T.,.. fun:Ins develops among the epi 7. it'll as and acini of the mucosa, f I a dense net-work. It may r rec•-)gnized microscopically if t • -:s be at all doubtful. Treatment .—Prophylactic measures in ,rder. the causative factors • _ 11.n.lnated as far as possible. .• .1. )f tile mouth and of all -:, .- 1 and ,terilization of feeding ... • and all ,thor feeding-implements :rfv.._rat've, to prevent reinfection ,• • n the,e are used. This should • • r_r.y. but thoroughly, four or • • 11 a day. The next step is to r.$ t the acidity of the oral secre . •:.- I y tl.e frequent use of alkaline •-- an 1 leverages. Borax, 20 grains J • sulphite of soda, GO grains • .P r•rmee: a saturated solution of . f p,..-.a=sium, or pure lime-water ar u-. ful a= rn mth-washes. In some (4=e:. e=pecially where ketor of the breath is present, a 1-grain-to-the-ounce solution of permanganate of potassium is more effective. The atomizer may be used when the patient is too young to handle swabs or rinse his mouth. These measures should be repeated every hour.
To alkalinize the beverages, lime water may be added to the milk, in the case of infants, in the proportion of 1 to 4.
Sugar and sweets, starchy food, and all syrupy excipients when remedies are prescribed should be avoided. The sys temic state requires careful attention; indeed, thrush sometimes persists, not withstanding all local measures, until a change of air, good food, and tonics have greatly improved the general health. Minute—i.e., tonic—doses of calomel or bichloride of mercury are valuable in this connection.
Gangrenous Stomatitis (Noma; Can. crum Oris; Wangenbrand).
Definition.— A disease usually ob served in children, from two to five years old, in which a gangrenous process be t:ring on the uums or inner side of the cheek and spreads with rapidity.
Symptoms.—Gangrenous stomatitis begins ahnost always during convales cence from an acute febrile process in unusually debilitated children, the first lesion being a small nodule, dense and sensitive, appearing on the gum or the check. The skin and the neighboring mucous surface becomes rapidly liard and swelled or there is cedema. There may be pain, but, as a rule, little discom fort. In mild cases the primary ulcera tion may be limited to one of the start ing-points and finally heal under local treatment, leaving the parts deformed and the patient disfigured if penetration of the cheek has occurred; but in the vast majority of instances the necrotic process rapidly' extends, the cheek is per forated, and the chin, the tongue, the ! jaws, and remote structures—such as the eyelids and ears—are involved in the de structive process.
Violent systemic manifestations are present. There is marked fever and practically intractable diarrhoea, the breath becomes intensely- foul, and the submaxillary and cervical glands are more or less enlarged. The prostration soon becomes alarming and all the evi dences of fatal marasmus appear. The disease is usually fatal in from one to two weeks, but the patients are often carried off by affections that appear as complications: aspiration pneumonia, pulmonary- gangrene, enterocolitis, endo earditis, etc. In short, the phenomena are those of a violent septicannia.
Etiology and Pathology.—The affec tion occurs in poorly-fed children, espe cially girls living in damp, filthy quar ters, and children recovering from vari ous infectious diseases, especially measles, scarlatina, diphtheria, and typhoid fever. It is essentially a disease originating primarily in lowered vitality-, and is not observed in vigorous healthy children.
The complications observed are usu ally ascribed to metastatic infiltration of the distant structures involved, except in the case of pneumonia, which is due to aspiration of gangrenous matter, and enterocolitis, due to the ingestion of uanoTenous detritus. A bacillus resem t, bling that of diphtheria, has been iso lated by Bishop, Ryan, and Schimmel busch; Babes and Zambilovici have also isolated a pathogenic organism capable of producing gangrene resembling noma in rabbits; but all these observations re quire further investigation.
Bacteriological examination in two cases of noma. In the first case bacilli and cocci were found, the former being very numerous in the necrosed portions and penetrating but little into the neigh boring parts, while the cocci had pene trated deeply into the lymphatics of tbe surrounding healthy parts. Cultures yielded a liquefying staphylococcus and but a single bacillus, staining by Gram's method and resembling the bacillus of diphtheria. Neither of these organisms proved pathogenic to guinea-pigs. In the second case a bacillus exactly resembling that in the first case was found. This bacillus differs markedly from the bacil lus of noma as clesci ibed by Schimmel busch. Lyder Nieolaysen (Norsk Mag. f. Laegevid., p. 137, '96).
Treatment .—Prophylactic measures are also of primary importance in this form of stornatitis. The child's diet should at once be changed to one cal culated to increase general nutrition. Nux vomica and gentian, combined. and in small doses, or strychnine are advan tageous to promote appetite. Strong beef-juices, peptonized milk, or koumiss should be given every two hours.