Course of the a normal course, the ulcerations begin to heal after 6 to 10 days. The exudate peals off, the tendency to bleed ceases, and the reparative process follows in the form of a rapid eicatriza tion from the periphery to the centre. With the clearing of tbe ulcers, an amelioration of 'Hie symptoms progresses step by step. The tender ness lessens, the taking of food is easier, and the children assume quite a different aspect.
disease is generally disseminated rind by no means rare. The endemic outbreaks of the affection in closed asylums are remarkable and have been extensively studied (Bernheim, etc.). Because the occurrence of the disease pre-requires the presence of teeth, the disease does not occur in the young nursling. Primary ulcerative stomatitis is observed most frequently, about the time of the second dentition, that is, about the seventh year, and at the time of the eruption of the first molars, that is, about the twelfth or thirteenth year.
Etiology.—Caries of the teeth and neglected care of the teeth play the chief ride in the causation of the disease. Certain cachectic con ditions of the young organism and its oral mucous membrane, as are often seen after the acute infectious diseases—especially measles, but also scarlatina, diphtheria, and typhoid,—seem to be very important. It is well known what a prominent part the inflammatory affections of the mouth play in the morbid conditions following measles. Not infre quently, we observe a genuine ulcerative stomatitis as a direct complication of measles (stomatitis ulcerosa cachectica). The de scribed conditions must, however, be regarded merely as predisposing factors.
The constancy of a typical bacteriolog,ical finding convincingly corroborates the truth of the former statement. In smear prepara tions of the exudate the predominence of two kinds of bacteria which are regularly asso ciated, attracts attention; a spindle-shaped bacillus (bacillus fusiformis), taking up the common aniline stains with avidity, and a deli cate, cork-screw or screw-shaped spirochreta, which appears less distinctly stained (Fig. 6).
While both bacteria were known to Miller as a frequent finding in carious teeth and Plant and Stooss had the opportunity to observe this microscopical picture in infectious anginas, special credit must be bestowed on Bernheim and Pospischill, who first demonstrated their causative relationship to ulcerative stomatitis.
The bacillus fusiformis in shape, arrangement, and staining capacity (vacuole formation in the plasma) has a superficial resemblance to the diphtheria bacillus and the unskilled might make an erroneous micro scopical diagnosis of this disease (Bernheim). However, its larger size and its tendency to group in diplobacillary bands, but especially its pointed ends (spindle-shaped), morphologically differentiate it from the Loffler bacillus. Not infrequently the body of the bacillus shows a semilunar curve and recalls the shape of a little boat. The fusiform bacillus as well as its constant associate, the spirocheeta, shows lively active movements in a native preparation. Staining is best accomplished fuchsin or Lofller's methylene blue. Recently the artificial growth
of the bacillus fusiformis bas succeeded in a serum culture medium under strict anaerobic circumstances. The cultures diffuse a fetid odor and inoculations on animals produce a local necrotic process (Ellermann). These facts, in addition to its constant presence in the mouth affected with the specific disease, amply prove its etiological relation to ulcerative stomatitis.
appearance is so characteristic that simple inspec tion of the mouth permits no doubt as to the nature of the disease; for even excepting the specific qualities of the mimary and secondary ulcerations, the penetrating fetor of the mouth, which is characteristic of ulcerative stomatitis, is never absent. In the differential diagnosis, the necrotic form of mercurial stomatitis and the scorbutic affection of the mouth need only be considered. In both instances the characteristic history and onset of the disease decide the question.
The prognosis is generally favorable, but the possibility of com plications should not be forgotten. In protracted cases, it may happen that the process involves the periosteum of the maxillary bone and leads to a partial necrosis. Abscess of the tongue, angina Ludovici, general sepsis, and especially noma are among the complications which have been observed this disease. Fortunately, such cases belong to the greatest rarities.
rational care of the mouth, especially- the teeth, stands foremost among the prophylactic measures. Particularly during the course and decline of the infectious diseases mentioned (measles and tyThoid particularly) attention to the hygiene is very necessary-. Carious teeth, the most frequent source of the evil, must be treated or extracted.
Treatment. the first place a vigorous local treatment should be instituted. It is necessary to prepare the ulcers for the reception of the antiseptics by a careful cleansing of the mouth. Of the inedicament.s to be recommended, a dark solution of potassium permanganate or hydrogen sulphide are particularly- valuable. For sponging and flushing the mouth the former is to be used several times a clay, the latter in 2 per cent. strength three or four times daily.
In obstinate eases, if this does not succeed, the direct application of iodoform gauze soaked with aluminum acetate may be tried. Pencil ling the ulcers with zinc chloride (5 per cent., 2 times daily) acts almost as well as silver nitrate and has the advantage in that it does not attack the healthy mucous membrane.
Local treatment is effectively aided by the internal administration of potassium chlorate (2 per cent., small teaspoonful every two hours). In protracted cases the nutrition of the child needs careful attention. As has already been stated, the general condition in many cases may suffer severely. For this reason it is necessary to give the children a nutritious liquid diet (milk with food preparations, eggs, etc.) and special vigilance must be used to see that the patients take a sufficient quantity. If this cannot be done in the natural way, one should not hesitate to resort to forcible feeding by means of the stomach tube.