points make their appearance at the extremity, or on the sides of the tongue, or at the angles and on the inner surface of the lips. These points have the appearance of minute fragments of curd adhering to the parts mentioned, the latter being of a dark-red color, hot and drv.

In mild cases, the inflammation, in a short time, disappears; the particles of white curdy matter become detached, and fall off, leav ing the membrane beneath of a smooth and healthy appearance.

Should the inflammation continue unabated, the points of curdy matter increase in number, and often extend over the whole surface of the tongue and mouth, or a number of the points unite together upon the tongue or inner surface of the lips and cheeks, in the form of patches, often of considerable thickness. These patches, sooner or later, become detached, and their place is quickly supplied by a new exudation. This separation and renewal of the patches are repeated so long as the inflammation continues. In other instances, however, the patches formed upon the tongue, and upon the inside of the lips and cheeks, coalesce, and the whole of these parts become covered with a whitish granulated crust, which often extends into the fauces, pharynx, and in some cases into the larynx.

The general symptoms vary with the degree of intensity in the local disease. When the latter is slight, and of short duration, the child is fretful, or dull and peevish; he exhibits pain from the motions of the mouth in sucking, or in taking food, especially when this is warm or in the slightest degree stimulating. In general, the surface of the body is hot and dry, and the thirst is increased.

In the more aggravated forms, there is often great restlessness, alternating with drowsiness, with disturbance of the stomach and bowels, and other symptoms dependent upon the affection of the alimentary canal, with which the inflammation of the mouth is very generally associated.

The duration of the disease is various; in slight cases it terminates in a few days; in others it may continue much longer, without producing any very severe or alarming symptoms. Excepting when complicated with inflammation of the alimentary canal, it is usually a troublesome, rather than a dangerous affection.

In those cases in which large patches of exudation form upon the inside of the lips or cheeks, or upon the velum of the palate, the disease, particularly in situations where a number of children are crowded together in ill-ventilated apartments-occasionally assumes a malignant character, and is then attended with very considerable danger. The patches of exudation acquire a dark color-the breath becomes fetid-the submaxillary glands enlarge and become painful-and the face swollen, and of a dusky red. The lips and gums become tumid, and bleed upon the slightest touch-while a fetid sanious saliva flows constantly from the mouth. Diarrhoea, also, often attends; the discharges being dark-colored and highly offensive. The surface of the body becomes dry and hot, and the child sleepless and restless. Finally, the patient sinks; death being occasionally preceded by a deep comatose condition.

The usual causes of this form of stomatitis, are bad or improper food, a neglect of cleanliness, and confined and impure air. It is often produced by the bad quality of the mother's milk, or by feeding the child with food unadapted to the condition of its digestive organs. Children prematurely weaned seldom escape an attack of it. It is very prevalent, in public institutions, where many infants are crowded together, especially in small, ill-ventilated rooms.

By some writers it has been supposed to be communicated by contagion; we know of no facts, however, in support of such an opinion. Baron, Billard, Valleix, Trousseau, and Guersent, deny its contagiousness excepting upon direct contact. Girelli states that he has known healthy infants to become attacked by sucking from the same breast as those affected with the disease; a similar statement is made by Marley. This fact may, however, be very readily explained by the deteriorated condition of the nurse's milk, without the necessity of admitting the communication of the disease by a contagious matter, derived from an infected infant, and communicated by the nipple it has sucked. M. Guersent states that he has known the thrush to be communicated from the nursling to the breast of the mother.

The true character of the disease appears not to be very generally understood. By the majority of medical writers, it has been confounded, as we have already remarked, with aphthæ, in connection with which it occasionally occurs. Breschet, Guersent, Veron, Lélut, and Billard, have studied both diseases with great care, and it is evident, from the result of their observations, that, while aphthæ are the result of follicular inflammation, the curd-like exudation, which takes place in the erythematic inflammation of the mouths of children, is the result of an altered secretion from the inflamed mucous surface. This may occur in the form either of small white particles or flocculi, or, as in other diphtheritic inflammations, of large patches of a soft pseudo-membranous matter, which Lélut has attempted to show is analogous to, or identical with the false membrane of croup; Billard terms it coagulated mucus, and Guyot, mucus rich in fibrine. Upon the separation of these morbid exuda tions, the membrane beneath is found to be smooth, and without solution of continuity; this fact we have tested in numerous examinations. According to Guersent, the morbid exudation is deposited beneath the epithelium, and its separation is consequent upon the rupture of the latter:-Plumbe is of a similar opinion. Guyot and Billard, however, never saw it in any case, excepting upon the surface of the epithelium, and this accords with our own observations.

Recently, Gruby has attempted to show that the disease is invariably produced by the development, upon the buccal mucous mem brane, of a cryptogamic vegetable.

According to the researches of this gentleman, the affection consists, at first, of small, conical, whitish elevations, twenty-five millimetres in diameter, dispersed over the mucous membrane of the mouth. These elevations quickly augment in size, and extend rapidly over the adjacent surface, until, finally, the whole of the mouth, fauces, and sometimes the entire extent of the alimentary canal, appear to

be covered with a pseudo-membranous layer, from two to three millimetres thick, and strongly adherent to the subjacent tissue. When a portion of this substance was examined under a microscope, Gruby found it to be composed entirely of a collection of cryptogamic plants, the roots of which, of a cylindrical form, transparent, and about the one-four hundred and eightieth part of a millimetre in diameter, are implanted in the cellules of the epithelium. During their development, projections from these roots penetrate the entire series of cellules of which the epithelium is composed, to arrive at the free surface of the mucous membrane.

According to Gruby, these cryptogamic plants have considerable analogy with the sporotrichium described by some botanists. Being very fragile, they become detached by the movements of the tongue and lips, and, mixing with the food, are carried into the alimentary canal, a considerable portion of the mucous coat of which they subsequently cover. The children in whom this extension of the disease takes place to any great extent, fall into a state of marasmus, and soon die.

Gruby, having never detected in the white matter anything else than the cryptogami just described, and the cellules of the epithelium-in no instance any product of inflammation being present-concludes, therefore, that the affection is nothing more nor less than a vegetation occurring upon the living mucous membrane. Views precisely similar to those of Gruby have been advanced by Dr. Berg, of Stockholm.

Dr. Oesterlein has also submitted the matter in question to microscopic examination, and has detected in it a vegetation similar to that described by the observers just named. This vegetation he has met with, however, only at the period of the fullest development of the disease, which latter he considers to be the product of an exudation resulting from an inflammatory condition of the mucous membrane. The production of the confervæ being, according to him, purely accidental. He attempted, repeatedly, to transplant them to other animal tissues or fluids, but without success.

Bouchut states that he has had many opportunities of verifying the correctness of Gruby's observations. They are indorsed, also, by Berg, Robin, and Green.

There is some dispute among medical writers as to how far this morbid exudation extends beyond the mouth and fauces. It is ge nerally admitted that, in severe cases, it has been found in the œsophagus as far down as its cardiac orifice. Some, including Billard and Valleix, have asserted that it has been observed throughout the entire tract of the alimentary canal, others, with Veron, maintain that it has, in no instance, been known to occur beyond the oesophagus-the curd-like crusts, occasionally found in the stomach, being, in their opinion, conveyed thither from the mouth, by deglutition. Guyot, however, gives a case in which the disease was detected after death, throughout nearly the whole tract of the intestines. We have not had many opportunities ourselves of examining after death the condition of the alimentary canal in infants affected with stoma

titis with curd-like exudation; in the few we have examined, we were never able to trace the disease beyond the oesophagus:-a similar statement is made by both Dewees and Eberle. Valleix maintains that the disease is almost invariably attended with softening of the gastro-mucous membrane, often accompanied by redness and thickening. There can be little doubt that in the majority of fatal cases, various morbid alterations of the mucous membrane of the alimentary canal are present, but these alterations have evidently no necessary connection with the disease of the mouth.

The treatment will depend very much upon the extent of the local affection in each case, and of the morbid condition of the alimentary canal, with which it is accompanied. In the milder cases, the frequent application to the parts affected, of some emollient wash, as directed in simple erythematic inflammation, with proper attention to the food of the child, the daily use of the warm bath, and exposure to a dry and pure atmosphere of a proper temperature, will be sufficient to effect a cure.

In the more severe and obstinate cases, Guersent advises a fourth part of chloride of soda to be added to the mucilaginous wash, and Billard a small quantity of alum; while Dr. Darling speaks in the highest terms of the solution of chlorate of soda. The application which we have found the simplest and most successful, is the borate of soda and white sugar-equal parts-rubbed together; a small portion of which, being occasionally sprinkled on the infant's tongue, soon becomes dissolved by the saliva, and applied to every part of the mouth; or the borate of soda may be mixed with honey, in the proportion of one part of the former to six or eight of the latter. By some practitioners a solution of borate of soda in water, with the addition of a fourth part of alcohol, sweetened with honey or sugar, is preferred. In many cases we have found the most decided good effects result from the weak solution of acetate of lead, noticed when speaking of simple erythematic stomatitis. Whatever washes. are used, great care should be taken in their application, to avoid all harsh rubbing, or, indeed, any degree of friction of the inflamed surface.

When large patches of curdy exudation occur, these may be touched with a mixture of hydrochloric acid and honey (one drachm of the acid to one ounce of honey), and when the exudation assumes a gangrenous aspect, a wash of chloride of lime,' or of a strong de coction of Peruvian bark with chloride of soda;2 a mixture of creasote and mucilage, or of vinegar and alcohol,' or a solution of nitrate of silver (from two to four grains to the ounce of water), may be employed, and repeated at shorter or longer intervals, according to circumstances.

3

In even the mildest forms of the disease, acidity of the alimentary canal, with some degree of diarrhoea, are often present; for this occasional small doses of magnesia and rhubarb with ipecacuanha,' will be found advantageous. In all the more severe cases, alterative doses of calomel, combined with magnesia or prepared chalk and ipecacuanha, will be demanded; and in those in which the exudation in the mouth assumes a gangrenous aspect, quinia should be administered.3

When combined with disease of the alimentary canal, the latter is to be treated by its appropriate remedies.

Follicular inflammation of the mouth is a frequent disease of infaney and childhood, and constitutes the affection ordinarily described as aphthæ, by medical writers. It is more commonly observed about the period of dentition, than at an earlier age. It is especially liable to occur in children in whom the lymphatic temperament predominates, or in whom hæmatosis is rendered imperfect, by improper or unnutritious food, a damp and cold, or an impure and stagnant atmosphere, exclusion from the light, and neglect of cleanliness. It is likewise a common occurrence in the course of most of the chronic affections of the intestinal canal.

The disease usually commences by the appearance of a few small white specks on the inner surface of the lips and cheeks, and upon the sides and inferior surface of the tongue, and often over the greater part of the soft palate. These specks are slightly elevated, and usually surrounded by a red circle, more or less decided. They may be few in number, and irregularly dispersed over the angles and inner surface of the lips and cheeks; or they may occur in groups upon the lips, cheeks, and sides of the tongue; or they may cover every portion of the cavity of the mouth; extending, in some cases, into the oesophagus, and even throughout the alimentary canal; in others penetrating into the pharynx, and, according to some writers, into the trachea also.

The inflammation of the follicles will often continue, for some time, without making any further progress; or, as often happens, the disease may be arrested in its first stage and the mucous membrane of the mouth return to its natural condition.

If, however, the inflammation continues, the specks enlarge, a