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 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, by whom it had been subjected to minute study.

Ueber die Schwämmchen bei Kindern, 1842—Van der Busch's translation from the Swedish, Bremen, 1848.

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.

Ziegler, A Text-book of Pathological Anatomy and Pathogenesis, translated by Macalister, vol. i. p. 319, London, 1883.

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 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 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).

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 spontaneously, so that it may be removed by the finger in large flakes without producing any hemorrhage whatever.

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

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

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

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

Duguet, Soc. Méd. des. Hôp., Mai 11, 1883; Rev. mens., Juin 1, 1883, p. 187.

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 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.

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.