While follicular stomatitis is more common during the first eighteen months or two. years of life, the ulcerative form of stomatitis is most fre quently seen after the age of two years, when the first dentition has been completed. The disease is a common one in hospital out-patient rooms, and appears to be predisposed to by insanitary surroundings, a poor die tary, a weakly constitution, or a cachectic state. On this account it may be seen in children who are overfed during convalescence from an acute ill ness, and is an occasional consequence of a gastro-intestinal disorder. It is said, also, sometimes to be epidemic. Its immediate cause is often un cleanliness of the mouth, allowing of the accumulation of tartar on the teeth, and sometimes it is set up by the irritation of a decayed tooth. In rickety children, and those whose teeth decay rapidly and whose general nutrition is unsatisfactory, ulceration of the gums is not an uncommon source of discomfort. The influence of feebleness of health, and an in sufficient dietary, in producing the derangement, is so marked as to seem to justify Dr. Cheadle's suggestion that many cases of ulcerative stomatitis occurring in ill-nourished children may be due to undeveloped scurvy.
In addition to the causes which have been mentioned, ulcerative stoma titis may be one of the consequences of a special constitutional disease. Thus, it is sometimes present in cases of lymphadenoma, being then due to the development of the lymphoid growth in the sub-mucous tissue.
Symptoms.—The ulceration begins in the gums, and is often confined to them. The gums at the affected part become red, swollen, and spongy looking, either generally or in patches. Their edges, especially where they rise up between the teeth, are soft, red, and unusually prominent, and they bleed very easily. The colour then grows deeper and more purple, and often at the borders of the gum the tooth is of a greenish-yellow colour. There is some pain in mastication ; salivation is copious, and an offensive odour is noticed from the mouth. Soon a soft, pultaceous, grayish-yellow matter forms upon the inflamed mucous membrane. This appears to arise from gangrenous softening of its most superficial layer, and adheres very closely to the tissue beneath it. If detached, an ulcerated surface is dis
covered, irregular in shape, grayish in colour, and bounded by a well-defined bright red line. If treatment is not promptly resorted to, the disease usu ally spreads from the gums to the tongue, the cheeks, and the lips. On the tongue the lesion is usually limited to the part of the organ in contact with the affected gum ; and, indeed, in the majority of cases, the ulceration is confined to one side of the mouth, and both cheeks are rarely affected at the same time. The shape of the ulcerated surface varies according to its seat. On the lips it is more or less circular ; on the gums it is elongated, and on the interior of the cheek, from conjunction of several neighbouring ulcers, it is irregular or sinuous.
As a consequence of the ulceration of the gums, the corresponding teeth often become loose, and sometimes fall out. Chewing fs very painful, and the child is unwilling, by movement of his jaws, to increase his discomfort. Even the motions necessary for swallowing the copious saliva seem to be painful, for a young child allows it to flow away from his half-open month. Like the breath, the salivary secretion is horribly offensive, and is often streaked or more or less discoloured with blood. If there is disorder of the stomach, the effort of retching may cause a more copious hmmorrhage from the inflamed and ulcerated surfaces ; and the blood, mixing with the vomited matters during their passage through the mouth, may appear to come with them from the stomach.
When the cheek becomes affected there is some swelling, but this is moderate, and no induration can be detected. The sub-maxillary glands are swollen and sometimes painful. The general health of the child suf fers much less than might be expected. During the first few days the temperature may rise to 102°, or even higher ; but the pyrexia quickly -subsides, and the nutrition of the patient appears to undergo little change unless diarrhoea occur. The duration of the complaint is very variable. If proper measures are taken, the ulceration is soon at an end ; but if left untreated, the lesion may persist for months, and is said sometimes to pass into cancrum oris.