A system of practical medicine. By American authors. Vol. 2

by Unknown

² Tardieu, Hardy and Behier, Barthez and Rilliet, Meigs and Pepper, and many others.

The general opinion at present, however, is that the apparent vesicle is an inflamed mucous follicle.³ Some observers contend that it is an inflammation of the mucous membrane pure and simple (Taupin); others consider it an inflammation, sometimes in a follicle, sometimes in the mucous membrane (Grisolle); others, a fibrinous exudation in the uppermost layer of the mucous membrane (Henoch). Some have described it as the analogue of a miliary eruption (Van Swieten, Sauvage, Willan and Bateman); others, of herpes (Gubler, Simonet, Hardy and Behier); others, of ecthyma (Trousseau) and of acne (Worms).

³ Bichat, Callisen and Plenck, Billard, Worms, and others.

The vesicle of the primary stage, though generally vouched for, is rarely seen by the practitioner, so rapid is the metamorphosis into the aphthous ulcer. Its very existence is positively denied by several authorities (Vogel, Henoch), and Vogel states that he has never, even upon the most careful examination, discovered a real vesicle upon the mucous membrane of the mouth—one which, upon puncture, discharged thin fluid contents and then collapsed.

Beginning in a few instances, only, in a simple stomatitis, the initial anatomical lesion presents as a red, hemispherical elevation of epithelium one to two millimeters in diameter, and barely perceptible to the touch of the finger, though described by the patient as positively appreciable to the touch of the tongue. Believed to have been transparent or semi-transparent at first, its summit is usually opaque when first seen by the medical attendant, appearing as a little white papule. Billard describes a central dark spot or depression—the orifice of the duct of the inflamed follicle, as he considers it. Worms and others, however, who likewise attribute the little tumor to an inflamed follicle, have failed to recognize any such central depression. There may be but four or five of these papules; rarely are there more than twenty. Diffuse inflammation between them is rare. A few new papules are seen on the second day, perhaps a few fresh ones on the third day. Eventually, contiguous desquamations coalesce into an irregular excoriated or ulcerated surface. These appearances and processes may be summed up as hyperæmia, increased cell-proliferation into circumscribed portions of the mucous structures, with distension of the epithelium (dropsical degeneration?), rupture, and ulceration.

This is the stage at which the local lesion usually comes under professional notice as a superficial circular or ovoidal ulceration or patch, with irregularly rounded edges and an undermined border of shreddy epithelium. It is level with the surface or but slightly tumefied, and is usually surrounded by an inflammatory areola that gives it a slightly excavated aspect. Sometimes this is a narrow red rim, and sometimes it is a delicate radiating arborescence of several millimeters. Adjacent ulcerations coalesce and produce irregularly elongated losses of substance. The floor of the ulcer is covered with an adherent semi-opaque or opaque lardaceous mass, sometimes grayish-white, sometimes creamy or yellowish-white when unadmixed with other matters; the color depending more or less upon the number of oil-globules present, the result of fatty degeneration of the epithelium.

For a few days, three to five or more, the surface of the ulcer increases slightly by detachment of its ragged edges, eventually leaving a clean-cut sore, gradually reddening in color, with an inflammatory margin indicative of the reparative process. Repair steadily progresses by the reproduction of healthy epithelium from periphery to centre, so that within a day or two the size of the ulcer becomes diminished to that of a pinhead; and this is promptly covered over, leaving a red spot to mark its site, until, in a few days more, the color fades in its turn, and no trace of the lesion remains. The period of ulceration is prolonged to one or more weeks in some subjects, chiefly those of depraved constitution.

It was the uniform configuration of the initial lesions, their invariable seat, and the central depression which he detected, that led Billard to the opinion that the so-called eruption or vesicle was an inflamed mucous follicle. This view was further supported by the fact that the disease does not occur in the new-born subject, in whom the lymphatic glands and follicles of the digestive tract are barely developed, while it does occur after the fifth or sixth month of life, up to which time these structures are growing rapidly, and thus predisposing the infant to this peculiar disease by reason of the physiological nutritive hyperæmia.

Discrete aphthæ are found principally in the sides of the frenum and on the tip and sides of the tongue; on the internal face of the lips, the lower lip particularly, near their junction with the gums; on the internal face of the cheeks, far back, near the ramus of the jaw; upon the sides of the gums, externally and internally; on the summit of the gums of edentulous children (Billard); exceptionally upon the soft palate; in rare instances upon the pharynx.

Confluent aphthæ appear in the same localities as are mentioned above, and are much more frequent in the pharynx and oesophagus than are discrete aphthæ. They are said to be found occasionally in the stomach and in the intestinal canal.