the early stages, however, it is distinguished by lack of the
peculiar lancinating pains of carcinoma, which, however, are not
invariably attendant, and by lack of secondary involvements of the
cervical lymphatic glands. At all times it should be distinguishable
from the carcinomatous ulcer by lack of the fungus-like appearance of
the bed of the ulcer which is usual in carcinoma.
From syphilitic ulcer it is distinguishable by the history of the case,
its tendency to be unilateral, and its failure to respond to
antisyphilitic treatment. Syphilitic ulceration of the tongue may
represent the primary, the secondary, or the tertiary manifestation of
the specific disease. The former will not be discussed in this
connection.
Secondary ulcers occur on the upper surface of the tongue, most
frequently at the anterior portion, as fissures, usually longitudinal,
the floors of which are ulcerated. They occur likewise at the sides,
tip, and even lower surface of the organ. They are often associated
with secondary ulceration in the mucous membrane of some portion of the
mouth. They are quite painful, especially to the contact of pungent
articles of food. Some ulcers occur as simple superficial excoriations
at some portion of the edge or tip of the tongue, giving little
evidence of any specific character.
Tertiary ulcers are usually sequelæ of gummata. They are much deeper
than secondary ulcers, sanious at bottom, often serpiginous in
configuration, and apt to extend in depth as well as in superficies,
sometimes penetrating through and through the organ. They are most
frequent in the very central portion of the tongue, or are
symmetrically disposed on either side of it.
PROGNOSIS.--The prognosis of tuberculous ulceration is bad, both as
regards tongue and patient.
TREATMENT.--The only topical treatment offering any prospect of local
cure is the bodily destruction of the ulcer and the surrounding tissue
with caustics, the best of which are the incandescent metals, or else
the excision, with the incandescent knife, of a portion of the tongue
comprising all the affected tissue. In the former case the tuberculous
process often reappears about the cicatrix; in the latter, at some more
distant point.
Tincture of iodine locally, detergent washes, and the like, often
secure a certain amount of comfort as palliatives. The same indications
prevail as in simple chronic glossitis, superficial and deep-seated.
Iodoform locally is of benefit, inasmuch as it relieves pain and
reduces collateral inflammation, but it is powerless to arrest the
onward march of the ulcerative process.
Hemorrhage from the Mouth.
DEFINITION.--A loss of blood from the mouth.
SYNONYM.--Stomatorrhagia.
ETIOLOGY.--Hemorrhage from the mouth is usually a symptom of some
disease or injury of the mouth, tongue, gums, palate, pharynx, or nose.
It may, however, occur as one of the phenomena of scorbutus or of
hæmophilia. It is said to occur occasionally as a vicarious {371}
menstruation. It may be slight, so as barely to tinge the saliva, or it
may be profuse enough to terminate fatally. Between these extremes
there is an infinity of gradations. As a result of disease it may be
caused by simple hyperæmia of the mucous membrane, by rupture of
dilated blood-vessels, by ulceration, by gangrene. As a result of
injury it may arise from wounds of various kinds, accidental or
self-inflicted.
The gums are the most frequent source of slight hemorrhage from the
mouth. The pharynx, probably, is the next most frequent seat.
Hemorrhage from the tongue, cheeks, lips, and palate is usually
traumatic or the result of ulceration.
SYMPTOMATOLOGY, COURSE, DURATION, COMPLICATIONS, TERMINATIONS, AND
SEQUELÆ.--The symptoms of hemorrhage from the mouth are the presence of
blood in the saliva or in the mouth itself, or in the expelled products
of expectoration, emesis, or catharsis, for sometimes the blood is
swallowed, and occasionally inhaled into the air-passages. The course,
duration, complications, and terminations of stomatorrhagia depend upon
its cause. Prolonged hemorrhage will entail anæmia; profuse hemorrhage
may terminate fatally.
DIAGNOSIS.--Careful examination of the mouth, tongue, pharynx, and
posterior nares, both by direct and by reflected light, may be
necessary to discover the source of the hemorrhage and discriminate it
from hæmoptysis and hæmatemesis.
PROGNOSIS.--The prognosis will depend upon the nature of the cause, its
susceptibility of arrest, the quantity of blood lost, and the general
health of the patient. It is grave, as a rule, in the subjects of
hæmophilia, as there is a constitutional malnutrition of the
blood-vessel system which cannot be counteracted.
TREATMENT.--Ergot or oil of turpentine internally, astringent
mouth-washes, and recumbency constitute the main features in treatment.
Morbid Dentition.
DEFINITION.--Departure from the physiological processes concerned in
the eruption of teeth, entailing certain local and systemic disorders.
SYNONYMS.--Dentitio difficilis, Pathological dentition, Odontitis
infantum.
The correct comprehension of the subject will be facilitated by
considering its etiology, pathology, and symptomatology in connection.
Indeed, morbid dentition has been assigned so prominent a part in the
etiology of various affections elsewhere discussed that a satisfactory
consideration of its own causation would require the repetition of much
that belongs more appropriately under other titles. While in some
infants the teeth erupt so quietly that the parents are astonished by
the accidental discovery of their presence above the gum, few children
escape a greater or less amount of local and constitutional disturbance
while passing through the process of dentition. So severe may these
disturbances become that, according to the mortality-tables of London,
as cited by West,[75] teething was assigned as the cause of death of
4.8 per cent. of all children dying under one year old, and of 7.3 per
cent. of those who died between the {372} ages of twelve months and
three years. It is furthermore well recognized that the period of
greatest mortality among children is that of the first dentition.
Associating these facts, we see, on the one hand, that while disorders
of dentition may act a causative part in the production of systemic
diseases or aggravate morbid processes due to ordinary causes, on the
other hand they may be but one expression of some profound
constitutional disturbance; or both aberration in the eruption of the
teeth and systemic disease may be dependent upon the influence of
dyscrasia. The period is one of active organic processes; the child is
becoming fitted for a new manner of existence; and change and
development are going on throughout nervous, vascular, respiratory, and
alimentary systems. Hence there exists peculiar susceptibility to
morbid influences; and any process, physiological or pathological, once
started, goes through its stages with excessive energy.
[Footnote 75: _Lectures on the Diseases of Infancy and Childhood_,
Philada., 1860, p. 425.]
Although the periods of normal eruption of the deciduous teeth vary
within extensive limits, and an invariable order in eruption is not
observed in all subjects, it may be stated as a rule that the lower
central incisors are cut in quick succession about the seventh month.
Some infants get these teeth during the fourth month (Vogel), and
others have to wait until the tenth or eleventh month, some even
longer. A few weeks after the appearance of these lower
incisors--within fourteen days in some subjects, not until nine or more
weeks in others--the central incisors of the upper jaw are cut, and its
lateral incisors shortly afterward, followed in their turn by the
lateral incisors of the lower jaw. In some instances--the majority,
according to Vogel--the eruption of the inferior lateral incisors is
delayed until the anterior molars are about to become exposed, usually
from the twelfth to the fifteenth month. Sometimes the upper molars are
cut before the lower, sometimes after them. From the sixteenth to the
twentieth, or even the twenty-fourth, month the canine teeth are cut,
and the four posterior molars follow between the twentieth and
thirtieth months, rarely delayed until the thirty-sixth
month,--completing the process of the first dentition.
From this it will be seen that the teeth erupt as a rule in pairs, and
that a longer or shorter interval of repose takes place between the
eruption of successive pairs.
Variations from the usual order beyond the limits noted above may be
considered abnormal. Numerous cases are on record both of precipitate
and of tardy dentition. Tanner cites from Haller nineteen examples in
which one or more of the central incisors have been found through the
gums at birth, and have had to be removed to prevent injury to the
mother's nipple; from Crump, a case of full dentition at birth,
reported to the Virginia Society of Dentists; and from Ashburner, a
case of a child beginning to cut its first tooth, an incisor in the
upper jaw, during its twenty-third month, the infant being very
delicate, with a large head, tumid abdomen, and peculiarly small-sized
extremities. The same author quotes from Serres cases of persons
passing through several years of life--in one instance seven--before
cutting their first teeth, and mentions on the authority of Tomes that
Boxalli and Baumes have each recorded an instance in which the patient
reached old age without a single tooth having ever appeared.
Rachitis is often the cause of tardy dentition, and in the subjects of
this {373} diathesis not alone are the teeth retarded in development,
but they decay early and even fall from their sockets.
The first indication of approaching dentition is the markedly increased
production of saliva. For some little time after birth the salivary
glands seem to remain wholly inactive, and until the fourth or fifth
month of extra-uterine life they furnish very little secretion. At this
period a decided change occurs. The mouth is constantly filled with
saliva, which dribbles from its corners. To this continual slobbering,
wetting the garments covering the chest, has been attributed the
bronchial catarrh which attends some infants; and diarrhoea has
likewise been referred to the swallowing of large quantities of saliva,
acting as a mild laxative by virtue of its saline constituents.
There may be no further manifestation until the seventh month, beyond
the broadening of the dental ridge. The exact position of each tooth is
usually indicated by greater prominence of the gum above it for some
time before it comes through, its entire outline being very distinct in
the upper central incisors. As the tooth approaches the surface the gum
becomes hot, shining, tense, and tumid, often painful. A slight amount
of catarrhal stomatitis is almost invariable. There is some elevation
of temperature; flushing of the cheek may occur; the child is restless,
peevish, and fretful; its sleep may be broken; it may cry out with
pain; its thumb, its fingers, any hard substance it can obtain, are
thrust into its mouth to allay the irritation of the gums. Otalgia is
not uncommon, and its occurrence may be inferred from the fact that the
child pokes its thumb or finger into the auditory canal or firmly
presses the tragus down over the external meatus. These may comprise
all the disordered manifestations, local or constitutional, or there
may be in addition loss of appetite, diarrhoea, vomiting, and the
various disturbances of reflex nervous origin to be alluded to later;
or, in the not common yet not rare instances already mentioned, there
may be absolutely no appreciable disturbance whatever.
Sometimes a disposition exists to the formation of small aphthous
ulcerations on the tongue or elsewhere in the mouth, particularly at
the duplicature of the lip and the outer surface of the alveoli.
Ulceration occurs most frequently at the tip of the tongue, probably
occasioned by friction from the new teeth. Usually there is a single
flat, round ulcer, its edges somewhat infiltrated, its bed covered with
a yellow lardaceous substance. It is extremely painful to the touch,
and thus every movement of the tongue occasions distress. It may heal
within a few days or continue for weeks. Ulcers in other situations are
less obstinate.
Occasionally--and more frequently in debilitated subjects or those
exposed to unhygienic surroundings--there is an unusual amount of heat
and swelling of the gum, which becomes excessively tender, usually over
the summit of a particular tooth--in which case there will be a little
tumor-like elevation--or around a tooth which has partially pierced
through it. Small sloughy ulcerations form in this situation. There is
great pain, and usually high fever and severe gastro-intestinal
disorder. This affection, often difficult of cure, is termed by some
writers odontitis infantum. So severe is the pain, and so great its
tendency to aggravate constitutional disturbances, that life may be
placed in jeopardy, and even fatal results ensue.
{374} Less severe than either of the forms just described, and yet far
more intense than the mild stomatitis which many authors regard as
physiological, is an aggravated form of catarrhal stomatitis sometimes
attendant upon morbid dentition, in which there is swelling of the
submaxillary glands and infiltration of the adjacent connective tissue.
In this case there is usually considerable pyrexia.
The constitutional disturbances of reflex nervous origin occasioned by
morbid dentition are of the most varied character, both in their degree
of gravity and in the manner and locality of their manifestation.
Doubtless the extensive ramifications of the great vagus nerve, and its
connections both of origin and distribution with the exquisitely
sensitive fifth nerve, as well as with the facial nerve and with the
sympathetic system, will explain why the irritation should now be
seated in the gastro-intestinal tract, giving rise to vomiting and
diarrhoea (gastritis, gastro-enteritis, enteritis, entero-colitis,
cholera infantum); now in the respiratory tract, provoking cough more
or less severe, or even a well-marked bronchitis; now manifest itself
in various cutaneous eruptions (urticaria, eczema, impetigo, lichen,
prurigo, herpes); and now accumulate in the cerebro-spinal axis,
manifesting its presence by slight spasms (dysuria, muscular
twitchings), or discharging with terrific force in some of those
convulsive seizures which are the dread of mothers and the cause of
much anxiety to physicians.
The mechanical causation of diarrhoea and bronchitis, insisted upon
particularly by Vogel, has already been alluded to. While this may be
one element, most certainly the nervous factor is too important to be
disregarded. Bronchitis, not attributable to ordinary exposure, occurs
coincidently with teething even in children who have been protected
against wetting of the chest; and the fact that more purely nervous
phenomena, and especially the dreaded brain symptoms, are usually
absent in children who have an excessive flow of saliva, and
particularly if there be also a moderate diarrhoea, would conduce to
the belief that nervous irritation, discharging itself in this manner,
does not accumulate in the centres.
Doubts have been expressed whether dentition can give rise to
convulsions in perfectly healthy children, although its rôle as an
exciting cause in predisposed subjects is admitted (Hillier). That
dentition alone, in the absence of any other predisposing or exciting
influence, will provoke any of the disorders with which it is
associated may be doubted in view of the fact already cited, that in
some infants there are no untoward occurrences. But there seems to be
no valid reason for separating the disturbances purely in the domain of
the nervous system from the other pathological processes originated or
aggravated by morbid dentition. Doubtless predisposition often
determines the direction and severity of the reflected phenomena; and
in the same manner reflected irritation may bring an organ within the
influence of the ordinary disease-producing cause.
The convulsive phenomena associated with dentition may take the form of
general eclampsia or spasms of particular groups of muscles. These
latter are very common--according to Vogel, universal--and vary in
intensity from that slight contraction of the facial muscles which
sends the mother into raptures of delight over the heavenly smile of
her {375} sleeping babe to the distressing seizure of laryngismus
stridulus. Sometimes the child may sleep with its eyes half open, the
eyeballs directed upward, and only the white sclerotic to be seen
through the gap between the lids, "producing an appearance which is
unnatural and alarming to the laity."
The attacks of general eclampsia are usually sudden. The child has been
to all appearances perfectly healthy, when, without warning, there
occurs a series of tetanic spasms like a succession of electric shocks.
The individual eclamptic shock cannot be distinguished from an
epileptic seizure. These convulsions sometimes continue for several
days, but frequently they cease after a few minutes. They may pass off
and leave nothing to testify to their occurrence; very frequently they
occasion permanent distressing lesions. Partial, so-called essential
paralyses, squint, or even idiocy, are cited among their sequelæ;
infants subject to repeated convulsions while cutting successive teeth
have eventually perished from cerebro-spinal meningitis; death has not
infrequently been an immediate result. In these graver cases teething
is probably but one of the morbid influences at work.
Purulent otitis media follows dentition in some infants, usually, if
not invariably, of a scrofulous diathesis. At the clinic of the
Jefferson Medical College Hospital fully one-third of all the cases of
otorrhoea in children are said to be so occasioned.
Blennorrhoeal conjunctivitis is a rare complication of teething, and
when it occurs usually accompanies the eruption of the upper molars and
canines (eye teeth). It is attributed to direct extension of the
gingival inflammation by continuity through the antrum of Highmore and
the nasal passages. By some it is said to occur only in strumous
subjects. It is unilateral, and is not contagious, so that there is no
cause for alarm concerning the unaffected eye. The lids soon swell
enormously and the eyeball is exposed with difficulty. There is
considerable pain. The secretion is more mucous, translucent, and
stringy than in genuine blennorrhoea. The eyeball always remains intact
and the prognosis is always favorable (Vogel). Milder forms of
catarrhal conjunctivitis are not very uncommon.
Thus far, we have considered only the process of the first dentition.
Before the shedding of any of the deciduous teeth, the first permanent
molars inaugurate the second dentition, appearing in position at about
the sixth year. Next, displacing their temporary predecessors, come the
central incisors, between the sixth and eighth years, the inferior pair
generally preceding the superior ones. The lateral incisors are cut
between the seventh and ninth years; the anterior bicuspids between the
ninth and tenth years; the posterior bicuspids between the tenth and
eleventh years; the canines between the eleventh and thirteenth years;
the second molars between the twelfth and fourteenth years; the third
molars, or wisdom teeth, between the seventeenth and twenty-first years
as a rule, occasionally much earlier, sometimes later.
The eruption of the permanent teeth does not usually occasion any very
great amount of distress; nevertheless, it sometimes acts both as a
predisposing and as an exciting cause of various disorders, local and
systemic. The various forms of stomatitis, tonsillitis, sore throat,
gastro-intestinal derangements, febrile disturbances, bronchitis,
internal rhinitis, {376} diseases of the eye, of the ear, of the skin,
chorea, epilepsy, etc., have all been noted as accompanying, if not
occasioned by, the second dentition. Ashburner[76] records, among other
similar instances, that of a lad twelve years old who presented a
marked case of chorea, and after three months' continuance of the
twitchings fell into a violent epileptic fit, from difficulty in the
eruption of the second pair of permanent molars of the upper jaw. The
use of the gum lancet relieved the convulsion, and there was no return
of the chorea.
[Footnote 76: _On Dentition and some Coincident Disorders_, London,
1834, cited by Tanner.]
Quite frequently, the eruption of the inferior dentes sapientiæ
occasions great and protracted suffering, especially when they appear
very close to or partially under the coronoid processes. Considerable
irritation is occasioned, in which the gums and adjacent tissues
participate. Inflammation may result and extend to the fauces;
mastication becomes impossible; severe odynphagia is excited.
Suppuration may ensue, and then the pus burrows in various directions,
finding exit at points more or less remote, internal or external. Among
the consequences of the eruption of a wisdom tooth into a crowded arch,
White[77] cites fistulæ, necrosis, exostosis, ulceration and sloughing
of the soft tissues, cystic and other tumors, ankylosis of the jaw,
amaurosis, otalgia, otorrhoea, deafness, facial paralysis, hemicrania,
oesophagismus, tonsillitis, erysipelas, aphonia, hysteria, neuralgia,
chorea, epilepsy, tetanus, death.
[Footnote 77: "Pathological Dentition," extract from annual supplement
to the _Obstet. Journ. of Great Britain and Ireland_, April, 1878.]
DIAGNOSIS.--The age of the child and the appearances already described
will afford a basis for diagnosis so far as the local manifestations in
the mouth are concerned. The diagnosis of local disorders at a
distance, or of systemic disturbances of whatever character, can be
made out only by careful consideration of all the attending
circumstances; and it is always to be borne in mind that while the
process of dentition is to be recognized as one of the causative
factors, grave injustice might be done the little patient, and its life
perhaps endangered, by failure to recognize the presence of other and
perhaps more potent morbid influences.
In cases of chorea or epilepsy, of eye or ear troubles, or of any
morbid condition not otherwise accounted for, occurring during the
period of the second dentition, especially at the sixth, twelfth, and
seventeenth years, or until the wisdom teeth are fully erupted, it is
well to inspect the mouth and to think of dentition as the possible
cause.
PROGNOSIS.--The prognosis will depend upon the character and gravity of
the associated symptoms, the presence or absence of diathesis, and the
etiological importance attached to dentition. It is impossible to lay
down a general law.