ULCERA PTERYGOIDEA (BEDNAR'S API-fa-LE) The above disease of the mouth was first described by Becinar and classified under the general name Hence arose the designation "Bednar's Aphthai" which is generally used even to-day.
Epstein, to whom we owe an excellent description of the disease, suggested the appropriate name "ulceration of the palatine angles" (Gaumeneckengeschwilre), which we will use Oil account of the confusion resulting from the term aphtlne.
The disease attacks exclusively the newborn and infants in the first weeks of life.
Nature, Localization, process is mostly bilateral and symmetrical, and is manifested by the appearance of circumscribed superficial ulcers in the region of the hamuli pterygoitlei. The ulcers are about the size of a pea or a bean and are encircled by a red areola. They are covered by a yellowish white mass which adheres firmly to its base; hence bleeding results on their removal. The ulcers are painful, and, therefore, cause an inability to nurse on the part of the infant.
a few days the necrotic masses are spontaneously exfoliated; the grayish red floor of the ulcer is denuded but is rapidly covered by I1CW epithelium from the periphery.
Both in regard to localization and the course of the disease, devia tions from the described typical picture may occur. Sometimes the ulcer may be found on one side only while the other side is intact. Occa sionally two lesions may; be joined by a bridge giving the ulceration the appearance of Fig. S. The pathogenesis of the disease makes it possible for the ulcers to occur on other parts of the mouth. Thus we see excep tionally ulcerations appear on the raphe of the hard palate, in the places where in young infants the epithelial pearls are to he found. These ulcers, in correspondence to the anatomical structures of the base, have the form of a rye grain or a lancet.
In some cases typical ulcers at the angles of the palate, and, in the middle line an ulceration of the raphe may develop. All of these lesions may become confluent by extension of the necrotic process so that the greater part of the palate may appear covered by the yellowish white deposit. In consequence of its symmetrical arrangement around the middle line, the deposit often assumes the strange shape of a butterfly whose body is formed by the central ulcer of the raphe, while the wings are represented by the lateral ulcers. These are the forms which are known as pseudodiphtheria, although they show very little resemblance to the clinical picture of diphtheria (see Fig. Sc).
Quite different are those cases in which the signs of a congenital stenosis of the upper air-passages precede the formation of the erosions. The causal connection of both these phenomena has recently been an nounced by Breceli (from Pfaundler's Clinic). A mistake in diagnosis in these cases is conceivable.
The lymph and blood vessels are opened by this ulcerative process. and since pyogenic agents are present in large numbers, the opportunity for a general infection is offered. These conditions attending the evolu tion of Bednar's ulcers may lead to a severe and serious disease, espe cially in debilitated and atrophic infants.
The morbid anatomy of this elisease, according to Frankel and Ep pinger, consists in mycotic necrosis of the epithelium. The micro scopical examination of the removed deposits of the ulcers shows that it is made up of desquamated epithelium, leucocytes and innumerable microorganisms. In smear preparations, as well as in the culture, streptococci predominate among the bacteria. These probably play a part in the etiology of the disease; certainly they may cause general sepsis.
Pathogenesis, do these ulcers always occur at the angle of the palate in the region of the hamuli pterygoidei? The most plausible answer to this question is that the mucous membrane of the palate there is tensely stretched and, consequently, can easily become the seat of superficial lesions during the act of nursing or washing the mouth. Epstein, particularly, attributes the local injuries to the forcible and routine washing the mouth, which, unfortunately even to-day is conunonly practiced by mothem and nurses. In favor of this argues the experience that Bednar's aphtlue occurs principally in infants in whom diligent wiping of the mouth has been done, while the disease has become infrequent since this practice has been discontinued. The disease follows thrush -with extraordinary frequency. It is rational to assume that the appearance of the deposits in the mouth induces the mother to cleanse the mouth vigorously. In favor of the mechanical theory is the fact that the disease occurs on the prominent parts of the mouth, such as the ridge of the palate and the. epithelial pearls.
Against this theory the opponents contend that Bednar's ulcers do not usually appear over the hamuli pterygoidei, but rather to the inner side and also on the horizontal plate of the palate bone. Extensive investigations of E. Fritnkel have shown that the mucosa at that place does not show any difference in regard to thickness; neither is its tension marked, for the mucous membrane possesses a distinct mobility which is uninfluenced by crying or sucking. The characteristic localization, as explained by Frankel, is that at this place in the mouth there is a ldnd of dead point which favors the accumulation and implantation of microorganisms.
For the prophylaxis of pterygoid ulcers, desistance from washing the mouth is the chief rule. In the second place, a rational treatment for thrush must be instituted, because it frequently favors the develop ment of the ulceration, especially when the ordinary method of washing the mouth is used.
Treatment.—If a 2 per cent. solution of silver nitrate is daily applied to the eroded place, the disease is readily controlled and the ulcers heal rapidly. If the infants show a disinclination to take food on account of pain, the application of a 1 per cent. solution of cocaine before feeding, or the insufliation of orthoform powder will give relief.