of Rhodes. Spurious works Andronicus.

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in the form of quite spherical or oval cells. In media containing
but little sugar and no acid (common beef-water-peptone gela-
tin) the cells bud out and develop into long threads (Compare
Klemperer and Plant.)

The single cells of the fungus are usually about 5/i in thickness
and about ioo/{ in length. They proliferate in the following
manner: At or near one or both ends a dilatation appears.
This immediately fills with the contents of the cell and gradually
a new cell is formed which finally separates itself from the old
cell by means of a transverse wall. The old cell is called the
"mother," the new one the "daughter" cell. The latter then



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144 DE FOREST: THRUSH.

forms new cells in the same way. The "daughter*' cells either
separate themselves from the "mother** cells and lead an inde-
pendent existence or remain connected with it to form branch-
ing colonies, looking when well developed and seen under the
microscope not unlike a bunch of mistletoe.

Bud fungi are almost constant inmates of the oral cavity.
If cultures from the acid food particles, present in dental cavities,
be made on slightly acid or neutral gelatin, round, rapidly
growing, opaque, white colonies will usually develop which,
under a low power may readily be recognized as masses of yeast
cells. These organisms being widely distributed by nature and
finding their condition of growth best fulfilled in slightly acid or
fermenting media, their occurrence in the human mouth is not
surprising. Compared to bacteria, the bud fungi play an insig-
nificant part in the oral cavity. They may be regarded as the
most harmless of all the mouth parasites.

Saccharomyces albicans^ the thrush fungus, is the only species
of bud fungus thus far observed which possesses pronounced
pathogenic properties.

Baginsky discovered that in test-tube cultures, on the surface
of the gelatin, exposed to the air, thrush fungi form only round
or slightly oval cells; those lying deeper develop into thick
mycelial threads; those still deeper into delicate ones. This is
a phenomenon which characterizes the growth of the fungus
occurring pathologically in the tissues of the mouth. The small
snow-white patches which first appear in the mouth are at first
quite firmly adherent to the underlying mucous membrane; later
they become less secure in their attachment and can easily be
washed from the mouth. If the membrane thus removed be
examined under the microscope, it is found to consist of epi-
thelial cells, leukocytes, and detritus, between which can be
observed the slender filaments of mycelia made up of small
segments (hyphae). These mycelia branch and interbranch until
a rather firm network is formed as in many fungous growths.
The branches themselves are of considerable length, as is shown
in the illustration (Fig. 7).

The contents of these branches is clear and shows, as a rule,
a glistening, highly refractive nucleus at each end. The rest
of the contents is finely granular in parts and in other parts
is quite clear. There are also found in the meshes of the mycelia
loose masses of small egg-shaped bodies which are the spores
{conidia) of the fungus.



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DE forest: thrush. 145

This fungus can be grown experimentally upon acid gelatin
plates in a Petri dish at the ordinary room temperature and forms
snow-white isolated colonies. In agar or gelatin culture tubes
in which a platinum needle smeared with the fungous growth has
been plunged in the ordinary manner, a needle-shaped mass will
develop with here and there whitish globular masses appearing
along the line of innoculation.

Upon potatoes the growth is in small nodular, snow-white
colonies.



Fig. 7. — Thrush fungus (Saccharomyces albicans).

a, Thrush fungus (mycelia composed of hyphae); 6, conidia; c» epithelial cells;

d, detritus; e, leukocytes.

In culture material containing sugar and almost always
upon the gelatin plate only the slender cells are produced, while
in the mass in a culture tube these develop into true mycelia.

If an injection from the culture tube be made into the circula-
tion of a guinea-pig, it will die in a short time and the internal
organs are found infiltrated with the mycelia of the fungus.

Diagnosis. — The occurrence of thrush in the mouth is charac-
terized by the white masses growing upon the mucous membrane
and consisting of branched, curved, and anastomotic threads and
also spores ; the latter are found either at the free end of the threads
or are quite free in the mass. Besides these, one often finds
other free cells of fungous material which are not foreign bodies,



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146 DE forest: thrush.

but are really a part of the developmental circle of the thrush
fungus. These are called "buds.**

To examine these masses of fungus for purposes of diagnosis
it is only necessary to mix a small portion of the dislodged mem-
brane with a little glycerin and put it directly under the micro-
scope. If one wishes so stain the masses, a solution of .alkaline
methylene blue can be used. Before the growth is examined,
it is best to allow the epithelial cells with the fungous growth
to remain for a short time in a 5 per cent, solution of sodium
hydrate. The specimens are best preserved in a glycerin
mounting medium. To stain sections of tissue, either the
alkaline methylene blue, carbol-fuchsin, or the Weigert modi-
fication of Gram's method is best. Any one of these procedures
should easily result in isolation and identification of the growth.

Differential Diagnosis, — ^There are a number of diseases of the
mouth occurring both in the new-born and in adults which pre-
sent appearances closely simulating the growth of thrush. These
must be borne in mind in clinical diagnosis. The writer has
tried to show in the accompanying illustrations the principal
conditions from which thrush is to be differentiated. They are
still better shown by colored plates in the atlas of Mikulicz upon
the "Diseases of the Mouth and Pharynx," Berlin, 1892. Un-
fortunately this atlas is now out of print. It is of interest be-
cause only after a very extensive search through the library of
the Academy of Medicine was the writer able to find in it the
single illustration of thrush that appears to exist.

Bednar's AphthcB {Bednar's Plaqiies; Ulcera Pterygoidea Palati).
— In nurslings and in young children, the extraordinary ease
with which the mucous membrane of the mouth can be injured
sometimes gives rise to diseases of traumatic origin. One of
the most common of those is usually spoken of as Bednar's
apthfle. These palatine ulcers of the new-born always appear at
a definite location, either at the point where the mucous mem-
brane of the gums unites with that over the pterygoid processes
or in the middle of the hard palate corresponding to the site of
the so-called epithelial pearls. Experiences in lying-in hospitals
have shown that these patches only occur in children in which the
mouth has been habitually cleansed. If this practice did not
exist, this form of apthae would never be observed. The etiology
of this disease is therefore traumatic. The patches appear at
that part of the buccal cavity where cleansing is easiest and where
too great force is easily used. It is apparent that in sick nurs-



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DE FOREST: THRUSH. 147

lings, especially in those where thrush exists, Bednar's aphthae
is most apt to develop.

The normal epithelial pearls so frequently observed along the
median line of the hard palate of children are normal vestigial
remains and of no pathologic import.

The habitual cleansing of the mouth before and after nursing
so necessary to avoid the development of thrush in the new-
born must be done carefully and especial care be taken not to
rub the mucous membrane of the roof of the mouth with suffi-
cient force to loosen the delicate layer of epithelial covering.



Fig. 8. — Case VI. Bednar's aphthae (Bednar's plaques, Ulcera pterygoidea palati) .

Should the characteristic patches of Bednar's aphthae develop,
care and cleanliness are all that is necessary to effect a cure.

Case VI. Bednar's AphthcsiFig. 8). — In this child, otherwise
healthy, reported by Mikulicz, the two white plaques here shown
developed four days after birth. During the next two days there
was partial exfoliation and a symmetrical discoloration of the
lateral portions of the adjacent mucous membrane of the gums.
The posterior border corresponded to the crista marginalis of
the posterior palatine foramina and from this line the plaque
extended forward and inward to within 5 mm. of the raph6.
Anteriorly the limit was marked by the transverse Suture between
the palate and the superior maxillary bones. Laterally the
course of the palatine artery formed the line of demarcation.

A slender ivory-like line of slightly raised hardened epithelium
extended along the raph^ of the hard palate and at the middle



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148 ' DE forest: thrush.

of this line were a few small "epithelial pearls*' about the size
of a millet-seed.

By the twelfth day of life the plaques were about half the
original size and three days later had disappeared. The exfoliated
mucous membrane was quickly replaced. No treatment was
given.

The structure of the median line remained unchanged. It
was not pathologic as similar epithelial pearls are often seen in
the new-born.

Acute PaptUar Glossitis {Glossitis Papulosa Acuta). — ^This
also is a very rare affection, first reported by Michelson, whose
drawing is herewith reproduced. Mikulicz observed similar
cases in Konigsberg. In both instances women were affected
who otherwise showed no especial disturbance. Fever, followed
by a chill, prostration, loss of appetite, and headache preceded
the attack. There then developed a burning pain in the tongue
upon which there soon appeared small white flakes which grad-
ually increased in size to i cm. in diameter. In some cases
the prodromal symptoms were not present and the tongue was
not painful. No syphilitic history existed. As the white spots
increased in size a certain amount of erosion took place, leaving
the center somewhat depressed and ulcerated. The border of
the growth was sharply outlined. A greenish pus covered the
affected area. The entire illness lasted for about three weeks
and was accompanied by a moderate degree of profuse catarrhal
stomatitis. The etiology of the process is thus far unknown.

The treatment followed the lines of local disinfection already
indicated.

Case VII. Acute Papular Glossitis (Fig. 9). — ^This patient
of Michelson was a laboring woman, thirty-four years old, of
Konigsberg. She had been hitherto quite well and had never
had any skin eruption. She was married and had two children,
the youngest one year old.

On the fourth of July, chill and fever occurred accompanied
by prostration, headache, and loss of appetite. She particularly
complained of a burning pain upon the tongue whose surface
at this time showed a number of minute blisters the size of a
mustard seed. During the following day a number of other
minute points appeared which rapidly increased in size. On the
sixth of July about ten of these round eruptions appeared on the
surface of the tongue about as large as the head of a pin and
raised from 1/2 to 3 mm. above the adjacent tissue. The cover-
ing was of opaque milk-white color with a slightly yellow center.
In the medium-sized papules a shallow dent appeared in the
center. The adjacent mucous membrane of the border of the
papules was intensely congested. Several similar papules ap-



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DE forest: thrush. 149

peared on the inner side of the lips. The gums were moderately
swollen and of the livid red color. On some of the teeth a creamy
deposit existed. Slight salivation, marked fetor of the breath
were present and the cervical glands were enlarged.

The drawing in this case was made on the seventh of July.
Temperature at this time was loi®. Pain had diminished some-
what, but the other symptoms were unaltered. The efflorescence
upon the tongue had materially increased in size and the borders
of the adjacent papules had become confluent. Between the
central depression and the periphery of the papule an intermedi-
ary zone of a brownish-red cotton-like appearance existed. The



Fig. 9. — Case VII. Acute papular glossitis (Glossitis papulosa acuta).

border about the larger plaques was less red than about the
smaller and younger ones.

On the following day, the older papules had a uniform yellowish
green, cheese-like appearance. A 4 per cent, boric acid mouth-
wash was now begun.

On the following day all symptoms were noticeably less severe.
Temperature was normal, and at the site of the former papules
there appeared round deep erosions with red serrate edges and
a pus-covered base. The symptoms of gingivitis were subsiding
and the swelling of the cervical glands had disappeared.

On the fifteenth of July, the patient was entirely well. The
mucous membrane was completely regenerated and no pathologic
changes could be observed in the mouth.

The bacteriological and histological examination showed a



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150 DE forest: thrush.

number of varieties of bacteria, but the exact cause of the disease
remained unknown.

Acute Aphthous Stomatitis {Aphthce; Stomatitis Maculo-
fibrinosa). — ^This is one of the diseases most commonly mistaken
for thrush. This name at the present time is applied almost
universally to that disease of the mucous membrane of the mouth
characterized by a rapid formation of circumscribed white plaques
of epithelium arranged in layers and bound together by fibrinous
exudate. To this, in 1823, Hillard especially restricted this
old hippocratic name of aphthae.

For our anatomical knowledge of this affection we are par-
ticularly indebted to the researches of E. Frankel. The small
masses of fibrin exuded upon the surface of the mucous mem-
brane hold together many dead epithelial cells, and around this
mass there is a red line of inflamed epithelial tissue.

Although the name of Stomatitis Maculo-fibrinosa is preferable
to the uncertain appellation of Aphthae, the latter is the name
most commonly used.

The clinical picture of this disease is very characteristic:
In a short time there appear, either singly or in considerable
numbers, white or yellowish-white plaques, from i to 3 mm. in
diameter or even larger. They are surrounded by a bright
red, slightly elevated border. The outline of these plaques is
sharply defined. The form, as a rule, is round or oval. After
a short growth on the surface, these plaques usually cease grow-
ing and the fibrinous layer becomes loosened at the edges and
finally falls off. Following its disappearance the epithelium, as
a rule, is quickly regenerated. If the attack is more serious,
similar patches appear in the neighborhood, and it is usual to
find places showing all stages of this pathologic process. These
develop in all parts of the mouth, but are least frequent upon the
gums. Each patch is very sore and causes a sensation of severe
burning. As a result of this, chewing, swallowing, and speaking
are all painful. Pronounced salivation is a common accompani-
ment. A rise of temperature occurs and the general malaise is
more pronounced at the beginning of the eruption. It is more
common in babies from ten to thirty months of age, but it may
also occur in children and in adults. Women are most apt to
suffer from this affection during menstruation, pregnancy, or
lactation. It is a frequent accompaniment of measles, scarlet
fever, and other serious diseases. Its exact etiology is unknown.

Case VIII. Acute Aphthous Stomatitis (Fig. 10). — ^This case



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DE FOREST: THRUSH. * 151

is reported by Mikulicz. The girl was fifteen months old. For
three days restlessness, loss of appetite, and malaise were noticed.
Both parents were recently syphilitic. Two days ago an erup-
tion apparently of chicken-pox appeared. The child was well
nourished and had several teeth, and the gums overlying the
upper molars were swollen, red, and painful. In various parts of
the mouth were numerous round or irregular pale yellow patches,
slightly raised and surrounded by a red inflamed border. Brush-
ing these patches with a camel's-hair brush caused no change
in color, but the slightest touch caused the child to scream from
pain. Pronounced salivation, fetid breath, and moderate swell-
ing of the submaxillary glands existed.

The treatment consisted of a single daily application of i per
cent, solution of nitrate of silver and frequent penciling with



Fig. io. — Case VIII. Acute aphthous stomatitis (Aphthae, stomatitis
maculo-fibrinosa).

IO per cent, boric acid solution. In the course of twelve days
the two molar teeth appeared and the stomatitis had entirely
disappeared.

Acute Gonorrheal Stomatitis (Stomatitis Gonorrhoica) , — This
condition, fortunately a very rare one, still may exist and for
its recognition we are largely indebted to the work of Rosinski,
who, after a number of observations in the new-born, accurately
described the disease and demonstrated by histologic investiga-
tion the gonorrheal nature of the affection.

In the seven cases which Rosinski reported, the first symp-
toms developed from five to twelve days after birth. They



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152 DE FOREST: THRUSH.

consisted in a diffuse stomatitis whose principal characteristic
was a peculiar bluish or rosy-red streaked color of the mucous
membrane of the mouth. Of especial value for the diagnosis was
the appearance in sharply localized areas of a superficial layer
of peculiar yellowish exudate. At first, only the epithelial layer
was involved; this was slightly raised and lay upon the exudate
as a smooth superficial mass. After about the third day, this
epithelial covering was lost and the exudate itself appeared free
upon the surface. The exudate, which at first was a yellowish-
white, now became a clear purulent yellow. At the same time
the surface of the exudate, at first barely prominent, became
considerably raised above the level of the surrounding mucous
membrane. As the disease progressed, there developed about
this exudate a demarcation zone of a bright scarlet color which
limited the line of inflammation more and more. A form of
pseudomembrane developed, but soon this was replaced by a
clear layer of medium-thick yellow purulent pus or a pulpy mass
of the same color. Examination showed this mass to be com-
posed of epithelial detritus, fibrin, and pus cells containing gono-
cocci. If this pseudomembrane was removed mechanically,
the smooth yellowish, and, in the later stages of disease, easily
bleeding surface, appeared. Ultimately the normal epithelial
covering was renewed with but slight or no scar formation.
The back of the soft palate and the back of the tongue were the
sites principally involved by this process. In two of Rosinski's
patients, a gonorrheal ophthalmia also existed. The duration
of the disease varied considerably : from four to six weeks were
the limits observed. A complete cure occurred in all instances.

The localization of the trouble is so peculiar that the diagnosis
can usually be made by this alone. A history of gonorrhea in
the mother is of course important, and gonococci were demon-
strated in all cases observed.

Since Rosinski*s article first appeared, a number of other cases
have been reported, although there is no doubt that the disease
is a very rare one.

In the treatment of this condition, silver salts are of course
of greatest value. The painting of the parts with a we^k
solution of nitrate of silver from 1/4 to 1/2 per cent, gives the
best results.

The prophylactic use of the 2 per cent, solution of lunar
caustic immediately after birth, as is done in the eyes by the
method of Cred^, is not to be recommended since the disease



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153



is of such great rarity. The use of so strong a solution of silver
in tl|e mouth is easily followed by symptoms of poisoning.

Case IX. Acute Gonorrheal Stomatitis (Fig. ii). — Rosinski's
patient from whom this drawing was made was normal at birth.
The mother at this time had an acute gonorrhea and the vulva
was studded with acuminate condylomata.

On the fourth day gonorrheal ophthalmia developed.

On the eighth day gonorrheal stomatitis first appeared, and on
the eleventh day, when the picture was made, the disease had
reached its height. With the exception of the ulcerated areas,
the mucous membrane of the mouth was a rosy-red. The roof
of the mouth was chiefly affected by the inflammation, and the
sharply defined outline suggested that of Bednar's plaques. A



Fig. II. — Case IX, Acute gonorrheal stbmatitis (Stomatitis gonorrhoica).

grayish-yellow, slightly raised exudate existed upon the alveolar
process, the greater part of the tongue, and the posterior half of
the roof of the mouth. Each inflamed area was bounded by
a bright scarlet line of demarcation. Gonococci were easily
demonstrated in the exudate and in the epithelial masses.

Up to the eleventh day, when first seen, no treatment had been
administered, but recovery had commenced and from this time
on the growth of new epithelium from the border inward readily
progressed. At the end of four wxeks cure was complete and no
scars remained.

Chronic Recurrent Aphthce. — This appellation was given by
Mikulicz to a rare but well-characterized affection not previously
described in literature. Three cases occurred in his experience.



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154 DE forest: thrush.

all in anemic chl orotic women from twenty to forty years of age.
The disease followed a recurrent course. In intervals of from
four to six weeks there suddenly appeared upon the edge of the
tongue small mustard-seed ulcers with superficial loss of epithe-
lium. Here and there at the beginning of the attack, minute
blisters appeared surrounded by a line of inflammation. In the
course of four or five days these spots increased to 2 or 3 mm. in
diameter. The number of eruptions varied materially: some-
times only one; sometimes three or four, but rarely more. A
general stomatitis of a mild type was present with a white-coated
tongue and with impressions of the teeth visible at the edge of
the tongue. A slight swelling of the mucous membrane of the
lips and cheeks also occurred and moderate salivation. No
fetor of the breath.

Spontaneous cure resulted , as a rule , after from eight to ten days,
and either the mucous membrane was replaced entirely or else
a slight scar was left at the site of the ulcer.

Case X. Chronic Recurrent Aphthce (Fig. 12). — ^This patient
of Mikulicz was a seamstress, twenty-two years old. She was
very anemic and her menstruation was irregular. For the
preceding six months at intervals of from four to six weeks,
small painful ulcers had appeared on the edge of the tongue.
Pain first called her attention to the site of the coming ulcer.
There then appeared an epithelial erosion the size of a pinhead.
This had a slightly reddened border. During the next few days
this ulcer became larger and deeper, and the base was covered
with a yellow or greenish -yellow coating. The border increased
in redness and became slightly raised and swollen. By this
time the inflammatory changes were most pronounced and the
remainder of the mouth also showed a general slight stomatitis.
The tongue became heavily coated and was so swollen that along
its border the outline of the teeth was easily seen. Slight
salivation existed, but the breath was not especially offensive.

Restitution then progressively took place; the floor of the
ulcer became clean, the inflammation slowly subsided, and the
loss of tissue was steadily replaced. At the end of ten days
cure was established and the cycle was completed.

The treatment consisted in the administration of iron and
arsenic internally; in the use of some mouth-wash, such as
chlorate of potash, boric acid, or alum, and in the use of the
lunar caustic pencil upon the ulcers themselves. This last
procedure caused a rapid cessation of pain, but the other treat-
ment seemed to have but little effect one way or the other.

Leticoplakia Buccalis (Psoriasis Linguce, Tylosis^ Keratosis^
Ichthyosis Buccalis). — The name of Leucoplakia Buccalis was
first introduced by Schwimmer to describe an affection of the



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DE FOREST: THRUSH. 155

mouth characterized by an alteration of the epithelium of the



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 16 of 109)