Part 57

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, 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.

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 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.

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 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.

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.