THE PATHOLOGICAL ANATOMY OF THE

ALIMENTARY CANAL.

CHAPTER XXXII.

I. OF THE MOUTH AND FAUCES.

CONGENITAL malformations sometimes consist in an excess of the natural number of parts, so that the jawbones, "the mouth, and the tongue, are double, and unite in one common gullet." More often they show themselves by defective formation of the mouth and fauces (astomia), of the upper jaw (ateloprosopia), of the lower law (agnathia and atelognathia), of the lips (achelia and atelochelia), of the tongue (ateloglossia). Arrest of development shows itself in the common single or double harelip, the fissure existing at the union of the intermaxillary with the upper jawbones; in fissures of the hard and soft palate; in fissures of the tongue, the lower lip, and the lower jaw, which are all very rare. In some rare instances, the orifice of the mouth is wanting (atresia oris). The buccal mucous membrane shows but little tendency to be affected by catarrhal inflammation; it is, however, often inflamed in one or more spots from some local irritation, or morbid action. Thus, a carious tooth, a piece of diseased bone, a crop of ulcerations, will excite inflammation in their vicinity. In adults, general inflammation of the mucous membrane is sometimes produced by the abuse or excessive action of mercury, and shows a marked tendency to pass into a state of ulceration and sloughing. Mr. Tomes mentions the occasional occurrence of spontaneous salivation, with considerable inflammation of the gums. Chronic inflammation of the gums is not uncommon, and has appeared to us sometimes to be of rheumatic origin. It may extend over the whole mouth, or be confined to the vicinity of two or three teeth. "The surface of the gums," Mr. Tomes says, "becomes minutely nodulated; and the secretion of epithelium increased; the papillæ are increased in prominence, while the substance of the gum is generally thickened, and the edges about the teeth become thick and round."

In another form of so-called chronic inflammation, the gum rather decreases in size, and "assumes a very smooth and polished surface, and mottled aspect;" the hard palate also becomes implicated, and there is acute intermittent pain. Ulcerations often form on the gums, as well

as on other parts of the mucous membrane of the buccal cavity; they are sometimes simple aphthæ, sometimes small, round, slightly excavated, and without any surrounding inflammation. In some cases, the ulcerations are attended with much inflammation, and swelling of the mucous membrane and subjacent tissues, and, in others, they are rather of a sloughy nature, and form upon a surface dark colored by asthenic congestion.

Epulis (ni, ovaor) is a fibrous tumor, which originates in the fibrous tissue of the gums, or in the periosteum, and not only grows outward toward the cavity of the mouth, but also penetrates into the Haversian canals and cancelli of the bone. Its surface is generally pretty smooth, "like the gum," or it may be rough and more or less lobulated. "Osseous spiculæ not uncommonly shoot," according to Mr. Tomes, "from the surface of the jaw into the tumor, and, in some cases, isolated nodules of bone (calcification?) are found in the substance." Polypus of the gum is a local hypertrophy of its tissue, occasioned by some mechanical irritation. It shows, "on section, an undulating fibro-cellular tissue, covered by a thick layer of epithelium." Vascular tumors, consisting essentially of dilated vessels, sometimes appear on the gums. Mr. Tomes describes one of a bright scarlet color, soft in texture, and easily compressed and emptied of blood, and prone to bleed on slight irritation. Cancer, almost always in the form of scirrhus, occasionally attacks the gums. Its size varies usually from that of a pea to that of a nut. It ulcerates after a time, and may throw out fungous growths.

The vesicles of herpes, and the pustules of variola, occasionally are developed upon the buccal mucous membrane.

The croupy process (the diphtheritis of Bretonneau) appears in adults, according to Rokitansky, in two forms. In one, "after a previous vivid or dark purple reddening of one or more papillæ, and the vesicular elevation of the epithelium at the point and the sides of the tongue, dots or patches, of the size of a lentil or pea, appear on the inner surface of the lips and cheeks, and, finally, on the mucous membrane of the fauces. They present an exudation which has a frosted, or flocculent, or villous appearance, or is more of a membranous character, and extends into the cavities of the follicles; it is of a grayish, or yellowish-white color, and of a lardaceous, or soft, creamy, or fluid consistency; if removed, a shallow, excoriated depression, surrounded by an inflamed margin, remains, on which the exudation is repeated, involving a further destruction of the mucous tissue. In the second instance, livid spots, which rapidly coalesce, and become invested with a dirty, gray, shaggy, pultaceous, and sanious exudation, form upon the softened, bleeding gums, and the mucous membrane of the cheeks, the fauces, and the tonsils. The gums themselves ultimately degenerate into a bad-looking, pulpy, sanious mass, and the mucous membrane of the cheeks and fauces, underneath the exudations, is equally found converted into a friable fetid pulp, or a firm slough." The epidemic adynamic character of the above described process, is now well known. Andral, writing more than twenty years ago, contended most justly that the congestion of the part affected, though first in order, was but secondary in regard to casual agency; and Rokitansky's investigations of the different kinds of intra and extra-vascular

fibrin, which we have before noticed, have made it almost certain that the essence of the disease consists in an alteration of the liquor sanguinis, which gives rise to unhealthy exudation from the blood vessels at various parts. Andral mentions that blistered and all denuded surfaces, during the prevalence of such epidemics, become covered with false membranes like those which form on mucous surfaces. Wounds and ulcers at such periods are found unusually inapt to heal, and all experience of the juvantia and lædentia, seems to testify that the local morbid process is extremely different from common inflammation, and is essentially dependent upon a grave alteration of the general system. The color of the exudation, which is naturally whitish, is often rendered darker by sanguineous effusion saturating it; when this is the case, its aspect, and the extreme fetor which it exhales, give to it a considerable resemblance to a gangrenous slough. This would be still more increased if it were situated, as it sometimes is, beneath, and not upon the layer of epithelium. The succeeding kinds of ulceration which we shall describe are, for the most part, seen in children. Aphthæ are small whity specks, sometimes so closely set together that they coalesce and form patches, which may be very extensive. They separate after a time, leaving the mucous membrane beneath either simply excoriated, or superficially ulcerated. After being detached they are often produced again, and this may occur several times in succession. It is not yet quite decided of what these specks really consist; analogy would support the olden opinion of their being simply a variety of false membrane, but some microscopists contend that they are solely clusters of parasitic fungi. We incline with Dr. West to the belief that the former opinion is the more correct, not that we doubt the correctness of the observation of a growth of fungi in the exudation, but that we think it much more probable that these are developed secondarily in an unhealthy, aplastic, animal matter, which is freely exposed to the contact of air. Dr. West suggests the idea that the sporules of this fungous growth might, by lighting upon the mucous membrane, and exciting irritation there, cause the production of the aphthous specks. This, we think, is very improbable, as, were this the case, but few children could hope to escape: the diffused sporules which affect one child, might as well affect all who were at all disposed. It should be mentioned that the term muguet is applied by the French to the more extensive deposits of this kind. Bad health, indigestion, or abdominal disorder are the precursors and attendants on aphtha. The whole of the buccal mucous membrane appears to be in a state of asthenic inflammation, and the same condition extends in some measure to the whole alimentary track. The disorder is, certainly, a general one, manifesting itself by a local symptom, and not confined to that part. Adults are sometimes affected by aphthæ as the result of indigestions, or as indicative of decaying vital powers. A late eminent physician prognosticated his own approaching decease from the appearance of aphthæ on his tongue. Dr. H. Salter describes small circular ulcers which form at the tip and along the edges of the tongue. These we have experienced ourselves, and can scarce think they should be separated from aphtha. According to him they are produced by the

effusion of lymph into one of the fungiform papillæ, which soon disappears by sloughing or ulceration, leaving an ulcer which continues to spread for some time.

Follicular stomatitis is described by Dr. West as sometimes idiopathic, sometimes a concomitant of measles. In either case it is rare, after five years of age. "The mouth is hot; its mucous membrane generally of a livid red, while a coat of thin mucus covers the centre of the tongue. On the surface of the tongue, especially near its tip on the inside of the lips, the cheeks, near the angles of the mouth, and less often in other situations, also, may be seen several small, isolated, transparent vesicles on the ulcers, which, after bursting, they leave behind. The ulcers are small, of a rounded or oval form, not very deep, but having sharply cut edges; and their surface is covered by a yellowish white, firmly-adherent slough." "When the ulcers are healing, no change in their aspect is observable, and they continue to the last covered by the same yellow slough, but, by degrees, they diminish in size; and seldom or never is any cicatrix observable in the situation which they occupied." The vesicles form in crops, not generally containing many; the resulting ulcers sometimes coalesce and form a continuous patch. The affection is sometimes complicated with herpes of the skin of the lips, and might almost be considered as a similar eruption of the mucous surface.

In ulcerative stomatitis, as described by the same observer, "the gums are red, swollen, and spongy, and their edge is covered with a dirty white or grayish pultaceous deposit; on removing which their surface is exposed, raw, and bleeding. At first only the front of the gum is thus affected; but as the disease advances, it creeps round the teeth to their posterior surface, and then destroying the gum, both in front and behind them, leaves them denuded, and very loose in their sockets. On those parts of the lips and cheeks, however, which are opposite to, and consequently in contact with, the ulcerated gums, irregular ulcerations form, which are covered with a pultaceous pseudo-membranous deposit, similar to that which exists on the gums themselves. Sometimes, too, deposits of false membrane take place on other parts of the inside of the mouth, the surface beneath being red, spongy, and bleeding, though not distinctly ulcerated. . . When recovery has commenced, the disease ceases to spread; the drivelling of fetid saliva diminishes; the white, pultaceous deposit on the gums, or on the ulcerations of the cheek or lips, becomes less abundant; the ulcers themselves grow less; and, finally, the gums become firm," and slowly, and perhaps with partial relapses, regain their healthy condition. The disease is common, rarely fatal, rarely associated with, or proceeding to gangrene. It is sometimes designated by the term Noma.

True gangrene of the mouth is a much less frequent, and much more fatal affection. It is very seldom idiopathic, almost always occurring consecutively to measles or some other disease. Messrs. Rilliet and Barthez found, out of twenty-nine cases, nineteen aged from two to five years, and ten aged from six to twelve. We again quote Dr. West's description, which pictures very well the only case which we have witnessed ourselves. There is at first scarce any suffering, and some unusual fetor