stomatitis (caner= oris, or noma) is fortunately much less common than the other inflammatory affections of the mouth and cheeks. The disease is a very serious one, and in the large majority of cases proves fatal to the child. Even when recovery happily occurs, the destruction of tissue, if at all extensive, leads to very unsightly contraction of the side of the face.
Causation.—Cancrum oris is seldom seen, except in hospital practice, or amongst the poor. It appears to be one of the consequences of a weakly habit of body, and is most probably predisposed to by insanitary condi tions and insufficient food. The cases which have come under my notice have been in children at the East end of London, living in miserable, squalid dwellings, and very poorly clothed and fed. Sometimes the gan grene arises as a sequel of a specific fever or serious inflammatory dis ease. Thus, it has been known to follow measles, typhoid fever, scarlatina, and small-pox. It may appear in scrofulous and tubercular subjects, or in children who have been exhausted by a prolonged attack of broncho pneumonia, or catarrhal derangement of the bowels: It is doubtful whether the injudicious and prolonged use of mercury can set up the disease. That it can do so, although stated positively, has been denied with much reason. In any case, it is important not to mistake the early symptoms of the dis ease for those of mercurial poisoning.
Ulcerative stomatitis is said, in rare cases, to end in cancrum oris. The two diseases appear to be induced by very similar conditions. A little girl, aged five years, died in the East London Children's Hospital from exten sive gangrene of the right side of the face. A few days afterward, her brother, aged seven years, was admitted with severe ulcerative stomatitis, inside the left cheek. The parents of these children were very poor, and the patients themselves had been half-starved and very insufficiently clad. Neither had lately suffered from any acute disease. Cancrum oris is rarely seen after the sixth year, and girls are said to be more subject to it than boys.
111orbid Anatomy. —On post-mortem examination of cases of gangrenous stomatitis, the affected part of the cheek or lip is found to be swollen, tense, and hard to the touch. It presents, at its most prominent part, a dry, black, well-defined slough. This varies in size and shape, according to the extent to which the mortification of the tissues has spread. It may
dip more or less deeply into the substance of the cheek, and always in volves both surfaces. The tissues in the neighbourhood of the slough are thickened, infiltrated, and hardened. Often the dry, black eschar occupies the surface of the cheek ; beneath it, the tissues are swollen and indurated, and in the interior of the mouth, at the affected part, the mucous mem brane is seen to be occupied by a greyish ulcerated surface, or a moist, loose slough, which can be readily scraped away with the handle of the scalpel.
The gums at the seat of disease are often sloughy and soft ; the teeth are loosened, and the alveolar processes blackened and necrosed. Some times the lymphatic glands in the neighbourhood are enlarged.
According to Rilliet and Barthez, the smaller blood-vessels of the dis eased cheek are obliterated by coaguim where they pass through the mor tified tissues. In parts merely infiltrated and swollen they are still perme able, although their walls are thickened. Batta Segale states that he has discovered micrococci and bacilli in the detritus obtained from the gan grenous lesion, but it is not clear that the noma was dependent upon the presence of these organisms.
Other organs may be the seat of disease. Bronchopneumonia is very common, and pymmic abscesses have been found in the lungs. Sometimes gangrene of other parts has been seen, especially of the lungs and the vulva or scrotum.
Symptoms.—In some cases pain in one side of the face is the first symptom complained of. The child looks pale and ill ; the face begins to swell, and at the same time, or soon after, examination of the cheek de tects a firm spot, around which the tissues are soft and oedematous. At this stage, inspection of the interior of the mouth will discover a small greyish ulcer of the mucous membrane, corresponding to the hardened spot felt in the substance of the cheek. The breath has a gangrenous odour, and a dark bloody saliva escapes from the mouth. There is little or no fever ; the pulse is small and frequent, and the child is unwilling to take solid food, probably from the pain excited by mastication. Soon the affected cheek becomes tense and shining, the swelling increases, and a small red spot forms on the surface. At thesame time a brown slough developes on the mucous membrane.