Book VIII, Chap. V.]

ON APTHE.

415 ble

constitution, or deteriorated by preceding diseases, and especially by chitarre, enteritis. This is again a circumstance which must be attended to in

the treatment.

Ulcerous stomatitis is soon cured when it is properly treated, and when it is not developed in too feeble a child, or in one labouring under

a serious disease of the digestive tube. In this case it may continue a cause, considerable time. It lasts from eight days to one or two months.

Diseases inal Cu rul.

Clear out The causes of stomatitis are rather difficult to discover; however, we may reasonably state, that teething exercises a great influence over the tutest. its appearance. It is sometimes the result of a mechanical cause, of caries of a tooth, of necrosis of the inferior maxilla, &c. of the intestine, feebleness of the constitution, predispose to it in a remarkable manner. It is more frequently developed in boys than in girls, and in children badly looked after, imperfectly nourished, Crich wretchedly lodged, belonging to the poorer classes living in damp, acidity Acidili unwholesome, and badly ventilated places. It is observed in all seasons. It is sporadic and contagious, as M. Taupin has demonstrated it to be, in the work we have cited. The contagion, then, takes place by direct transmission, by means of a glass, a spoon, or of any other body the children carry to the mouth.

The treatment of this disease rests on many important indications. Tone should firstly be given to the constitution of the infants by means of tonic medicines, and the existing diseases should be treated by suitable remedies.

We then proceed to the local treatment of the disease. If by chance it originates from the irritation of a decayed tooth, this should be extracted. Putting aside this case, the means usually put in use against stomatitis are the following:

At the commencement, emollient gargles, emollient injections, in those young children who cannot gargle, are very useful. When the inflammation extends, it should be treated by topical remedies.

In the first rank may be placed the cauterization of the ulcerated parts with the nitrate of silver or hydrochloric acid, and in the intervals, the use of an application of equal parts of honey and borax. This means, in daily use by M. Trousseau at the Necker Hospital, has proved successful in many children.

M. Bonneau, physician at the hospital for children, recommends the employment of dry chloride of lime, and he regards it as a very useful remedy. The chloride of lime should be very dry and perfectly pulverized. The moistened finger is put into this powder, and thus charged, it is rubbed on the diseased parts. If necessary, this operation should be repeated twice a day. It determines the detachment of the concretions which cover the ulcers, modifies their surface, and facilitates their cicatrization.

عمار

1

Csill song a veil àvelige presented in the fold of the p vines bent in diren who are too fat. His mother, thinking with top applied some powder of wwe sublimit, white shea Sinister of chemical preparations, had

the scretum, the frid of the groin and the thigh, to an extent of 4 inches by

ios, a bug aged six, the administration of

calomel was followed by salivation, ulceration of the gums, and ultimate exposure of the body of the inferior maxillary bone of the left side, about one inch of the entire thickness of which separated; he rapidly recovered.-P.H.B.]

ON APHTHÆ.

Like Willan and Bateman, we apply the name of aphtha to the vesicular eruption of a roundish shape which takes place in the interior of the mouth. We put aside the simple erythema of the mucous membrane of the mouth, the ulcerous stomatitis of which we have just spoken, thrush, gangrene of the mouth, diseases entirely different and easily distinguished, as will be seen further on.

Aphthæ is characterized by small whitish vesicles formed on the mucous membrane of the mouth, at the places where the epithelium is most apparent. Thus they are observed on the internal surface of the lips and the cheeks, on the gums, tongue, soft palate, and sometimes in the pharynx. They are not accompanied by the inflammation of the buccal mucous membrane. It is said that they may be developed in the intestinal canal, but the fact is far from being demonstrated. An ulcerous enteritis, with its ordinary characters, is sometimes there

observed; but I do not think that the nature of this alteration can be kucou

allied to that of the affection which exists in the mouth.

Shortly after the appearance of the vesicle, an induration, scarcely perceptible, forms at its base. It bursts and allows the liquid it encloses to escape. It is then replaced by a small greyish ulceration, with a red border, slightly projecting, which remains stationary for a time, and cicatrizes, or else enlarges, and then assumes a state favourable for cicatrization.

These ulcers are not, in general, accompanied by inflammation of the general, accompanied by inflammation of the mucous membrane. There is no concomitant stomatitis. They last from four to five days, and disappear without leaving any traces. Their number is variable. It is thought that, according to their quantity, two varieties of aphthæ should be described; and rightly so. In fact, in some circumstances, the eruption is discrete, in others it is confluent. These two kinds differ much as regards the prognosis.

Discrete aphthæ are thus called because they are few in number. They are developed both amongst children and amongst adults. They are not observed amongst children at the breast until after the commencement of dentition.

It is a slight and rather common disease. It is generally accompanied by a little fever and slight irritation of the bowels. It is developed in reference amongst children whose constitution is feeble and tubercular. The ulcerations last from five to seven days, and disappear. They se slight pain. The children incessantly carry the hands to the th, and cry to attract the attention to this part.

Confluent aphthæ are more rare, and are not observed amongst young

D D

418

SPECIAL PATHOLOGY OF INFANCY.

[Part III. children. This disease is more unfavourable. It is nearly always allied to a serious general condition, to pulmonary phthisis, or to the puerperal influence at the time of the epidemics which attack nurses. Its progress is much more slow, and its cure more difficult.

The treatment of aphthæ, especially, consists in the employment of topical means.

In young children, the employment of gargles is impossible. The operation requires an intelligence which the subjects do not possess. The diseased parts should, then, be touched with a pledget of lint or cotton dipped in a decoction of marshmallow, in barley water, or in undiluted milk. A small quantity of the syrup of poppies may be added, or some drops of the tincture of opium, so as to calm the child

Ithalies if it appears to experience great pain in the mouth.

cally

We may employ with more advantage, and in the same manner, a mixture of equal parts of honey and barley water; a mixture of equal parts of borax and honey; the application containing alum, the decoction of rhatany root, of oak bark, with the syrup of lemon or the syrup of currants.

If the aphthæ resist these means, they should be cauterized with a crayon of alum or of nitrate of silver.

When by observation of the patient, we arrive at the conclusion that the disease is the result of a general morbid condition, natural weakness, the scorbutic state, a tendency to inflammation of the bowels, &c., it becomes necessary to add to the use of topical applications the influence of different therapeutic agents suitable to remedy these diseases.

The subcarbonate of iron, the syrup of bark, are very advantageous to weak children. The antiscorbutic syrup may be given to the scrofulous, and to those which present some symptoms of scorbutus.

If the subjects are predisposed to diseases of the bowels, and if the disease consists in a transient gastric derangement, the syrup of Tipecacuanha may be prescribed in a dose proportioned to the age of the child; or slight purgatives, castor oil, senna draught, or still better, calomel in powder or pill. Great reserve should be used in the employment of these means; if the child is attacked by a chronic entero-colitis, the means recommended against this disease further on, should be made use of.

5TH. ON GANGRENOUS AРÍTÍÆ.

Those who have had frequent opportunities of observing the aphthous disease of children, know that in some cases one or more of the ulcerations suddenly assume a serious and unexpected aspect. They extend, invade the neighbouring and deep tissues, and occasion a loss. of substance which is sometimes considerable; they form a circumscribed eschar, which might be really termed gangrene of the mouth, if its extent exceeded these limits.

on the

-There is reason, therefore, in referring gangrenous aphtha to gangrene ay lam of the mouth, of which they are perhaps the first stage. The nature of the disease is evidently the same; but the progress of the symptoms, and the extent of the lesions, distinguish these two diseases. henceforth impossible to confound them.

It is f

As Billard remarks, aphthe often pass to the gangrenous state; their orm. edges shrivel, assume an ashy, ragged, softened appearance; a brown eschar forms in their centre, which soon detaches itself, leaving a reddishes and granulated surface exposed. In place of the eschar on the centre of the ulcer, a substance of a very soft consistence is sometimes formed: it is of a brownish colour, and possesses a very evident gangrenous odour. The surrounding parts become swollen, assume a violet appear- ill ance, are soft and easily depressed. During this period, the mouth of the child is always half open, whence a fluid and streaky saliva dribbles; the face is pale, the patient listless, depressed, gently dies without having presented any febrile reaction or cerebral excitement.

With these symptoms, vomitings, diarrhoea, combined with hiccough, or frequent regurgitations, are sometimes observed. The pulse is always of extreme weakness; the skin is remarkable for its pallor and insensibility.

The gangrenous transformation of aphtha is rare; it is a very serious occurrence, one which may be followed by the most serious consequences and determine death, in consequence of the state of weakness in which the children are observed when this complication manifests itself.

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The progress of the gangrene of the aphthæ should be arrested from 1 its very commencement. This can only be done by means of an Fac energetic treatment. Instead of losing time in the employment of palliative remedies, caustics should be applied on the diseased parts, so as to modify their vitality, and to place them in the conditions favourable to cicatrization.

An when Gangrenous aphthæ should be cauterized with a brush moistened. with hydrochloric acid, or with a stick of nitrate of silver. Cauterization by the acid nitrate of mercury must not be employed in this case, in consequence of the salivation which might result.

The first cauterization should be deep; and it should be renewed f as often as the state of parts requires it.

6TH. ON GANGRENE OF THE MOUTH.

This disease, of which we find little mention in the old authors, does not appear to have attracted the attention of medical men until about three centuries ago. Since this epoch, it has been the subject of many interesting monographs, for they are, generally speaking, well written and leave little to be desired.

Gangrene of the mouth, also described under the term of gangrenous

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