LECTURE XXXII.

ATROPHY OF YOUNG CHILDREN-not a special disease, but a condition that may be induced by various causes.

THRUSH, a peculiar affection of the mouth, generally associated with impaired nutrition-its characters, different opinions as to its nature-general state of children in whom it occurs. Microscopic researches as to its nature, the deposit produced by a cryptogamic vegetation-conditions that favour its development—inferences as to its treatment.

DENTITION-high rate of mortality while it is going on-erroneous views with reference to the cause of this, and to the nature of the process-physiology of dentitionorder of appearance of the teeth-pauses in their evolution-frequently attended with local suffering―various morbid conditions of mucous membrane of the mouth excited by it.

Management of children when teething-circumstances in which lancing the gums is likely to be useful-dietetic and medical management-treatment of affections of the mouth-caution with reference to cure of cutaneous eruptions during the time of teething.

Ar our last meeting we were occupied with various preliminary enquiries, of importance to the thorough understanding of the diseases of the digestive organs in early life, on the study of which we are now about to enter. We examined the structural and functional peculiarities of those organs in the young, and endeavoured to ascertain wherein consists the special fitness of the mother's milk for the nutriment of her infant. We further tried to discover the mode in which other food acts injuriously on the infant, and sought from the knowledge thus acquired to deduce rules for our guidance, whenever it should become necessary to provide a young child with a substitute for that sustenance which nature intended that it should receive.

These considerations naturally brought under our notice the symptoms which betoken that the process of nutrition is imperfectly carried on, and the appearances which, when death takes place from this cause, are revealed on an examination of the body. It may seem to you, however, that the atrophy of young children calls for a more elaborate study than ours of yesterday. and for a more minute account of its symptoms. But to attempt this would be to enter upon almost endless details, which would leave upon your memory no clear impression. Whether all food

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is withheld from an infant, or whether it is supplied with food. which it cannot assimilate, or whether disease prevents it from. digesting food on which a healthy infant would thrive, the main result is the same, and the child dies of inanition. Various accidents may abridge the infant's life, or may make it sink in one case, in circumstances somewhat different from those which precede its death in another. Sometimes the vital powers grow so feeble that the inspiratory efforts no longer suffice to fill the lungs with air; sometimes the irritable stomach rejects all food, while at other times diarrhoea comes on which no medicine can check. But in these symptoms there is nothing characteristic of one special cause, they may occur alike in the infant who, though healthy when born, was early deprived of its mother's milk, or in the child who is the subject of general tuberculous disease, or whose strength has been exhausted and its digestive powers impaired by dysentery. The symptoms, then, that accompany the atrophy of new-born children must be expected to vary much in different cases; while the considerations brought before you in the last lecture will, I think, furnish you with a clue to the complete understanding of them all.

Before we pass, however, to the special study of the diseases of the digestive organs and their appendages, I wish to call your attention to that peculiar condition of the mucous membrane of the mouth, popularly known as the thrush, which is so frequently met with in connection with the artificial feeding of young infants, so almost invariably associated with the evidences of their impaired nutrition, that the present seems to be the best place for noticing it.

If you examine the mouth of a young infant on whom the attempt is being made to bring it up without the mother's milk, you will often observe its mucous membrane to be beset with numerous small white spots, that look like little bits of curd lying upon its surface, but which on a more attentive examination are found to be so firmly adherent to it as not to be removed without some difficulty, when the subjacent membrane is left of a deep red colour and often bleeding slightly. These specks appear upon the inner surface of the lips, especially near the angles of the mouth or the inside of the cheeks; and upon the tongue, where they are more numerous at the tip and edges than towards the centre. They are likewise seen upon the gums, though less frequently, and in smaller number. When they first appear they are in general of a circular form, scarcely larger than a small

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THRUSH-ITS GENERAL SYMPTOMS.

pin's head; but after having existed for a day or two some of the spots become three or four times as large, while at the same time they in general lose something of their circular form. By degrees these small white crusts fall off of their own accord, usually leaving the mucous membrane where they were seated redder than before-a colour which gradually subsides as the mouth returns to its natural condition; or the white specks are reproduced and again detached several times before the membrane resumes its healthy aspect. In some cases these specks coalesce, or the deposit, from its first appearance presents more of the character of a false membrane, and the mouth is then seen to be extensively coated with it; though even then, if the deposit is carefully removed, the mucous membrane beneath will be found neither bleeding nor abraded, but merely redder than natural. In these circumstances the deposit generally loses something of the dead white colour characteristic of the smaller spots, and presents a slightly yellowish tint. On the continent, where the severer form of the affection is not infrequently seen, it was supposed, though the opinion is now with propriety abandoned, to be an essentially different ailment from the slighter forms of the disease, in which the points of deposit are distinct, while further confusion was introduced into the subject by the employment of the term aphtha* to designate both this affection, and another of a perfectly different nature (which I shall speak of hereafter), characterised by inflammation and ulceration of the mucous follicles of the mouth. The term aphtha will be most properly employed as a synonym for this follicular stomatitis; while I prefer to restrict the use of the word thrush,t of which the French muguet, the old English term millet, are synonyms, to the ailment some of whose characters I have just described, and for which there is at present no correct designation in scientific terminology.

Children in whom either form of this deposit exists in any considerable degree usually appear out of health; and it will generally be found on enquiry that this indisposition had preceded for some days the eruption in the mouth. For the most part

* The use of the word apea by Hippocrates, and its application by him to ulcerations of the uterus, plainly shows that in his mind the idea of a breach of surface was always associated with it; though it is very probable that under a mistaken belief of its nature he may also have used the same word to designate true thrush. See Foesius, Economia Hippocratis, sub voce.

A word the etymology of which is uncertain; as is that of its Swedish synonym Torsk, and the Danish and Norwegian Trödske.

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such children are emaciated, and present those symptoms that attend upon imperfect nutrition, while the bowels are in general relaxed, and the evacuations of a green colour, and very sour. The acridity of the motions sometimes irritates and inflames the margins of the anus, and a blush of erythematous redness not infrequently extends over the nates and buttocks, while in some instances a deposit of a similar kind to that in the mouth occupies the edges of the intestine. In spite, however, of the popular notion with reference to this point, the appearance of the deposit at the margin of the anus is of extremely rare occurrence, though redness and soreness at the edge of the bowel are very frequent. The deposit in the mouth sometimes renders sucking very difficult, and may even impair deglutition, while the child, thus obtaining but little food, lies in a state of torpor and drowsiness, the result of its debility.

In its more serious form this affection was said to prove fatal to a large number of the inmates of the different foundling hospitals on the continent. Observation has shown, however, that although the deposit exists in the mouth of very many children who die in those institutions, yet their death is due not to the local affection, but to the constitutional disease, of which that is only one out of many evidences.

In spite of the exaggerated importance that was long attached to the local affection of the mouth, which was erroneously imagined to be the cause of all the symptoms of disordered health, of which it is in reality merely the accompaniment, much uncertainty existed as to its real nature, though it was generally imagined to be a variety of pseudo-membranous inflammation, not unlike that of croup or diphtheria. This hypothesis, however, which left many peculiarities of the disease unexplained, has been conclusively set aside, and the real nature of this, as of so many other ailments, has been made quite clear by microscopic research.

In the year 1842 Professor Berg, of Stockholm, physician to the Foundling Hospital in that city, communicated to the Swedish Society of Medicine his discovery of a cryptogamic vegetation in the deposit of thrush; and a German observer, M. Gruby, confirmed M. Berg's researches in a paper addressed in the same year to the Royal Academy of Sciences at Paris, though his views differed in some points from those of M. Berg. From the time of this discovery two opposing views of the nature of the affection have till recently been maintained. According to

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MICROSCOPIC CHARACTERS,

the one opinion, the parasitic growth, like the muscardine on the silk-worm, or the confervæ developed on other living animals, itself constitutes the essential part of the disease; while, according to the other, the white substance in the mouth is in reality an inflammatory exudation, in which, though confervæ may be developed, yet their presence is accidental, and subject to many exceptions.

The correctness of the former opinion, which was maintained by M. Berg, and substantiated in great measure by his researches, has now been so generally admitted that I need not further occupy your time with details of the controversy, but will describe as briefly as possible the nature of the affection, as it has been ascertained by means of the microscope; and as it is described by one of the most recent observers, M. Robin.*

In connection with various disorders of the digestive apparatus in children, and also in the course of some exhausting diseases in the adult, the mucous membrane of the mouth, and sometimes also that of the pharynx and oesophagus, becomes the seat of inflammation, which, though by no means severe, is yet attended with a change of the secretion from alkaline to acid, and with an abundant production of epithelium. This state of the mucous membrane, though not absolutely essential, is yet in the highest degree favourable to the development on its surface of a fungus, the Oidium albicans, the sporules of which in these circumstances increase with great rapidity, and elongate into tubular fibrils, by whose multiplication and accumulation, together with the abundant epithelial scales, a thick white layer is formed upon the dorsal surface of the tongue, the palate, the velum, the interior of the cheeks, the lips, and even in some cases the pharynx and œsophagus. It appears, too, that during the first

*Not to encumber this lecture with the citation of authorities, it may suffice to refer to the valuable essay of Dr. Berg, of Stockholm, analysed in the Journal für Kinderkrankheiten for September and October 1847, and since translated into German, under the title Ueber die Schwämmchen der Kinder, 8vo. Bremen, 1848, as a most able defence of the first-mentioned opinion; and to the papers by Dr. Kronenberg, of Moscow, in that journal for February and September of the same year, for observations and arguments tending to support the opposite view. The elaborate essay of M. Seux, in his Recherches sur les Maladies des Enfants, 8vo. Paris, 1855, also claims mention here, for in it every question connected with this affection is treated of with an almost painful minuteness. With reference to the production of confervæ on the mucous surfaces of the human body in disease, the fullest account has been given by Hannover, in Müller's Archiv, for 1842, p. 281; and by M. Robin in his Histoire Naturelle des Végétaux Parasites qui croissent sur l'Homme et sur les Animaux vivants, Svo. Paris, 1853.