342 RULES FOR THE USE OF THE GUM-LANCET. spective of the nature of the affection from which it suffers. proceeding is nothing better than a piece of barbarous empiricism, which causes the infant much pain, and is useless or mischievous in a dozen instances, for one in which it affords relief. Still less is the gumlancet to be applied, merely with the view of expediting the process that nature is engaged in. The gradual protrusion of the teeth occasions the slow absorption of the superjacent gum, and for this process the division of the gum by a scalpel forms at best but a clumsy substitute. The circumstances under which the use of the gum-lancet is really indicated are comparatively few. You may employ it when a tooth is so nearly through that you can feel sure it will burst the gum in a day or two at latest, for then, by making an incision through the very thin gum, you may certainly spare the infant some suffering. Or, you may lance the gums if they be red, and swollen, and tense, and injected; but then you scarify them in order that they may bleed, and that their congested vessels may be thus relieved: you do not divide them to let out the imprisoned tooth. Under such circumstances it may be necessary to repeat your scarification several times with the same object ; and it is therefore well to explain beforehand to the mother the reasons of your proceeding, lest she should expect to see the tooth at once make its appearance. There are, besides, cases in which the general constitutional disturbance that often attends dentition continues for several days, or even weeks, while yet the condition of the swollen gum remains unaltered, and the tooth does not seem to approach nearer to the surface. In such a case you may try the experiment of lancing the gums, or you may try it in the case of a child in whom you have already observed that catarrh, or fever, or diarrhoea, has been excited by the approach of each tooth to the surface, and has ceased immediately that the tooth has pierced the gum. Lastly, in the cases of sudden, and apparently causeless convulsions, which are occasionally met with in children, you will be justified in lancing the gums if you find that the process of dentition is going on with activity; but you would do no good if you lanced the gums during one of those periods of repose which you will remember interrupt from time to time the evolution of the teeth. You must therefore inquire not merely what teeth the child has cut, but also when the last made their appearance; and must seek for some evidence either that the process is still going on, or that its activity is once more recommencing, before you would have ground for supposing the source of irritation of the nervous system to be such as your gum-lancet would relieve. If the process of teething be going on perfectly naturally, no interference, medical or other, is either necessary or proper. The special liability of children to illness at that time must indeed be borne in mind, and care must be taken not to make any alteration in the infant's food while it is actually cutting its teeth, but rather to choose the opportunity of some one of those pauses to which reference has been made, as occurring between the dates of irruption of the successive teeth, for any such change. Should the child at any time appear very feverish, some simple febrifuge medicine may be given; as for instance, GENERAL MANAGEMENT OF TEETHING CHILDREN. 343 a mixture of the bicarbonite of potash not quite neutralized with citric acid, to each dose of which two or three minims of the tincture of hyoscyamus may be added, if the child be very restless and fretful.1 The diet must be carefully regulated; and as the heat of the mouth may induce the child to suck too often, in order to obtain the grateful relief of moisture, and by so doing to overload its stomach, water or barleywater should be freely given to it; and the mother should be cautious not to put it too frequently to the breast. If the child have been. weaned, still greater care will be required, for it will often be found that it is no longer able to digest its ordinary food, which either is at once rejected by the stomach, or else passes through the intestines undigested. Very thin arrow-root made with water, with the addition of one third of milk, will suit in many cases; or you may occasionally substitute for this, equal parts of milk and water thickened by dissolving isinglass in it till its consistence equals that of thick barleywater; or may employ the white decoction of Sydenham with the addition of one part of milk. If the bowels be disordered, half a grain of Dover's powder night and morning will often restrain their over action; while the child may take during the day a mucilaginous mixture, containing small doses of the vinum ipecacuanha and of (No. 21.) 2 R Mistura Acaciæ, 3vj. Liquoris Potassæ, mxxx. Aquæ puræ, 3xiij. M. ziij. 6tis horis. For a child from 12 to 18 months old. some alkali, as the bicarbonate of potash or the liquor potassæ. The dysuria from which infants sometimes suffer when teething is relieved by a similar plan of treatment, with the addition of small doses of castor oil if the bowels do not act regularly; while the tepid bath is often extremely serviceable in diminishing that great heat of skin which exists in many of these cases. That state of the mouth in which small aphthous ulcers appear upon the tongue and about the alveola is usually connected with disorder of the digestive organs, to the relief of which our treatment must be chiefly directed. It is seldom necessary to do more locally, than to pay great attention to cleanse the mouth every time after the child has sucked or taken food, and afterwards to apply to it a solution of borax, in the manner I pointed out to you at the commencement of this lecture. Now and then the submaxillary glands become swollen and tender while the infant is cutting some of its teeth; but this condition generally subsides of its own accord. Sometimes, however, the irritation extends to some of the absorbent glands beneath the jaw or near its angle; and in scrofulous subjects they occasionally inflame and suppurate. In such children, too, strumous ophthalmia and otorrhoea are not infrequently excited by dentition. 1 See Formula No. 2, p. 43. 344 TREATMENT OF THE AFFECTIONS OF THE MOUTH. That severe form of inflammation of the gums to which the name of Odontitis has been given sometimes occasions great suffering, and may even endanger the child's life, though no instance has come under my own notice in which it proved actually fatal. The gum-lancet will here do no good whatever; its employment would be intensely painful, and that unhealthy ulceration which attends the inflammation of the gums would attack the edges of the cut, and thus aggravate instead of relieving the child's sufferings. Local depletion by leeches, however, is extremely useful in such cases. Some writers have suggested that the leeches should be applied to the gum itself; but I have always contented myself with the much easier plan of applying them to the angle of the jaw, and have seldom been disappointed in obtaining very marked relief of all the symptoms. The diet must be most carefully regulated, the state of the bowels attended to, and a mildly antiphlogistic plan of treatment adopted, while the borax lotion may be used locally with advantage. There is, however, one remedy which acts in the various forms of stomatitis almost like a charm, and which proves exceedingly useful even when inflammation of the mouth is associated with the process of teething. This remedy, for the introduction of which into practice in cases of stomatitis, the profession is indebted to Dr. Hunt, is the chlorate of potash, which may be given dissolved in water and sweetened, in the dose of one grain every four hours to a child a year old, with almost a certainty of effecting a cure in the course of four or five days. 1 In conclusion, I may just refer to those eczematous and impetiginous eruptions of the face and scalp which often occur in teething children. The old prejudice which regards diseases of the skin appearing at this time as having in them something salutary, and that consequently it is not desirable to attempt their cure, is not destitute of a certain foundation in fact. Instances of the sudden disappearance of eruptions on the scalp during the period of dentition, being followed by serious impairment of the general health, by convulsions, or by other signs of mischief in the brain, are far from uncommon. Their removal, therefore, must never be attempted except by the gentlest means, while every threatening of the supervention of cerebral congestion, or of more serious disease of the brain, must be most closely watched for and most vigorously combated. Sometimes, too, it will be found that whenever the cutaneous affection has made a certain advance towards cure, the signs of other disease invariably appear. In such a case it is wiser to content yourselves with keeping the local ailment in check, rather than, by persevering in the attempt to cure it, to endanger in far more serious respects the welfare of the child. 1 Medico-Chirurgical Transactions, vol. xxvi. p. 142. INFLAMMATION OF THE MOUTH. 345 LECTURE XXIX. INFLAMMATION OF THE MOUTH, OR STOMATITIS-its three varieties. Follicular stomatitis-often a secondary affection-most frequent before dentition is completed-its symptoms-character of the ulceration of the mouth-not a serious disorder. Its treatment. Ulcerative stomatitis-principally affects the gums-its course usually chronic-has very little tendency to degenerate into gangrene-Its treatment-the chlorate of potash almost a specific for it. Gangrenous stomatitis-extremely rare, but very fatal-essential differences between it and the other forms of stomatitis-dependent on alterations of the blood, such as occur in fevers-its mode of commencement, symptoms, and course-state of the gangrenous parts on dissection. Treatment-importance of efficient cauterization-what caustics are to be used, and how they are to be applied. The disease does not depend on the administration of mercury. CYNANCHE TONSILLARIS—unusual in young children-its symptoms not peculiar. HYPERTROPHY OF THE TONSILS-its frequency and importance in childhood-its symptoms-extreme dyspnoea sometimes produced by it-modifications it produces in form of mouth and nose-deformity of chest resulting from it, how produced.-Treatment -necessity for excision of tonsils. CYNANCHE PAROTIDEA—most common near period of puberty-epidemic and contagious -its symptoms-metastasis of inflammation rare-Treatment. AMONG the local accidents which complicate dentition, we noticed a condition of the mucous membrane of the mouth, which, though not attended by serious danger, is often the source of much suffering to the patient. Inflammation of the mouth, however, is an occurrence by no means confined to the period of teething, but it comes on in children of all ages, assumes very different forms, and leads to very different results in one case from those which characterize it in another. The mucous follicles of the mouth are the chief seat of the disease in one case, the substance of the gum in another, that of the cheek in a third. In the first, the affection issues in the formation of several small ulcers, which heal eventually of their own accord; in the second, an unhealthy process of ulceration destroys the gums and denudes the teeth, but it is tardy in its advance, and tends to a spontaneous cure; while, in the last, mortification involves all the tissues of the cheek, and spreads with a rapidity which remedies generally fail to check, and which is arrested at last only by the patient's death. Each of these varieties of stomatitis requires from us more than a passing notice. The first the follicular stomatitis of some writers, the aphthous stomatitis of others, is met with either as a concomitant or sequela of measles, or as an idiopathic affection. In the former case it depends on the extension to the mouth of a state of inflammation similar to that which gives rise to the eruption on the skin; in the latter, it is often associated with obvious gastric or intestinal disorder. Under either of these conditions it is rare after five years of age; and though it often depends on causes quite independent of dentition, yet from the period 346 SYMPTOMS OF FOLLICULAR STOMATITIS. when teething has commenced, to the end of the third year, is the time of its most common occurrence. When it constitutes an idiopathic affection, more or less fever, and restlessness, loss of appetite, and unhealthy state of the evacuations, and frequently a relaxed condition of the bowels, precede the local ailment for several days. Attention is generally called to the state of the mouth by the child being observed to suck, or to take food, with manifest pain and difficulty; while at the same time the secretion of saliva is greatly increased, and the submaxillary glands are swollen and tender. The mouth is hot, its mucous membrane generally of a livid red, while a coat of thin mucus covers the centre of the tongue. On the surface of the tongue, especially near its tip, on the inside of the lips, particularly on the lower lip and about its fold, on the inside of the cheek, near the angles of the mouth, and less often in other situations also, may be seen several small isolated transparent vesicles, or the ulcers which, after bursting, they leave behind. The ulcers are small, of a rounded or oval form, not very deep, but having sharply-cut edges; and their surface is covered by a yellowish-white, firmly-adherent slough. When attention is first directed to the mouth, several of these small ulcerations usually exist, for the vesicular stage of the affection appears to be generally very short, while the ulcers are indolent, and sometimes continue for many days without shewing any disposition to heal or to increase in size. The eruption of a single crop of vesicles, and the change of these vesicles into minute ulcerations, that heal in the course of time, do not complete the history of this affection, for while the mucous membrane in the situation of some of these ulcers at length resumes its natural condition, other vesicles appear, which again degenerate into little ulcers, and thus keep up the ailment, sometimes for weeks together. In some cases, not above five or six of these little ulcers exist at once, or they may even be less numerous, while it is very seldom that more than fifteen or twenty of them are observable at one time. By the successive appearance of fresh ulcerations, and the coalescence of several, an ulcerated strip of considerable extent sometimes forms, especially at the tip of the tongue, or on the lower lip. When the ulcers are healing not change in their aspect is observable, and they continue to the last covered by the same yellow slough, but by degrees they diminish in size; and seldom or never is any cicatrix observable in the situation which they occupied. In some cases the affection is complicated with a herpetic eruption about the edges of the lips, the vesicles of which. degenerate into ulcerations similar to those observed in the interior of the mouth, and by their soreness add very much to the sufferings of the patient. Even though no remedies be employed, this affection shows no tendency to rapid increase, neither is it, in general, associated with any disposition to the formation of false membrane in the mouth, still less with any tendency to gangrene. It is sometimes a source of much annoyance to the child, but need never excite any serious solicitude, except when it occurs as a sequela of measles. In that case, however, as was observed some days ago, it occasionally becomes associated with diphtheritic deposits on the fauces, and with ulcerative inflammation of |