K?
■
■
Hi
2:sJ*
/&3
LECTURES
THEORY AND PRACTICE
PHYSIC.
BY WILLIAM STOKES, M.D.,
LECTURER AT THE MEDICAL SCHOOL, PARK STREET, DUBLIN; PHYSICIAN TO THE MEATH HOSPITAL, ETC., ETC.
AND
BY JOHN BEEL, M.D.,
LECTURER ON MATERIA MEDICA AND THERAPEUTICS ; FELLOW OF THE COLLEGE
OF PHYSICIANS OF PHILADELPHIA;
CORRESPONDING SECRETARY OF THE PHILADELPHIA MEDICAL COLLEGE ;
MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, AND OF THE GEORGOFILI
SOCIETY OF FLORENCE, ETC., ETC.
SECOND EDITION
IN TWO VOLUMES. VOL. I.
ED. BARRINGTON & GEO. D. HASWELL.
NEW YORK — J. &. H.G. LANGLEV : CHARLESTON, S. C.-WM. H. BERRETT.
RICHMOND, VA. — SMITH, DRINKER, AND MORRIS.
LOUISVILLE, KY.-JAMES MAXWELL, JR.
18'42.
[Entered, according to act of Congress, in the year 1842, by Barring-ton and Haswell, in the clerk's office of the district court for the eastern district of Penn- sylvania.]
WB
i fix
v.l
PREFACE
TO THE SECOND EDITION.
It was not without some misgivings that I undertook, two years ago, to edit the Lectures of Doctor Stokes, — fearing that my addi- tions might not enhance the value of this gentleman's labours, and knowing that adequate scope was not allowed me for separate efforts. The rapid ^ale of a large edition of our joint work has, however, reassured me on these points, while it has imparted fresh desire to contribute a fuller share on my part than was required of me on the former occasion. In order to preserve a harmony, in one respect at least, between the British and American portions of the present edition, I have continued the lecture style throughout.
By the large additions which it has received, the work is now made to assume the character of a System of Medicine more than heretofore ; at least, the circle of the most important and violent diseases, those which constitute the chief outlet to human life, is in a great measure complete. It consists at present of the following classes of diseases : — I. The Digestive System ; II. The Biliary Ap- paratus; III. The Spleen and Pancreas; IV. The Urinary Appa- ratus ; V. The Respiratory Apparatus ; VI. The Heart ; VII. The Nervous System ; VIII. Fevers. Of these classes, the third, fourth, fifth, and sixth, are contributed for the first time, and constitute large and material improvements in the present edition. To the first class, or the Diseases of the Digestive System, my additions, both on the score of number and detail, have been considerable. It may, perhaps, be alleged, that to one of these, Epidemic Cholera, I have allowed disproportionate space; but, if the extent of its range — diffusion over the whole earth, its mortality — equal to the destruc- tion of millions in a few years, the suddenness of its invasion, and the rapidity of its progress, leaving often little time for study or counsel, be considered ; and if, also, we bear in mind the fact, that, numerous as have been the separate publications on this dread malady, there is no one to which we can refer for anything like a complete history of its pathology and medical treatment, or of the hygienic con- siderations of cause and prophylaxis, it will, I hope, be conceded that the task which I have attempted, however imperfectly exe- cuted, was becoming the requirements of the case. The disease may again appear among us, and it will be, of course, desirable
IV PREFACE.
that the practitioner called upon, in the emergency, should be p^ prised of his true position, as regards the benefit which rna) expected from any remedy or particular plan of treatment, not encouraged by the success of his predecessors, it will be is duty not to repeat their vain trials, and not to expose himself to their failures by the same mistakes and deficiencies.
In preparing the lectures on the Diseases of the Respiratory System, I have incorporated much valuable matter derived from the work of Dr. Stokes on the Diagnosis and Treatment of Diseases of the Chest, besides that which appears in a lecture form, as directly from him, but, also, taken from the work just mentioned. On this last point, an explanation, if not apology, is due to Dr. Stokes, — not for any change of his language or train of argument ; for the text, with the exception of a few words, has not been altered, but for my arranging in quasi lectures some of the matter which he published in a volume, without his having previously presented it in this shape. The only difference, however, between the originally printed matter and that which I have introduced formally as from Dr. Stokes, is in its receiving the division and headings of lectures. Perhaps less objection will be found with this innovation, as there was not even a division into chapters in the work on Diagnosis and Treatment of the Diseases of the Chest.
The class of Fevers has not been treated so much in extenso as precedent would have warranted ; but by withholding common- place literature, and the mystical disquisitions of the past age, without, however, yielding too much to the arithmetical affectation of the present, and by steadily bearing in mind the wants and ex- pectations of the American practitioner for information respecting the fevers of the United States and analogous climates, rather than those of European hospitals, camps, and jails, less disappointment will, it is hoped, be felt at my abbreviations on this head. I have curtailed to some extent my former lectures on Congestive Fever, but have still retained those distinctive features which imparted to them that interest in the minds of the physicians of the South and West, which I was sanguine enough to anticipate when I first took up the subject. Let me, in conclusion, exhort them to send back to us in the city, in return for our issues, full and carefully prepared his- tories of their fevers; for a complete elucidation of the nature and treatment of which they must not look to the hospital statistics nor collegiate teaching of Europe, without the aid which it is in their power so amply to supply.
JOHN BELL.
CONTENTS OF VOL. I.
LECTURE I. General Observations page 13
LECTURE II. DISEASES OF THE DIGESTIVE SYSTEM.
General remarks on local diseases — Fixed rules for the guidance of students — ■ Great importance of diagnosis — Existence of pure fever rare — Doctrine of the Humoralists and of the Brownists — Pathology of the digestive system . 25
LECTURE III.
DR. BELL.
Diseases of the Mouth and Pharynx. — Connexion in structure and function between them and diseases of the stomach and bowels — Stomatitis — its different species — Simple erythematic stomatitis — Its nature, causes, and treatment — Follicular or aphthous stomatitis — Its varieties, complications pathology, analogous to follicular gastritis and enteritis — Connexion with dyspepsy in adults, and in children with cholera and diarrhoea — Remedies, general and local — Importance of hygienic measures — Ulcerous stomatitis — Pultaceous stomatitis, or muguet — Its pathology — Treatment. ... 35
LECTURE IV.
DR. BELL.
Pseudo-membranous Stomatitis. - Its complications ^f.^^l^rl^ insidious aooroach — Pathology — sometimes prevails epidemica ly — Treat- ment^ LdTfied by the state of the digestive system and degree of local excite- S™L^^^
Sr-Orgr7nouSm\S^^
f separate disease- Different opinions as to its violence and danger _ Two
.acres of gangrene of the mouth — Its pathology— common origin in the gums
Treatment, general and local — Emetics, tonics, and the warm bath and
7"' tions — Iodine — Topical remedies — numerous — The chief one is sul-
^te of copper 45
CONTENTS.
LECTURE V.
DR. BELL.
Glossitis — Its varieties and causes— Symptoms — Termination— - Diagnosis Treatment — Importance of scarifications — Symptomatic or eeco™diy * sitis — Treatment modified by the nature of the primary disease. — i ak — Primary— Supposed contagion of- Terminations— MetaatesM to °l J! organs — Treatment— Secondary or symptomatic parotitis— mat cau. y mercury, -its treatment. - Diseases of Dentition -Predisposition to nu- merous diseases in early infancy — Causes besides dentition me s V bility of the organs of the child, and peculiar exposure to external apnib Sympathies of the dental apparatus — Direct and remote — Treatment during dentition — hygienic and medicinal — The measures chiefly demanded . p. oo
LECTURE VI.
DR. BELL.
Diseases of the Throat. — Their various origins and complications. Retro- pharyngeal phlegmon— Difficulty of diagnosis, and danger of this inflammation — Cases. — Angina simplex — Its causes, symptoms, and treatment — Sometimes associated with typhoid fever. — Chronic angina — Inflammation sometimes lo- cated in the uvula, sometimes in the palate — Treatment of the same. — Tonsil- litis— Most common in young subjects — Symptoms, duration, treatment — Importance of bloodletting — Purging — Gargles. — Chronic Tonsillitis — In- convenience and even danger in this disease — An indirect cause of spinal cur- vature— Treatment, local and general ; by caustics and inunction and internal remedies — Diseased follicles of the tonsils — Morbid secretion, — how distin- guished from tuberculous matter — Morbid states of hearing and deafness caused by enlarged tonsils, and diseased mucous membrane of the throat — Voice and speech modified from similar cause — Change of voice after extirpa- tion of tonsils ~1
LECTURE VII.
DR. BELL.
Angina Membranacea— The simple and the malignant varieties— Malignant angina, or diphtheritis— Earlier notices of it— Causes— Connexion with scar- latina — Persons most liable— Epidemical and endemical, and sometimes spo- radic—Symptoms— Diagnosis— Its anatomical characters— Membranous exu- dation—Is sometimes ulcerous and gangrenous— Prognosis— 4. o-e temperament particular exposure and lodging modify result. — Treatment— Bloodletting sometimes admissible— Emetics— Revulsives— Stimulants— Calomel— Blisters under what indications required— Topical treatment— Stress laid on it in ma- lignant angina— Chief articles employed— Summary of treatment in some of the worst cases marked by suddenness of invasion and prostration of the powers ofllfe ' . eg
LECTURE VIII.
Pathology and treatment of diseases of the digestive svstem niffx^ *r r
pstntis-Pa^^
Gaslntisand ^ententis^ot always found in connection-Phenomena character^™ acute gastritis — Symptoms and sympathetic relations — Diagnosis — Gastr ti? simulating other diseases . '"*
CONTENTS.
LECTURE IX.
Gastritis— No one symptom decidedly indicative of the particular condition ot any organ — Sympathetic irritation liable to terminate in organic disease — Sympathetic relations as connected with the viscera of the thorax — Treatment or simple acute gastritis — Antiphlogistic remedies — Purgative medicines inju- rious— Enemas and injections — Use of ice beneficial — Effervescing medicine hurtful p. Ill
LECTURE X.
Pathology and Treatment of Gastritis — Application of blisters — Emetics can be seldom used in acute gastritis — Hsematemesis and delirium tremens com- plicated with gastritis — Treatment of these affections — Dyspepsia, or chronic gastritis — Hypochondriasis — Termination of chronic gastritis .... 120
LECTURE XI.
Treatment of Chronic Gastritis. — Frequent excitement of the vascular system necessary to the performance of the functions of the stomach — Local bleeding
— Regimen — Counter-irritation over the stomach — Treatment of Broussais
— Use of. vegetable tonics — Oxide of bismuth — Acetate of morphia . 129
Friction with croton oil — Attention to diet during convalescence — Organic dis- ease of the stomach — Principles of treatment — Diet and attention to the bowels — Duodenitis — Inflammation of the jejunum 137
LECTURE XII.
DR. BELL.
Dyspepsia. — Temperaments and constitutions most liable to the disease — Habits of life inducing it — Concomitant diseases — of brain, liver, skin, lungs, and kidney — These are sometimes causes, sometimes effects of dyspepsia — A complex disease, sometimes caused by, sometimes causing spinal irritation — Modifica- tion of treatment required — Andral's case and reflexions — Dr. Chapman's notice of chief causes — Tobacco, its injurious tendency and effects — High ex- citement of brain in England and United States. — Dyspepsia with Morbid Gastric Secretion — Pyrosis or Waler-Brash — Its causes and treatment. — Cardialgia, — its mixed nature and treatment — Mercury — Ipecacuanha — Sul- phuret of potassa — Gunpowder 142
LECTURE XIII.
DR. BELL.
C astrodysia, or Gastralgia — Its symptoms — Diagnosis — Causes — Treatment — Hytf ienic means the first to be attended to — Alleviation of pain — Caution respect- [nff stimulants— Draughts of hot water — Blending of gastritis and gastralgia — Hydrocyanic acid — colchicum — emetic tartar in small doses — oil of turpentine
;lubnitrate of bismuth — oxide of zinc — subcarbonate of iron — carbonated
chalybeate waters — nitrate of silver. — Periodical gastrodynia requires sul- phate of quinia — Danger of alcoholic stimulants — Superiority of water as a
drink Attention to the lower bowels — The kind of food proper — Regulation
of the cutaneous functions — Mental habits to be studied — Change of scene and travel 154
CONTENTS.
LECTURE XIV.
DR. BELL.
Gastro-duodenal Dyspepsia — Relations of the duodenum — Varieties of duo- denal disease — the acute and the chronic or atonic — General characters — Particular symptoms — direct and sympathetic — Causes — common in the United States— Necessity of a better pathology of diseases called bilious and hepatic —Treatment— depletion if the acute disease be present— Counter-irritation— Emetic tartar— castor oil— nitrate of potassa— mercury— taraxacum— mineral acids — In the atonic variety, — purging — suitable food — exercise — laxatives, tonics, and alteratives. — Follicular duodenal dyspepsia — Its symptoms, progress, and treatment. — Strumous dyspepsia— its course, complications, and treatment — General directions v. 164
LECTURE XV.
Ileitis, — complication and nature of — Dothinenteritis — Ulceration of the mucous membrane — Symptoms and diagnosis of ileitis. — Diseases of the small intestines — Symptoms of ileitis — Occurrence of diarrhoea with fever symptomatic of this form of inflammation — Frequency and symptoms of the disease in children. — Tabes mesenterica, — treatment of 178
LECTURE XVI.
Treatment of ileitis — Advantage of leeching — Stimuli sometimes beneficial — Infantile remittent fever — Inflammation of the mucous membrane — Enteritis with diarrhoea — Effects of opium in inflammation of serous and mucous mem- branes— Pathology and treatment of diarrhoea and dysentery — Perforation of the intestine — Diseases of the large intestine 190
LECTURE XVII.
Diseases of the Large Intestines — Treatment of diarrhoea — Apyrexial period of diarrhoea — Danger in suddenly arresting the discharge — Purging in phthisis — Dysentery — Epidemic dysentery 199
LECTURE XVIII.
Sporadic Dysentery — Nature of this disease — Treatment; mercurial, stimulating, antiphlogistic — Recommendation of Dr. Elliottson — Success of Dr. O'Beirne fn the use of tobacco injections — Tympanites, or meteorism — Windy colic, reme- dies for the cure of 208
LECTURE XIX.
DR. BELL.
Dysentery. — The anatomical lesions in dysentery, — same in all parts of the world— Dr. Cheyne's experience in Dublin ; Mr. Twining's in Calcutta ■ Dr. Cornuel's in the West Indies.— Stomach, small intestines, and liver, sometimes
inflamed concurrently with the colon.— Causes of dysentery crude ingesta
atmospherical vicissitudes— damp and impure air — particular seasons and cli- mates,— Malaria not a cause — The disease not contagious — Duration Termina- tions—Prognosis—Treatment— venesection— leeching— mercurials ipecacu- anha— diaphoretics.— Rectal inflammation — its treatment.— Hepatic Flux
its symptoms and treatment 216
CONTENTS. 5
LECTURE XX.
DR. BELL.
Enterorrhcea — Includes both diarrhoea mucosa and d. serosa. — Gastrorrhcea. — Pathology of enterorrhcea — Two varieties of the disease — Acute and chronic stages — Connexion between dentition and development of the intestinal mucous follicles — Treatment of enterorrhcea based upon subduing intestinal irritation — diet, and sudorifics and opiates, sometimes astringents — In lymphatic subjects and in epidemic visitations, emetics and purgatives proper. — Importance of diet for the cure ofdiarrhcea in all its forms — Kind of diet most beneficial — Ente- rorrhcea with Membranous Formations — Pellicular exudation on intestines of very young children — Associated sometimes with stomatitis — Later in life with dysentery — Probably the result of morbid follicular secretion, with or without inflammation — May appearand recur frequently, — sometimes without much general disorder — in duodenal dyspepsia — Causes and seat not known — Treatment p. 235
LECTURE XXI.
DR. BELL.
Colonic Dyspepsia The colon — its extent, situation, and functions. — Atomic
colonic dyspepsia — Constipation — its general character, symptoms, causes, and various terminations — Spinal irritation connected with dyspepsia — Treatment of the colonic disease — Importance of a suitable diet. — Inflammatory colonic dyspepsia — Connexion with chronic colitis — Causes and treatment. — Irritable colonic dyspepsia — Enteralgia — Peculiar temperament of persons suffering from this disease — Treatment; to be simple and mild. — Follicular colonic dys- pepsia— its analogy to follicular duodenal dyspepsia — Treatment . . . 244
LECTURE XXIT.
DR. BELL.
Diseases of the Cecum. — Peculiarities of position, structure, and function of the cascum — Its liability to be disordered — Symptoms of fecal accumulations in it — Treatment — Importance of enemata — Best means of employing them — Suspicion of hernia being present — Liniments and friction — Attention to diet. — Inflammation of the Cecum — Its varieties. — Stercoral Ccecitis — Symptoms and treatment. — Acute Ccecitis. — Inflammation of the peri-caical tissue. — Perforative ulceration of the caecum and of the appendix vermiformis — Causes — . Symptoms — Prognosis — Treatment. — Chronic inflammation of the cacum — Its causes, complications, and cure 259
LECTURE XXIIL
DR. BELL.
Diseases of the Rectum. — The structure and sympathies of the rectum — Chief diseases of the rectum, viz., hemorrhoids, ulceration, stricture, and cancer. — Danger from neglect of proper knowledge of rectal diseases. — He- morrhoids—Definition — Disease, both hemorrhage and tumours — Varieties of hemorrhoids or piles — The anatomical characters of the three principal ones, — varicose, erectile, and cystic or spongy (mariscse) — Hemorrhoidal Flux or Discharges — Their sources — Quantity and colour of blood discharged. — Mu- cous or Sero-Mucous hemorrhoidal discharge — Causes — Constipation and drastic purgatives overrated as causes of hemorrhoids — Consequences and
Complications of hemorrhoids 273
1*
6 CONTENTS.
LECTURE XXIV.
DR. BELL.
Treatment of Hemorrhoids.— Relief afforded by hemorrhagic discharge.— Dis- advantage of this natural method.— Measures, medicinal and hygienic, required in a first attack of hemorrhoids. — Treatment of the fixed disease.— Difference between stopping and curing a disease.— Attention to the general system, and to the removal of plethora and visceral disease.— Sometimes active measures — v.s., leeching, calomel, &c, required — To vary the treatment according to pre- ceding or accompanying disease. — Chronic variety — Balsams, turpentine, and cubebs, useful. — Periodical hemorrhoids — treatment of— Precautions to avoid an attack of the disease. — Hemorrhoids with anemia. — Extirpation of tumours practised sometimes with advantage — Danger — Constitutional measures more prudent. — Necessity of preparing the system for the operation of removal — Re- stricted regimen afterwards — External and topical applications — washes, oint- ments, injections, pads to cause pressure. — Remarkable case by M. Guyot. — Reasons for enlarging on the subject of hemorrhoids. — Ulceration of the rec- tum— Two varieties — treatment of. — Prolapsus of the rectum — its peculiarities and treatment. — Stricture of the rectum — Mistakes and malpractice respecting this disease. — Spasmodic stricture — Fissures — Carcinoma of the rectum — Treatment, palliative. — Neuralgia — Preternatural pouches or sacs. — Blenor- rhagia — Pruritus Ani , p. 284
LECTURE XXV.
DR. BELL.
Colic — Its chief divisions — Community of causes, and of many symptoms and other pathological features of these varieties — Inference to guide us in the treatment. — Simple Colic — Its seat, and diagnostic symptoms — Varieties of simple colic — Treatment — Preliminary inquiries to be made — Remedies accord- ing to the cause of colic — from cold, indigestible matters, or stercoraceous accu- mulations — Carminatives — Enemata — Purgatives — Venesection — Cupping — Liniments of narcotic substances — Oil of turpentine — Croton oil. — Infantile Colic — Two varieties of — the stercoraceous and that from indigestible matters — Modifications of treatment in consequence — Importance of attention to the diet and health of the mother — Danger from habit of giving opium to children — Periodical infantile colic 309
LECTURE XXVI.
DR. BELL.
Bilious Colic — Time of its attacks — Causes and Symptoms — Anatomical lesions- Treatment— Venesection — Opiates — The warm bath or fomentations Purga- tives— Enemata — Means of acting on the bowels — Calomel Caution against
too early excitement of any kind — Recourse at times again to bloodletting— Dover's powder — Blisters — Practice by others — Sydenham's directions Eme- tics sometimes used. — Dry Bellyache — Analogous to bilious colic Does
not arise from lead — Common formerly in the West Indies and in America
Description by Hillary— Paralysis of limbs— -Metastasis.—CoLic of Madrid,
Closely resembles the preceding — Causes of— Symptoms — Anatomical lesions !
Devonshire colic — Causes. — Vegetable colic, similar to the preceding1 Treat- ment of this kind of colic, including the preceding varieties 319
CONTENTS. 7
LECTURE XXVII.
DR. BELL.
Ileus — Affinity between ileus and colic — Symptoms of ileus — Causes — Anatomical characters — Volvulus, or intussusception, — Invagination of intestine. — How formed ; its varieties and termination — Diagnosis of intus- susception — Treatment. — Preliminary inquiry into the existence of hernia — Localization of intus-susception — For this last, bloodletting, opium and tartar emetic, and enemata — Venesection generally called for in ileus — Blisters — Turpentine epithem — Dry cupping — Purgatives — Stimulants in last stage — Other remedies — cold — tobacco injection — Other narcotics externally and internally — Injections of linseed oil — Crude mercury in quantity. — Opera- tion of gastrotomy — its doubtful propriety and dangerous consequences, p. 330
LECTURE XXVIII.
Painters' Colic — Effect of metallic poisons on the nervous system — Symptoms of painters' colic — Pathology of neuroses — Action of lead on the system — Abdominal and cerebral symptoms — Species of painters' colic — Dr. Thomson's researches on lead — Effects of, in animals — Effects of, on the generative system 341
LECTURE XXIX.
Pathology of painters' colic — Researches on the state of the nervous and digestive systems — Treatment — Use of narcotics, purgatives, tobacco, &c, &c. — Treat- ment of paralysis from lead — Efficacy of strychnia and brucia — Colic from copper — Poisonous effects of mercury — Remarkable case— Affection of the respiratory muscles 352.
LECTURE XXX.
DR. BELL.
Cholera Morbus — Definition — Sydenham's description — Divisions of cho- lera.— Sporadic or Common Cholera — Symptoms — Not a very fatal disease — Proportion of cases and deaths in the British troops in different regions — Greater proportionate mortality in northern than in southern latitudes — Often exceptions tot his. — Causes — Mutations of temperature from heat to cold, and errors in regimen — Seat of the disease — Not often depending on inflammation. — Diagnosis. — Treatment — Diluents — External irritation — Emetics — Opium — Venesection occasionally — Calomel — Calomel and opium — Laxatives — Oc- currence of gastro-enteritis, — its appropriate treatment — venesection or leech- ing— laxatives, diluents, mild diaphoretics, and the warm bath. — Conva- lescence from cholera — Its treatment 363
LECTURE XXXI.
DR. BELL.
Epidemic Cholera. — A counterpart to the pestilences of olden times— The great pestilence in the fourteenth century — Less mortality with advanced civilization. — First appearance of the epidemic cholera in India — Its progress in that country and in Eastern and Western Asia and the islands — in Russia; Poland; Hungary; Austria — Its appearance in England, Scotland, and Ireland; United States; Mexico; Havana; Southern Europe; Algiers — Order of suc- cession of the attacks of cholera — No regular rate of progress or rule of trans- mission— Quarantine restrictions useless — Singular limitations of its range by the smallest change of locality. — Causes. The special cause unknown — Pre-
3 CONTENTS.
disposing and modifying causes, in weather and season ; low situations; poverty, destitution, and vice of the inhabitants; bad food; watery fruits and vegetables; intoxicating drinks; sudden debility of the nervous system; fear; great and unusual exposure to atmospherical extremes and changes — Atmosphere and other phenomena anterior to and contemporaneous with cholera — Attacks of the disease mainly in the summer-half of the year — Prevalent winds — Sickness and mortality among animals coincident with cholera in different countries — Cholera not transmissible by contagion p- 371
LECTURE XXXII.
DR. BELL.
Symptoms — To be described under the head of diarrhceal stage, or cholerine; con- firmed cholera, collapse and reaction — Importance of attention to the first, or diar- rheal stage — Time of attack of. — Confirmed cholera — Disorder of the stomach and bowels ; of the circulation ; animal heat — Vomiting and purging vary in extent — Collapse without evacuations — Mind undisturbed — Symptoms of dis- ordered innervation — Spasms and cramps — Symptoms of collapse, or blue stage — Sinking of the circulation the most constant and alarming symptom of cholera — Thirst, and sense of heat in the stomach — Respiration, how affected — Symptoms connected with the blood and circulation — Sameness of cholera in all parts of the world — Stage of reaction, or consecutive fever — Analogy between cholera ana1 pernicious or malignant intermittents — Torti cited — The lecturer's case of comatose intermittent — Urea in the blood, an al- leged cause of the consecutive fever. — Prognosis — Common and individual signs — Modification by age, sex, occupation, and race — Promptness of recovery — Congestions with slower convalescence — Immediate causes of death — Re- moter causes, in the constitution and habits of the individual — Misleading signs in the consecutive fever. — Post mortem appearances — The adventitious but common — Automatic muscular movement — Increase of temperature. — Organic alterations — venous congestions — whitish and albuminous fluid in the intestines — congestion of the lungs, — of the kidneys — Appearances after reaction . 387
LECTURE XXXIII.
DR. BELL.
Post Mortem Appearances in subjects dead of cholera — The occasional yet com- mon ones mentioned in the last lecture — Peculiar and distinctive ones— Change in the blood — emptiness and contraction of the bladder — whitish fluid in the intestines — exudation on intestinal mucous surface — development and other changes in the follicular glands— psorenterie— Dr. Horner's observations— a ve- sicular eruption on the entire surface of the digestive tube— exfoliation of epider- mic and venous lining of the tube — Great number of the gastro-intestinal mucous follicles— Changes in the fluids,— in the blood, — in the secretions from the bowels— Special pathology of cholera — Analogy to poisoning — Two orders of
functions affected— Experiments by injection of poisons into the veins Dr. Na-
mias's experiments with cholera blood— Organs and tissues simultaneously af- fected—respiratory, digestive mucous, and cutaneous— Mortality from cholera— In India— Russia— Poland— Hungary— France— Great Britain and Ireland- Berlin— Naples— Geneva— Leghorn— Sunderland— Glasgow— Quebec — Mon- treal—New York— Philadelphia— Cincinnati— Law of Recoveries and Mor- tality in. cholera. A\\
LECTURE XXXIV.
DR. BELL.
Treatment of Cholera.— Study previously of its mortality, and comparison with that in other diseases— Almost certainty of death, unless medicine be given—
CONTENTS.
The sedative class of remedies most useful in cholera — Evidences of increased innervation — Increased glandular secretion — Indications of cure — Treatment of the Diarrheal Stage. — Necessity of prompt attention to the first symptoms of irregular digestion — Mild purgatives, sometimes an emetic ; laudanum ; dilu- ents; rest; moderate warmth — Case — Selection of purgatives — Treatment of Marked Cholera. — An emetic — Bloodletting — Sedative or contra-stimulant remedies — Calomel ; its primary and sedative effect ; is to be given in large doses, sometimes alone, often with a full dose of laudanum — Opium . p. 424
LECTURE XXXV.
DR. BELL.
Treatment of Cholera (Continued). — Drinks; warm; cold; ice — Stimulating drinks injurious — Tartar emetic as a sedative ; its successful use — Ipecacuanha with similar intention — Magnesia — External medication — Warm, tepid, and cold baths, all sedative — Stimulants externally; blisters; cauterising skin; dry heat ; continued frictions of the skin — Internal Stimulants ; the milder kind preferable ; tonics ; sub-acetate of lead and sub-nitrate of bismuth are seda- tives— More active stimulants; ammonia, capsicum, camphorated ether — Treat- ment of the stage of Collapse — Difficulty — Stimulants and sedatives often alike fail — External remedies ; friction, ammoniacal liniment ; friction with ice ; the cold dash — Sudden collapse treated sometimes by venesection — Arteriotomy useless and cruel — Cups to the abdomen — Astringent injections — Stimulant in- jections— Astringents — Special stimulants ; oil of turpentine and capsicum — Ice grateful and serviceable — Cold water treatment — Dr. Shute's views in directing it — Tobacco enemata 441
LECTURE XXXVI.
DR. BELL.
Treatment of Cholera (Concluded). — The saline treatment — General experi- ence not in its favour — Saline injections into the veins — Delicacy and difficulty of the operation — Treatment of the Stage of Reaction. — This and the diar- rheal stage less common in India — Convalescence. — Prophylaxis. — Chief means are temperance, cleanliness, and equable temperature of the body — Importance of early attention to the very first symptoms of the disease — Con- nexion between cholera and other diseases — Influenza — Influenza and cholera in 1780 and 1781 — Both have pursued a similar course, including divergencies from the main line — Prevalence of bowel affections in cholera seasons — In- creased mortality at this time from other diseases — Scarlet fever with cho- lera 453
LECTURE XXXVII.
DR. BELL.
Cholera Infantum. — Is endemial in the United States — Scarcely noticed by the English and French writers — Dr. Cheyne's atrophia ablactatorum resembles it. — Symptoms — Ushered in generally by diarrhoea — state of the circulation — skin — discharges from the bowels — thirst — nervous symptoms — state of the brain — expression of the countenance. — Prognosis. — Causes — High heat of summer — Irritation of teething — Errors of regimen — Predisposition — Anatomi- cal lesions — chiefly disease of the mucous follicles of the intestines — softening of the gastro-intestinal mucous membrane — Billard's case — Entero-mesenteric fever of Serres and Petit,— dothinenteritis of Bretonneau ..... 465
10 CONTENTS.
LECTURE XXXVIII.
DR. BELL.
Cholera Infantum (Continued). — Farther dissections exhibiting inflammation of the small intestines and follicles — Dr. Horner's opinion of the nature of cho- lera infantum— M. Billard's view of the cause of follicular development applied to the pathology of infantile cholera. — Resemblance between this disease and epidemic cholera — Hepatic pathology of cholera infantum not sustained by autopsic examinations— Mode in which heat causes hepatic derangement- Contents of intestinal canal. — Treatment — Indications to guide us — To re- duce excessive sensibility and to remove irritations— Modification depending on temperament and constitution — Treatment of first stage— Demulcents, chalk mixtures, — an opiate, if the teeth irritate — Calomel in minute doses — Oil^of turpentine — Cold affusions arid cold water injections— Sugar of lead . P. 477
LECTURE XXXIX.
DR. BELL.
Cholera Infantum (Concluded). — Caution not to irritate the stomach by needless repetition of either food or medicine — Danger of relapse during hot weather — Remedies for the diarrhoea after vomiting has ceased — Nitrate of silver — alu- mina— Dr. Durr's cases, illustrative of German practice — Astringents, — of secondary value— Treatment when the disease remits— Renovation by fresh air — Treatment in the state of collapse with diseased brain — Proper food for the patient — Drinks, — great importance of selecting them and regulating their use — Removal of irritation from teething— Paramount importance of pure air, day and night — Bathing — Continued watchfulness on the part of the mother to withhold all irritating ingesta — Preservation of equable tempera- ture of the skin — Prophylaxis, — cool air, cool bathing, cool drinks, and proper food at stated intervals 487
LECTURE XL.
Gastritis, with delirium tremens— Varieties of intestinal worms — Organization and origin of— Occurrence in the foetuses of various animals— Formation— Patho- logy of— Perforation of the intestines by— Worms in tumours and abscesses, 496
LECTURE XLI.
Symptoms of intestinal worms— Sympathetic irritations— Affections of the nervous and respiratory systems— Various diseases mistaken for worms— Exciting causes of worms— Farinaceous and milk diet— Verminous fever— Treatment of worms —Specific and mechanical purgatives; calomel, turpentine, &c , &c —Reme- dies for each species of worms— Preventive measures 506
SUPPLEMENT TO LECTURE XLI.
DR. BELL.
Double indication in the treatment of worms— Iron with purgatives— with calo mel, followed by purgatives— Bark of pomegranate root— Spigelia Manlandin — Chenopodium anthelmintica— Pride of China— Common salt — Treatment of ascartdes- Purgatives occasionally-Injections,— chiefly of turpentine, aloes &c— Mixed treatment of worms,— by bitter, saline, and sulphurous water* 514
CONTENTS. 1 1
LECTURE XLII. , DISEASES OF THE BILIARY APPARATUS.
Pathology of Javndice — Its coexistence with a flow of bile — Case of aneurism of the hepatic artery — The disease, independent of mechanical obstruction — Co- louring of the various parts — Effects on the milk, and humours of the eye — Jaun- dice with preservation of health — Icterus infantum p. 517
LECTURE XLIII.
Jaundice from gastro-duodenitis — Researches of Broussais and Marsh on — Jaun- dice without hepatic inflammation — Nervous symptoms — Treatment — Yellow fever — its occurrence in this country — Predominance of gastric irritation in warm climates — Typhus icterodes — Jaundice from biliary calculi — Different situations in which biliary calculi may be found 526
LECTURE XLIV.
Diagnosis of jaundice from biliary calculi — Proof of the passage of the calculus — • Indications of treatment — Rupture of the gall-bladder after the use of emetics — Spasmodic jaundice — Treatment of spasmodic jaundice — Dis- charges of fatty matter — Researches of Drs. Bright and Elliotson — Connec- tion with malignant disease examined — Source of fatty matter . . . 536
LECTURE XLV.
Acute and Chronic Hepatitis — Pathological differences — ISffect of climate — General and local symptoms — Character of fever — Pain of shoulder — Use of pleximeter — Complication with jaundice — Resolution — Abscess — Various openings of the latter — Cicatrization 545
LECTURE XLVI.
Diagnosis of the rupture of hepatic abscess — Pulmonary openings — Case of double opening — Puncture of the gall-bladder — Gangrene of the liver — Its connection with hepatic apoplexy — Diagnosis of distended gall-bladder — Its causes — inflam- mation of the parietes over the liver — Sympathy of the integuments . . 555
LECTURE XLVII.
Aneurism of the hepatic artery — Distention of the liver with bile — Treatment of hepatitis — Employment of mercury — Symptoms of suppuration — Dr. Graves's operation for giving exit to matter in hepatic abscess — Rupture into the perito- neum— Chronic hepatitis — Complication with disease of the heart — Embryonary state of the liver 565
LECTURE XLVIII.
Treatment of chronic hepatitis — Neuralgia of the liver succeeding hepatitis — Connection of hepatic with gastro-int.estinal disease — Modes of transmission of disease from the mucous surface of the liver — Phlebitis of the vena porta — Ob- struction of this vein— Case of pulmonary, hepatic, and intestinal fistulae — Hepa- tic neuralgia 5*5
1 2 CONTENTS.
LECTURE XLIX.
DR. BELL. DISEASES OF THE PANCREAS AND SPLEEN. — CHLOROSIS.
Pancreas— Its pathological states not well appreciated — Symptoms of inflam- mation of the pancreas— Few positively diagnostic ones — Post mortem ap- pearances of the organ — Its morbid secretions — Connection of these with pyrosis— Diagnosis.— Treatment. Moderately depleting remedies, with opiates and narcotics, and counter-irritants. — Diseases of the Spleen. Connexion between the spleen and the liver, and stomach, and bowels — Community of affection with these organs in paludal fevers — Organic lesions of the spleen and their sympathetic disturbances — Exploration of the spleen — its situation and size. — Splenitis. Obscurity of its symptoms — Enlargement— characters of the tumour — Structural changes. — Chronic Splenitis. Symptoms equi- vocal— Terminations of inflamed spleen— suppuration — softening — congestion — Sympathetic disorders from splenitis 586
LECTURE L.
DR. BELL.
Treatment of Diseases of the Spleen. — Remedies for acute splenitis the same as for other phlegmasia? — Mercury in general inadmissible — Avoidance of extreme views and practice — Sedative narcotics useful — Free purging in enlargements of the spleen, or chronic splenitis ; to be followed or alternated with chalybeates — Mr. Twining's plan of treatment — Spleen mixture — Addi- tion of sulphate ofquinia — Venesection and cupping, or leeching, occasionally directed before the use of chalybeates — Salutary crisis by hemorrhages — Native (Bengalese)?remedies for diseased spleen ; chiefly aloes and iron, with occa- sionally castor oil — Acupuncture — Enlarged spleen with intermittent and remittent fevers, requires sulphate of quinia — Great utility of this medicine — Iron in other varieties of tumid spleen — Connexion between spleen cachexia and chlorosis, scurvy, and anemia. — Chlorosis — Its real nature — Depending on impoverished blood — Changes in the blood at this time — Causes — Symptoms — Means of renovation — Iron, the chief medicinal agent — Hygienic restoratives — Hemorrhages do not always contraindicate the use of iron 596
LECTURES
THEORY AND PRACTICE OF PHYSIC.
LECTURE I.
GENERAL OBSERVATIONS.
Gentlemen : — You may have often heard that the approaches to science are rugged and uninteresting, and some of you have perhaps experienced the truth of the remark. Hence the custom of delivering an introductory lecture, in order to lay before the young mind, when first entering on each path of knowledge, the objects, the results, the attained good, and the hoped-for glory of the pursuit. These are to be displayed with clearness and with truth, yet it is obvious that much of the effect of such a lecture must depend on the nature of the subject and the judgment of the speaker; and it is well when the exalted nature of the one is attainable by the capabilities of the other. Such a lecturer, then, should be an earnest lesson on the objects, the pleasures, and the advantages of that science, of which the course is destined to treat; its history, its true mode of study, its interest, actual state, and future prospects, may all form legitimate subjects, and when thus rightly viewed, an introductory lecture, so far from being a mere ornamental appendage, may become a most important part of the course.
With these views let us approach our subject, the theory and practice of medicine. Let us contemplate that study and that profession, which, venerable by all antiquity, yet in itself is " ever new." Even in its infancy, when the world was in darkness, was medicine a glorious science when compared with its cotemporaries, and its first professors were ennoblad and exalted by its influence. As their mantles descended through a long line of illustrious suc- cessors, we see medicine progressively expanding, and even when
vol. i. — 2
14 GENERAL OBSERVATIONS.
the night of barbarism hung gloomily over the earth, we see its genius triumphing over the surrounding darkness, and shining in the east as a beacon to the shipwrecked mind of man : and I trust that I shall be able to prove to you, that, in our own time, when the human mind has made such astonishing advances, medicine has kept pace with her sister sciences, and it is a gratifying reflection to think, that, among the most distinguished promoters of the col- lateral sciences, physicians have ever held a commanding rank, thus proving themselves foremost in knowledge, as they have ever been in philanthropy, in private and public charity, and in all good will to man.
It is scarcely necessary to allude to the title of this course of lectures, further than to remark, that, however different they may be in name, it is yet impossible to draw the line of distinction between the theory and the practice of medicine. If medicine were merely the knowledge of a number of empirical remedies for particular symptoms, given without our inquiring into their mode of action, or any acquaintance with the dependence of one func- tion, or one viscus, on another, of any knowledge, in short, of physiology in the healthy or diseased state, then we might have a practice of medicine independent of what is called its theory. But medicine now holds a higher place, and much of its improvement is traceable to our advances in physiological and pathological science. Thus to treat, or teach, the treatment of a disease, we must know the healthy function of the organ, or organs, the history of development, the influence of other organic systems, the changes produced by disease, and, as far as possible, the action of all external or internal agents on the viscera. But this is the theory of medicine.
For example, let us suppose that we are called either to treat or to teach the treatment of a case of enlarged liver. Let me here remark, that in selecting this case I do not wish you to suppose that I am one of what might be called the hepatic school of medi- cine, in which the existence of almost every organ, except the liver, seems to be forgotten, and of which the creed seems to be, that there is but one viscus, the liver one source of disease, biliary derangement, and one cure, mercury ; a creed which, though not enforced and defended by the sword, has lost perhaps as much of human life as others whose history is written in letters of blood.* But no one can doubt the importance of the organ, and I have taken it to illustrate the connection between the theory and the practice of medicine.
* [I wish it could be said that we in the United States are not amenable to this censure. But, alas ! the spoonful doses of calomel, and pills with calomel for their basis by the dozens, are, or have been, prescriptions which have cast a stigma on too many American practitioners, who see but one disease, — that of the liver. — B.]
TWOFOLD OBJECTS OF MEDICINE. 13
You detect an enlarged liver ; you are called to cure the dis- ease : —
1st. You must be aware of the healthy state of the organ, and of its healthy functions, as shown by the volume, sensibility, influ- ence on digestion, and the healthy state of the secretion. You must know all these, as it is by the departure from these conditions that you recognise this disease at all. — But this is the theory of medicine.
2dly. You must know the history of its development, because there is a period of life when the natural state of the liver is in a greatly enlarged condition, and this may continue even to adult life, and produce an enlarged liver, not the result of disease but the arrest of development, and the question will arise as to whether the case before you is an example of this, or of recent and actual disease. The whole treatment turns on this. — Yet this is the theory of medicine.
3dly. You must know the influence of other organic systems. An enlarged liver may be produced mechanically by obstructions in the lungs or in the heart ; it may be produced from the sympa- thetic irritation of a duodenitis, or be the result of original disease in its own structure. All these circumstances must be known and taken into account. If it be merely obstruction in the venae cavae hepaticoe the ordinary treatment will not answer ; if there be duo- denitis we must modify our treatment, and so on. We must know these things; we must know how to recognise these diseases before we can prescribe or practise successfully. All this is that part of the theory of medicine called pathology, or the physiology of the diseased body.
4thly. You must know the effects of disease on the liver itself. Some of these are removable by art, others are totally incurable. You must know these in order to determine on the probability of their existence.
5thly, and lastly. You must know the influence of remedial agents on the liver and the adjacent organs. You must be fami- liar with the effects of stimulation of the mucous surfaces of the stomach and duodenum. Then, indeed, and not till then, will you be qualified to treat the case with judgment and success. The same remarks, I need scarcely add, will be found applicable to the diseases of each viscus in the body.
The objects of medicine, gentlemen, are twofold ; first to cure disease, no matter where seated or how produced ; and secondly, to relieve bodily suffering in cases where a cure is impossible. Its great end is to prolong life, and to diminish the bodily evils which result from the infirmities of our nature and other circumstances. Some of you may ask, where then is the distinction between medi- cine and surgery ? In truth, there is no distinction in reality, and there should be none in theory. The human constitution is one ; — there is no division of it into a medical and surgical domain; the same laws and the same principles of treatment apply to the cure of a fractured bone and the cicatrization of an internal ulcer.
16 GENERAL OBSERVATIONS.
Unlike the corporations of medicine and surgery, the supposed purely medical and purely surgical parts of the body live in excel- lent harmony. Here, then, there is no division, no jealousy, no separation of interests.
I am by no means prepared to deny that advantages may arise from a practitioner devoting himself to this or that branch of his profession ; but if he seeks for eminence, he will first educate himself generally. Let him attain extended views of pathological medicine ; let him make himself master of the actual state of the science, and then he will find that there is not a single fact or law with which he has become acquainted that will not have its bear- ing on his particular pursuit. It is in the education of medical men that the ruinous effects of the division of the professions of medicine and surgery are most perceived : and 1 feel convinced that, of the two, the surgical student is the greater sufferer, be- cause his views of pathology are injured. All the great laws in pathology are drawn from the consideration of visceral disease ; yet the attention of the surgical student is diverted from this, and directed to what, I will say, can never elevate him in the ranks of science. He is taught anatomy, and what is called surgical disease, but he is kept ignorant, by this wretched system, of the great part of his profession, until he comes to practise, when, if he has a mind fitted for observation, he will find, that for one dislocation there will be hundreds of visceral diseases; and he will discover what was concealed from him during his pupilage, that many, many more die of what are called medical than surgical diseases. During the late war, more men in the British navy died of fever than of all other causes — including the sword. But, I rejoice to say, in Dublin the exclusive system of education is fast wearing way, and one of the many excellences of our national school of medicine is the instruction in general pathology. There are few schools of medicine where now a more enlarged and liberal spirit of education exists.
In the study of your profession, gentlemen, let me warn you not to allow yourselves to be misled by the idea that surgery and me- dicine are different in their nature. The mere surgeon, or the mere physician, only knows half of his profession. Reckless of human life, he may practise the healing art as a trade, but he never can know it as a science. But, as there are infinitely more cases of what are termed medical than surgical disease, it is plain, that the surgeon, ignorant of medicine, will far exceed the physician igno- rant of surgery, in the extent of his malpractice. I have Tong observed the ruinous system which has been pursued by teachers, as connected with this subject. The pupil was taught to consider] that if he was a skilful anatomist, if he understood the routine surgery of an hospital, and had carefully studied certain works on surgery, and some obsolete books of pathology, he was thereby prepared, in the language of the schools, to go forth to teach and practise the art and mystery of medicine in general. Now, all this
A GENERAL AND LIBERAL SYSTEM. 17
was wrong. You may be profound anatomists and be bad surgeons, and worse physicians ; you may have by heart the writings of Pott and Dessault, of Hunter and Thompson, and be totally incapable of treating a simple or complicated fever, or a case of visceral disease.
But it is not necessary to say more. Society demands that the old system of a division in education should be abolished ; and ere long, I even trust to see a fusion of the profession, when much ot the present evils must cease, when medical men shall have a common centre, from which they shall receive a common impulse; when their efforts shall be solely directed to the increase of medical science, and the political and moral exaltation of their profession; and last, yet not least, when the ingenuous pupil shall not be led astray ; when we shall not be told by one teacher to despise this, and by another to neglect that part of his profession ; but, having the whole of the noble science of medicine thrown open to him, his mind unwarped by prejudice, unfettered by fear, shall be permitted to take that right view of his pursuit, that alone can lead him, and assuredly will lead him, to the honours and success which truth bestows on all its votaries.
1 have said, that the exclusive system of education had singularly diminished in Dublin. Indeed, our national school has earned great reputation for general pathology ; and, from a long and cordial intercourse with the class of Dublin, I will affirm, that there are few places where we can see such zeal, talent, and thirst for know- ledge among the students. As an Irishman, addressing my own countrymen, let me congratulate you on the fame the Dublin School of Medicine and Surgery has now acquired, and is every day acquiring; and when the strength of Irish talent, aided by the proper working of our unrivalled institutions, is brought into play, may we not anticipate a still more glorious result ? This reflection has often cheered me, that within the last few years there has been a greater stimulus infused into the science and literature of this country. Amid the ungenial influences of political excitement, and the animosities of party, how gladly should we contemplate the advance of what will prove an honour to our national character, and an advantage to mankind. It is like the growth of the coral into rocks and fertile islands, though surrounded by the strife and waste of waters. Our scientific societies have multiplied; our periodical literature, the want of which furnished so fruitful a theme for cavil, lias been extended so as to afford a wholesome and vigor- ous supply in the varied departments of literature and science ; and our monthly and quarterly publications are taking their proper place among the ranks of British journals. When we turn to works of a more permanent kind, we also see cause for satisfaction. Many most important works in anatomy, surgical pathology, physiological medicine, and widwifery, have lately issued from the Irish press : and the Irish contributions to the Cyclopaedia of Prac- tical Medicine are allowed on all hands to give to that work no mean portion of its value.
18 GENERAL OBSERVATIONS.
There are few more wholesome exercises for the mind, few so necessary and so useful as the comparison of the actual state of any science with its advance and character at a former period; and it is in this, most chiefly, that the value of what is called the history of medicine consists. We study it then, not as a matter of antiquarian research, of learned curiosity, but as the picture of the human mind, now on the right path, now misled by error, yet still struggling onward ; as the record of a dear-bought experience, and a beacon to warn us of the rocks and shoals that beset its future progress unto truth. To analyse the actual state of medical science, to show you all that has been done within a little time, to display all old pretensions to the character of a true and thrice noble science, would far exhaust my capabilities and your patience. Let it suffice to contemplate the improvement considered generally, and the means by which that improvement has been attained.
It is an error too generally received, that medicine owes all its advances to the researches of modern times. Far be it from me to undervalue these, but I believe that the opinion I have alluded to is wrong, and is perhaps kept alive by our own vanity ; for by a specious deception we often take to ourselves the honours and dis- tinctions of the time we live in. The truth is, that medicine, like many other of the sister sciences, has been long steadily advancing, and the flippant every day remarks that the inductive system (that is, the observation of facts and the embodying of those conclusions that legitimately flow from them) has only been introduced into medicine in our time; and that our predecessors in medicine put theory first and fact second in their medical philosophy, are " as false as dicers' oaths.'' Have the authors and teachers who are so fond of decrying the medicine of a former day, at a time when they are (perhaps innocently) making use of its facts and observations — have they read the writings of the father of medicine? Have they studied that " aureum opus,'" so well called from its lustre, its purity, and its surpassing value? Was Avicenna a mere theorist? Did Morgagni observe no facts, nor truly record them, even at the expense of his medical reputation? Is there no induction in Bag- livi. Was Haller unacquainted with the method of experiment and induction ? Or is the discoverer of the circulation of the blood, the good, the great, the injured, but the immortal Harvey, forgotten? Where do they place Boerhaave ? and shall the name of Sydenham go down with his ashes to oblivion?
The true state of the case is, that medicine, in its present ad- vanced state, only represents the improvement in other branches of human knowledge, all of which are so intimately linked together, that, although their extremes be far removed, there is a point where all are reciprocally cause and effect; so that if we take any one of them, it is easy to show its intimate bearings with, and importance to, all the rest. We have been long advancing in medicine; and though I admit most fully the vast strides which have been made, still I must here declare 'my firm conviction, that the study of the older authors is too much neglected, and that in them you will find
MODERN SYSTEM OF INVESTIGATION. 19
a treasury of knowledge, much of which you may think to be the production of modern limes.
If the writings of the ancient authors only contained a small portion of the information with which they abound, it would be a sufficient stimulus to their study ; to reflect that it is in them, in the medical writings of the ancients, that the germs of the induc- tive philosophy are first to be found. It is, then, in the old regions of medicine that we find the fountains of that mighty river, which, for two thousand years, has fertilized the earth, and made man its lord. Had the progress of man not been retarded by the ignorance which is the child and servant of barbaric despotism, an earlier Newton might have enlightened the earth, an earlier Laplace have measured the heavens, or a Cuvier declared the glories of a past and present creation. The mind of man would have burst its chains, and ages ago have formed that holy alliance with knowledge and her first-born, liberty, which now is its safeguard and its glory. I repeat it, in the writings of Hippocrates you will find the principles of the inductive philosophy. A physician showed Bacon the road to immortality.
We find that there is in the mind of man a tendency to reverse the true mode of reasoning, and to seek for a principle before it has observed facts, and this was the cause of the retardation of medicine, as well as of all other sciences. Hence the various schools, from Pythagoras to Cullen or Brown, in our day. But a slow, though sure, revolution was long going forward ; and I believe that Cullen and Brown were even behind the actual state of medicine in their time. Physicians turned disgusted from the war of words and doubt, to seek in tangible objects the certainty which these only can produce ; in a word, they began to follow the Baconian system more generally. They reverted to the instructions of Hippocrates, and from that period our modern improvement may date. They turned their attention to the examination of those changes which disease produces on the human body, and connected these with the symptoms observed during life. And what has been the result of this ?
1st. The accumulation of an enormous number of facts, relative to the changes of organs produced by disease.
2d. The connection of a vast number of these changes with particular symptoms, and hence the advance in diagnosis.
3d. The establishment of the true value of symptomatology, and the verification of that all-important fact, that opposite stales and organs may produce similar symptoms.
4th. The knowledge of the vast class of latent diseases; in other words, diseases which exist without influencing the phenomena of animal life, or, in some cases, the phenomena of both animal and organic life. Diseases, either without symptoms at all, or only with such as previously were not supposed capable of leading to their detection. You know that the phenomena of life are divided into two classes, viz., those of organic or vegetable life, such as
2Q GENERAL OBSERVATIONS.
nutrition, circulation, absorption, respiration, secretion. While those of animal life, or the life of relation (so called from its being the source of our connection with surrounding bodies), are tne senses, the phenomena of mind, and muscular motion. Ihe one life seems more under the influence of the ganglionic, and the other under that of the cerebro-spinal system of nerves.
As some of the junior part of the class may not have accurate ideas as to the meaning of symptoms, I may state that disease is recognised by signs and symptoms.
By signs, we mean those mechanical alterations, produced by disease, in the conditions of parts, which are recognisable to the external senses of touch, sight, and hearing ; changes in appearance, volume, shape, resistance, peculiarities of feel, and the production of sounds. We may make a diagnosis by signs alone. Take, for example, a case of tympanitis. The abdomen is prominent, enlarged, circular, elastic, and sounding like a drum when struck. Thus we learn that the belly is distended by air.
Now, symptoms are totally different; they consist in certain changes produced in functions ; and these functional changes are to be considered in a threefold manner ; —
1st. Changes in the functions of the part itself.
2d. Changes in the phenomena of organic life.
3d. Changes in the phenomena of animal life.
Let us take, for example, a case of inflammation of the stomach. We have, first, changes in its own functions — morbid sensibility, vomiting, thirst, anorexia. In the next place, we have changes in the functions of organic life — fever, from the action on the circu- lating system; hurried respiration, and cough, and hiccup, from the action on the respiratory system ; jaundice, from its action on the biliary system ; suppression of the secretion of the skin, kidneys, &c. All these, you observe, are lesions of the functions of organic life.
But we may have other symptoms; prostration, headache, deli- rium, convulsions ; these are lesions of the life of relation, or animal life.
Now, in many cases, we have to combine these sources of knowledge to form a correct diagnosis. Take, for example, a case of hepatitis.
The patient has had pains in the hepatic region, fever, jaundice, hurried breathing, tenderness. After some time he has a tumour ; the side dilated ; the hypochondrium dull on percussion. Well, the signs point out an enlargement of the liver ; the symptoms, that the cause of that enlargement was an acute hepatitis.
In general, we may state, that signs only declare the actually existing mechanical condition, while symptoms, either present or past, point out the cause of the change, whatever it may be. Both must be studied together ; but you will learn more from symptoms without signs, than from signs without symptoms. But to return to the results of the improved method of investigation.
BENEFITS FROM PATHOLOGICAL ANATOMY. 21
Great light was thrown on fever in general ; and it is, I believe, quite true, that all the advances which we have made in the know- ledge of fever, are due to the prosecution of pathological anatomy. Almost all of what we may call our general knowledge of fever, is due to Hippocrates; but anatomy has revealed its effects, its com- plications ; and the all-important fact that the cause of its fatality is often local inflammation. This knowledge, however, is not so new as is taught by some modern systematists. Galen De Affect. Intern, c. xli.) taught, that in continual fevers bleeding and cold drinks were the powerful remedies. Sydenham declares, that the ignorance of the inflammations in malignant fevers has been more fatal to the human race than the invention of gunpowder. Baglivi, that malignant fevers often depend on a visceral inflammation, and Van Svvieten knew the frequency of intestinal ulcerations in typhus.
Among the direct results of pathological anatomy, it is shown that disease is seldom confined to one organ, or even one system, and thus it has utterly shaken the nosological system of Cullen and his predecessors, which, you know, consisted in classifying disease by symptoms, which were supposed to point out a certain and single disease. For example, the nosologists class phthisis as an affection of the lung; but pathological anatomy has shown, that in many cases it is the result of a disease invading many organs and systems, and that the pulmonary disease is but a link in the chain of morbid actions. Pathological anatomy, also, has demon- strated the inflammatory nature of a vast number of diseases, and has thus given us a key to treatment, to prevention, and to pallia- tion, when ihe disease is incurable.
The last grand result of pathological anatomy is the discovery that a vast number of affections, supposed to be merely lesions of function, are more or less connected also with alteration of struc- ture. Thus many of the dyspepsias of the nosologists are proved to be examples of gastritis, or of other organic diseases; cases of asthma turn out to be chronic inflammation with emphysema; the palpitations may depend on organic disease which has sprung from a carditis, and so on. I need not now dilate on the vast importance of such facts to practical medicine.
But let us now come to an all-important inquiry. Is patholo- gical anatomy to be considered as the basis of medicine? or is it, even when combined with clinical observations, the foundation of all medical knowledge? This inquiry, you will at once perceive, involves the question as to whether Hippocrates and his followers have done anything for the science, or whether medicine is wholly new, an infant, and consequently a weak and imperfect science. Are we to despise the works of the ancients, to be ignorant of them, and to allow medicine to be in its infancy? In fact, if we review the history of medicine from the Hippocratic era to the absurdities of Hahnemann, we find that there have been two orders of men, one constituting what we may term the school founders, who made
22 GENERAL OBSERVATIONS.
a theory, and sought to square facts to meet that theory ; these have only brought disgrace on medicine. The other class consists of the Hippocratic observers ; that is, of men who sought for facts, who collected and pondered on these facts, in other words, who were Baconian philosophers. It is the labour of these that has really advanced medicine. Asclepiades, who lived in the first century of the Christian era, declared that the medicine of Hippo- crates was a cold meditation of death. The celebrated Thessalus, who lived under Nero, in writing to the emperor, makes use of the following words : —
" I have founded a new sect, which is the only true one. I have been forced to this, because none of the physicians who have preceded me have discovered anything useful, either for the pre- servation of health, or for the cure of diseases, and because Hippo- crates himself has put forward many dangerous maxims."
And what was this new doctrine 1 That nature in each case pointed out to the patient what was the most fit for him, and that hence he should be diligently supplied with everything that he fancied.
We have next Paracelsus. He commenced his course of lectures at Basle, in the year 1526, by publicly burning the writings of Galen and Avicenna, and assured his auditors that a single hair of his head contained more knowledge than Hippocrates and his suc- cessors. He taught the cabalistic medicine, the intimate connec- tion between the planets and the viscera : he was a vitalist, but embodied his vitalism under the shape of a demon, who resided within the system, and which he called Archaeus. Diagnosis was to repose on the examinations of the stars, and not on symptoms. He invented the doctrine of tartar, which is the cause of all dis- eases of accumulation, obstruction, and concretion ; " and I call it tartar," says he, " because it contains the oil, the spirit, and the salt, which burn the patient as hell does."
Hahnemann, the founder of the homoeopathic doctrine, may be quoted next as an example of these school founders ; and he, like his predecessors, expresses himself with all that arrogance, which ignorance, when it pretends to learning, invariably assumes. Speak- ing of the Hippocratic medicine, he says —
" Since this art only consists in a gross imitation of a danger- ous and insufficient process, it must he admitted that the true medi- cine was not discovered until by me. It is the infallible oracle of the art of curing; it is the sole mode of really curing disease, be- cause it reposes on an eternal and infallible law of nature."
And what is this mode and doctrine 1 We have it in four pro- positions, and it is hard to say which of them is most revolting to common sense. We are told that it is absurd to seek for the cause of symptoms in order to remove them; that we must cure diseases by the exhibition of substances which would otherwise produce them ; that the dose is to be inconceivably small ; and that there are three original diseases from which spring all the maladies
HIPPOCRATIC OBSERVATION. 23
which afflict mankind — syphilis, sycosis, and the itch. These are the fruitful causes of all diseases, — epidemic, sporadic, idiopathic, and symptomatic. Like his predecessor in quackery and deceit, he, too, has his syphilis, sycosis, and itch, the oil, the spirit, and the salt, which burn the patient as hell does. Like Paracelsus, too, he maintains the curability of diseases, and is a disciple of animal magnetism.
Let us next see how Broussais announced his doctrine to an admiring world.
" After so many vacillations in its march, medicine at length follows the only path which can conduct it to truth — the observa- tion of the relations of man, with external modifications and the relations of the organs of man, one to the other.'9 This is the physiological method, because it cannot be followed without study- ing life.
I am more anxious to draw your attention to this doctrine, as Broussais may be considered as the source of the anatomical school, which, of late, was so completely the fashion — if I may use such a term ; and it is a striking instance of the danger that attends the idea of our having made a discovery, to see a man like Broussais, than whom few have really added so much to medicine, falling into the same fault of arrogance and contempt towards his predecessors.
At this moment, the medical world, particularly on the continent, is divided into two great sects. One may be called that of the pathologico-anatomists, the other the Hippocratists. The first declares that diseases are primitively local in all cases ; that the symptoms — say in a case of fever — are only the results of sympa- thetic irritation from some local disease, which is to be attacked with vigour ; that pathological anatomy is to be the foundation of all practice ; that there is nothing approaching to a specific in medicine ; and that nature makes little or no attempt to cure. Their favourite maxim is that saying of Bichat's — " What is observation, if we are ignorant of the seat of disease ?"
This is the sentiment of an anatomist, but not of a physician : and we must regret that it once escaped the author of the " Re- searches on Life and Death," a book of such interest and such beauty, as to captivate even the non-medical reader, and make the very name of Bichat be hallowed in our memory. Many are the diseases of which we know not the seat: yet in which observation — Hippocratic observation — is of the greatest utility.
We know not the seat of fever, let the followers of Broussais say what they may to the contrary ; yet is observation of symptoms of no avail in fever? Are the effects of contagion, the history and nature of epidemics, the termination by crisis, the results of treat- ment, of symptoms as connected with prognosis — is the observa- tion of these useless or unnecessary 1 Sydenham knew not the seat of variola ; yet he declared the true principles of its treatment. There are very many diseases on which pathological anatomy
g4 GENERAL OBSERVATIONS.
throws but a negative light — if I may use such a term —particu- larly affections of the fluids, and the neuroses.
So much for the doctrine of the anatomical school. I beg ot you not to misunderstand me as undervaluing pathological anatomy ; 1 only wish to show you its true value. I believe there could hardly be adduced a single fact in pathological anatomy that has not .its distinct bearing on practical medicine. And it is true that the dis- eases whose treatment is best understood are those whose patholo- gical nature are best known. Even in fever, the actual nature of which has not been revealed, great advantage has been derived from anatomical researches ; for all the advance in our knowledge of this Protean disease consists in ascertaining the number, nature, and seat, of the local inflammations which accompany or rise in the course, and complicate the disease.
Let us, lastly, revert to the opinion of the Hippocratists. They admit that vast advantage has arisen from pathological anatomy ; but they see that its light is limited within certain bounds. They believethat great advantage is to be derived from the careful study of symptoms, even in cases whose pathological nature is not re- vealed by the knife. They believe that there are many diseases whose local origin cannot be demonstrated; for instance, fever. They deny that pathological anatomy is always to be our guide; but admit a rational empiricism, and the use of remedies which may'be called specifics; and, lastly, they hold that nature, in many cases, makes an attempt to cure; and that the physician, in the words of Hippocrates, is to be the minister and interpreter of nature, rather than her master.
Let us, then, combine the precepts of the founder of medicine with the lights of modern science. — Let us take observation, and that observation rendered fruitful by study, for our guide; and let the observation equally embrace the phenomena of the living as well as the dead. Let us bs Hippocratists in the dissecting room as well as at the bedside. By comparing the practice of these two schools, we get more accurate ideas as to their doctrine. The anatomists, holding that all diseases are local, direct their whole attention to the discovery of the lesion, and its connection with symptoms. This, with their doctrine that almost all diseases are inflammatory, leads them to a strict general and local antiphlogistic treatment. Fever is to them symptomatic, and the supposed source is to be vigorously attacked in the commencement. Diathesis, the nature of the epidemic, and the powers of nature to effect a cure, are comparatively neglected. They inhibit purgatives for fear of increasing the local inflammation, and lose many patients for want of a timely support of the powers of life.
They deny specificism in diseases as well as in medicine, and are sorely puzzled to explain the extraordinary powers of bark, and mercury, and sulphur, and iodine. They despise the experience of the past.
The true Hippocratist,on the other hand, believing that we have
REMARKS ON LOCAL DISEASES. 25
not yet arrived at the knowledge of the local origin of all diseases, and particularly fevers, grounds his practice accordingly. He draws his experience from the recorded knowledge of the past, and his own unbiassed observation. When he recognises a local in- flammation, he meets it with judgment, taking into account the habits, diathesis, epidemic, constitution, and tendency to crisis. He trusts much to nature, and watches her operations, particularly in fever. He is not afraid of moderate evacuations ; the phantom of a local inflammation does not always haunt him; and even where he recognises its existence, that does not prevent him from using a stimulating and supporting treatment, if the general state of the patient requires -it. He treats particular diseases by particular remedies, the utility of which has been proved by experience — such as syphilis, scrofula, intermittent fever, and so on. He uses the expectant medicine, which is not inactive treatment, but founded on the observations of the powers of nature — " JVatura morborum medicatrix ;" but he never loses the opportunity of doing good, when such presents itself, remembering the first aphorism of his great master: —
" Occasio preeceps."
I have great hopes for medicine, for I see men's minds turning to the true path ; and I trust that all whom I now address will deem themselves as labourers in the great work. Think what a noble science you profess ! the only one relating to earth-born things, which, while it ennobles the mind of man, yet softens and expands his heart; whose source is all science, whose end is good to man. Above all things follow truth ; nature can never deceive — see that you be her faithful interpreter. The great evil is, that there has as yet been adopted no means by which the experience of the past can be brought fully to bear on the actual teaching and practice of medicine. Too often has the physician to create his own instru- ments. But when all the scattered facts of medicine are collected, whether they be the observations on the living or the dead body, as old as history, or as young as to-day: when these votive tablets are hung up in the temple of truth, and their facts verified, com- pared, and classified, then, and not till then, will you see medicine in all her glory.
LECTURE II.
General remarks on local diseases — Fixed rules for the guidance of students - Great importance of diagnosis — Existence of pure fever rare — Doctrine of the Humoralists and of the Brownists — Pathology of the digestive system.
I commence the course by entering at once on the subject of particular diseases. J am aware that the common practice is to occupy the early part of a course on the theory and practice of medicine with preliminary discussions on general pathological vol. i. — 3
25 REMARKS ON LOCAL DISEASES.
subjects. To this I have strong objections. Every man who as- sumes to himself the office of teacher, no matter what the fact may be, should presume that his auditors are ignorant of the subject he is about to teach; if he does not, he must be unjust to his class. Some of the class must be ignorant of the information he wishes to convey, and he should take it for granted that all are so. To commence with the consideration of general disease would argue that the whole class was acquainted with the subject in all its bearings, and capable of understanding its principles without any previous illustration. I think this is beginning at the wrong end. My plan is first to teach the facts, and then the general principles and conclusions to which these facts lead. It is of the deepest im- portance in the study of medicine to be able to form a collection of laws or fixed principles. In your professional career, nothing will give you so much satisfaction as having in your minds a number of established facts and fixed rules to bear on every case which comes under your cognizance. We commonly hear of the uncer- tainty of medicine and the instability of its practice ; it is said to have as many phases as the moon, and as many changes as the tide ; but, after all, I think this expression is more general among those who know little than among those who know much. Those who have successfully laboured in treasuring up a store of deep and extensive knowledge are firmly convinced, that, though some cases are involved in doubt and obscurity, the general certainty of medicine is at present increased far beyond what it was in former times. No man, except one in full and extensive practice, earned by industry and capacity, can be aware of the vast improvements of modern'practical medicine, and of the number of lives which are saved by the judicious treatment which the rapidly progressive improvement of medical science has introduced. Medicine is much more certain now than it was in past times. There are two reasons for this; one of which is, that at the present period diagnosis, the guide and master-key to sound treatment, is more certain. Here, gentlemen, is a great source of certainty in the practice of medicine. You will find, in the course of a few years, that the old saying of "doctors differ," will become less frequently applicable, because, as the education and acquirements of' medical men become more ex- tended, diagnosis will be reduced to fixed rules, and difference of opinion will be very seldom observed. A vast number of local diseases, formerly wrapt in obscurity, are now detected with the most unerring certainty, and this certainty of diagnosis must bear on fixed principles of treatment and similarity of practice. Another vast source of increased certainty is the fact, now extensively established, that the element of a great number of diseases is the same. This is an important law, because the deduction from it is, that the principles of treatment are the same in these cases. The principles of treatmerft in a case of hydrocephalus and in a case of vomiting from gastritis may be, and often are, completely identical, because, in many cases, both are reducible to a common action. In
FEVER WITH VISCERAL DISEASE. 27
the one case we have to deal with inflammatory action in the stomach, in the other we have to treat an inflammation of the membranes of the brain. The principle in both cases is to deplete the suffering organ, and to diminish or remove everything that keeps up irritation. Pathological anatomy, too, has effected a vast deal for medicine by the improvements in diagnosis which it has introduced, and by reducing to one class a vast number of affections formerly supposed to be unanalogous and distinct.
Before I commence entering on the consideration of the patho- logy and treatment of diseases of the digestive system, it is neces- sary that I should mention another peculiarity of the mode of teaching the theory and practice of medicine adopted in this school. The ordinary way of lecturing medicine in the schools is this : the teacher begins by going over, at great length, the whole subject of fevers, and then proceeds to the consideration of the signs, symp- toms, and treatment of local diseases. We reverse this mode here; we begin by teaching the pathology and treatment of local diseases, or affections of particular organs; and having studied these with care and attention, we then proceed to the consideration of fevers. In point of fact, we are thoroughly impressed with the truth of this splendid conclusion in medicine, that local diseases may be considered, as it were, the alphabet of fevers, and that to have a distinct and accurate conception of the whole subject of fever, it is essentially necessary that we should be acquainted with all kinds of local disease. To commence with a class which the teacher presumes, or should presume, to be ignorant of the pheno- mena of local diseases, unacquainted with the rules on which their diagnosis depends, and unacquainted with the principles which should regulate their treatment — to begin with such a class by entering at once on the subject of fever, would, in my opinion, be extremely wrong. You will read in books and hear teachers speak of bilious fevers, of nervous fevers, of catarrhal fevers, of gastric fevers, and of simple fevers. These expressions are founded on the fact of the complication or noncomplication of fever with local dis- ease in various parts of the system. If simple fever was the rule, and its complication the exception, then, indeed, there would be some reason for pursuing the ordinary track of medical instruc- tion, and we might commence by teaching the subject of fever, independent of local inflammation. But the truth is, that fever, in the simple form, is the exception, and its complication the rule, and that to have a correct idea of fever, in the general acceptation of the term, we must previously possess an intimate knowledge of the affections of particular organs. The progress of medicine has established, by the most unquestionable evidence, that simple fever is a matter of extremely rare occurrence ; so rare, in fact, that you might pass through the practice of a fever hospital for years without meeting with a single case which you could say was, through its whole course, a case of pure, essential fever. Sooner or later its character is changed, and the complication with visceral disease
28 REMARKS ON LOCAL DISEASES.
comes on ; you may take this with you as a well-proved fact. You will have, at some period, a complication with local disease in the head, or local disease in the chest, or in the belly, or in the circulating system, or perhaps all the great viscera in the body will be simultaneously affected. My experience on this point, after having attended the feverwards of the Meath Hospital many years, is this, that among all the cases which were admitted under such circumstances, there were very few indeed in which I could not say that the patient had something more than fever. Many were admitted who presented no indication of disease in the head, chest, or digestive tube; all that could be said of them, at the period of their admission, was, that they had fever; but my experience of them is, that, in a vast majority, there was, during their progress, unequivocal evidence of the supervention of visceral disease. I do not go as far as the disciples of Broussais have gone, nor do I mean to say that all fevers are symptomatic ; all I assert is, that, at some period, most fevers are complicated with local disease. I admit that there is a vast number of symptomatic fevers, but I believe there are two which are essentially simple, typhus and intermittent. The progress of medicine has shown that these may exist in the simple form, and that their complications may be secondary ; this I believe to be the fact, but the almost invariable liability to complication is a point of the highest importance. We scarcely ever see typhus accompanied by symptoms of local dis- ease ; and, with respect to intermittent, in ninety-nine cases out of a hundred, visceral disease of the head, or chest, or belly, may, and will, supervene.
Another great fact bearing on this subject, and which patholo- gical anatomy has established beyond the possibility of a doubt, is, that in the great majority of cases having a fatal termination, death is caused by disease of some particular organ or organs. The old notion of the cause of death was, that the patient died of debility or exhaustion. In cholera, in tetanus, in hydrophobia, we cannot, to be sure, demonstrate any appreciable lesion of structure, and we may say, if we like, that the patient died of debility ; but this does not hold good in cases of fever, for on dissection you will generally find disease sufficient to account for death, even though there had been no fever at all. From these circumstances it fol- lows that, in the management of fevers, the attention of the physi- cian must be directed to the local affections, or, at all events, that to understand fever well, and to treat it successfully, he must be acquainted with the nature and treatment of every form of visceral disease. It will be sufficient for me to call your attention to this fact, that there is not a single acute local disease which may not occur during the progress of a fever. This is a broad and general proposition. If you look to the nervous system vou will "find in patients who have died of fever, traces of lesion'in almost every part of it, inflammation or congestion in the cerebrum, in the cere- bellum, and in the spinal cord. If you go to the respiratory system
FEVER WITH VISCERAL DISEASE. 29
you will see all kinds of shades and varieties of inflammatory action, thickening and ulceration of the bronchial membrane, hepa- tisation, congestion, and destruction of the parenchymatous tissue, effusions of lymph, serum, or pus, into the pleural cavities. As you proceed in your examination you will discover new lesions ; you may see the whole lung filled with lately formed tubercular matter; you will meet with the destructive ravages of phthisis. You will find the pulmonary tissue converted into a dark and fetid mass by gangrene. You may see carditis, hypertrophy, inflamma- tion of the external or internal coverings of the heart, inflamma- tion of the lining membrane of the arteries, phlebitis (a common occurrence in typhus fever) ; and passing on to the lymphatic sys- tem, you will often find evident traces of inflammation in its glands and vessels, an occurrence which I shall be able to demonstrate to you when treating on the subject of gastric fever. If we go to the digestive system we find that disease has here taken a wider range; congestions and ulcerations of the stomach and intestines, morbid states of the liver, congestion and inflammation of the spleen or kidneys, evidence the fatal extent of local inflammation. I think I might safely challenge any one to point out any one single organ which may not become diseased during the progress of a typhus fever. I do not wish you to suppose that typhus is a symp- tomatic affection. I think we may define it, in general terms, as a diseased state of the whole system, in which various local diseases arise, modify the character of the original complaint, give it an addi- tional intensity, and are generally the cause of death. Go round the wards of an hospital during the prevalence of an epidemic fever, examine every patient in succession, and bring this principle to the test. You will see one labouring under the morbid excitement of high delirium ; his face injected, his eyes sparkling, his carotids throbbing with intensity. Come next day, and you will find him in a state of profound coma, perfectly insensible to everything around him : — two or three days afterwards he is dead. You follow his body to the dissecting room, and open his brain; unequivocal marks of excessive congestion, inflammation of the substance of the brain, or of its membranes, sufficiently indicate the cause of the fatal termination. Here is a case of inflammation of the brain. You find another with cold skin, his face of a dirty hue, faintly tinged with red, his breathing quick and hurried, and the spitting- vessel by his bedside filled with adhesive mucus tinged with blood; you percuss his chest, and find dulness over the whole surface of one lung; you apply the stethoscope, and discover intense bron- chitis, hepatization, or suppurative pneumonia. Farther on you see another in a state of deep prostration, with a sunken counte- nance, constant hiccup, and low delirium. Take down his bed- clothes, and you find his belly swelled, tympanitic, and tender on pressure ; then his tongue, lips, and gums, are parched and encrusted with dusky sordes ; his thirst is insatiable; he vomits, and has an emaciating diarrhoea. After death you find traces of an extensive
3*
30 DISEASES OF THE DIGESTIVE SYSTEM.
and fatal gastro-enterilis; in others yon will find exemplified the very climax of inflammation, and all the three great cavities are simultaneously affected.
But these, you will say, are cases in which the complications are evident, and where an ordinary knowledge of ihe phenomena of local disease will be quite a sufficient guide. Well, here is another case. You will meet with instances of fever without any apparent local symptoms, where the patient lies in what you would consider a quiet state, and free from danger: nothing seems to be the matter with him, except that he is very weak ; he perhaps does not sleep at night, and his tongue is a little foul ; he complains, in fact, of nothing but weakness and some thirst, and you think his fever is going on very well. Some morning or other, on coming to the hospital, you are astonished to see the change which has been wrought in him since the day before; his countenance is altered, his pulse can hardly be felt, and life is fast ebbing away. You ask the nurse about him, and she tells you that, during the night he suddenly complained of violent pain in his belly. On examining him, you find distinct evidence of intense peritonitis, and, after death, dissection reveals the existence of a perforating ulcer of the intestines, of which there was apparently no sign during life, except fever and the unexpected occurrence of peri- tonitis. The frequency of the complication of local disease with fever, its insidious latency, and the fact, that death, in the majority of fever cases, is caused by visceral inflammations, all clearly point out the necessity of being intimately acquainted with every modi- fication of local disease before you proceed to the study of levers.
Diseases of the Digestive System. — I commence with the digestive system. I am anxious to do this for several reasons, but for none more than this — that, to the improvements made in the pathology of the digestive system we owe much of the rapid advancement of modern practical medicine. Before our time the pathology of the digestive system was very little known, and if not quite a terra incognita in medicine, there existed respect- ing it a great deal of misconception. The schools were deeply tinctured with the doctrines of the Humoralists and the Brown- ists; and this had the effect of giving rise to irrational theories and false notions of the true state of the system in disease. The humoral pathologists, who sought for disease in an alteration of the fluids alone, neglected the study of visceral lesions; and when they turned their attention to the digestive system, they only considered it, its secretions, and not its actual condition, or the state of its sympathies. The liver, with them, was an or^an of the highest importance, and the secretion of bile claimed a vast share of their attention. To it they gave a paramount influence, and to an alteration in its quantity and quality they attributed most of the changes which occur, not only in the digestive tube, but also in the whole system; and hence the great object of their practice was to attempt to restore its healthy condition, convinced that if this were once accomplished everything would go on favourably.
NEGLECT OF MORBID ANATOMY. 31
From this, too, arose the purgative plan of treatment in various forms of intestinal disease, a plan too often rashly pursued, even where there was unequivocal proof of inflammation in the diges- tive tube.* Their sole purpose was to evacuate sordes,to produce a flow of healthy bile, and to eliminate depraved secretions ; and they did this without possessing any knowledge of local inflamma- tion, or of the effects of disease of the digestive system on other organs. The followers of Brown, on the other hand, only admitted disease of the digestive system in a state of intense, manifest vio- lence, as, for instance, ileus or violent enteritis; but in the great majority of cases, they did not recognise intestinal inflammations, because their prominent symptom was prostration, or, to use their own terms, an asthenic condition of the whole system. They saw nothing but prostration; they prescribed for nothing but debility; they gave wine instead of iced water; ordered bark instead of local depletion. They exasperated the disease by stimulants ; and then, thinking they had not gone far enough, they heightened the stimu- lant and doubled the debility.
Another cause of the low state of pathology in former times was the general neglect of dissection. The fact is, that in fever there were no post mortem examinations made, until very lately. Mor- gagni, who did so much for pathological anatomy on almost every other subject, did little for fever, because he was afraid to dissect the bodies of persons who had died of a contagious disease. This was the idea which prevailed among the older pathologists; and hence this source of knowledge was avoided, and for many succes- sive centuries the state of the viscera in fever was a matter of specu- lation, doubt, and uncertainty. Even at the present day it is only done by the ardent pathologist, who cares not about filth and stench, and who had rather encounter the miasm of contagion than remain in the mists of error. Nothing is more common, I regret to say, even at the present time, than this: — A person says he has dis- sected cases of fever, and when asked whether he had examined the intestinal canal, he says that the intestines appeared healthy, but he did not make any particular inspection of them ; he only opened the belly, and, finding no trace of inflammation in the peri- toneum, he went no farther. Now, nothing can be more useless than such an examination. If we compare the information afforded by an inspection of the serous membranes of the three great cavities, we shall find that the least is given by an examination of that of the abdomen. .Disease of the substance of the brain is rare with- out affections of its investing membrane; disease of the substance of the lung is exceedingly rare without the occurrence of disease of the pleura; but you may have most extensive and fatal disease of the intestinal canal, without the slightest lesion of the peritoneum. In this point, therefore, it differs from the pleura, and from the
* [Our medical brethren of the south and west, will see, if not reproof, at least a salutary hint, in these remarks of the lecturer. — B.]
32 DISEASES OF THE DIGESTIVE SYSTEM.
arachnoid membrane. The fact of the rarity of disease of the peri- toneum in cases of disease affecting the parts beneath, was noticed by Dr. Graves and myself, in our report of the Meath Hospital, and also by Mr. Annesley, in his account of the diseases of India. You will see cases of hepatic abscess, which present a distinct tumour externally, and where you can detect a perceptible fluctuation ; and yet, if you examine these cases, after death, you may not find any adhesions of the peritoneum, even in the situation of the ab- scess. You will find the mucous and muscular coats of the colon extensively destroyed, you will see the stomach all but perforated, you will meet with cases where the whole ileum is one extensive sheet of ulcerations, with no disease in the adjacent peritoneum.
In entering on the consideration of diseases of the digestive system, we shall begin first with the mucous expansion of the sto- mach and intestines, and then proceed to the affections of the solid viscera connected with them. The mucous surface of the stomach and intestines is of enormous extent and extraordinary sensibility, possessed of innumerable and powerful sympathies ; its influence is felt by almost every organ in the body, formed for receiving and elaborating everything destined for nutrition; its conditions, both in health and disease, are entitled to the deepest and most attentive consideration. To facilitate the study of its affections, and for the sake of some practical arrangement, we shall divide its diseases into five classes, beginning with the oesophagus, or that portion of the digestive tube which is above the diaphragm, and then pro- ceeding to the stomach, duodenum, ileum, colon, and rectum. But, in order to give you a clear idea of diseases of the intestinal canal, I shall commence with diseases of the stomach; because, if you consider the whole range of animal life, you will find that its func- tions are the most important, the stomach constituting, as it were, the source and fountain of life, which is nutrition, and giving by its existence a character to all the upper classes of animals. No organ possesses such remarkable sympathies as the stomach, whe- ther we look upon them as sympathies of organic or of animal life, none possesses such remarkable power and influence in modifying the condition of every part of the system. But, putting aside phy- siological reasons, let us come to practical matters. The success of almost every form of medical treatment, all the advantages to be derived from the administration of internal medicine, depend upon the stomach ; in fact, in whatever point of view we consider it, we must look upon a knowledge of the state of thestomach as the great key to sound and successful practice.
It is a most useful reflection to consider the extraordinary fre- quency of disease in some portion of the digestive tube. It is now admitted by every person possessed of experience in the causes of mortality, that more human beings die with acute or chronic dis- eases u( the digestive tube than with diseases of any other part of the system. This has been established by numerous investigations and is admitted by the best pathologists; and, indeed, I Think it
LOCAL AND REMOTE PHENOMENA. 33
can be easily accounted for, when we call to mind how many per- sons die of some form of fever or other, when we look to the ravages of remittent and yellow fever, to the hundreds of thousands who annually perish by the various classes of fevers. Now, in almost every one of these cases, disease of the digestive system forms one of the most prominent pathological characters. Recollect, besides, all that die of dysentery, whether sporadic or simple, and here is inflammation of the colon ; see, too, how many die with diarrhoea — here, too, there is intestinal disease; remember how many die of the malignant intermittent of the West Indies, in which unequivocal proofs of disease of the stomach and intestines have been found. Observe what a close connection there is between tabes mesente- rica and inflammation of the mucous membrane and surface of the intestines; think what a vast number of persons fall victims to the harassing effects of constipation and dyspepsia ; and recollect that there is a host of diseases in which the train of morbid phenomena commences in the digestive system, and then exhibits itself by functional alteration or organic disease of other parts.
We recognise the presence of disease in the digestive tube, first, by the local phenomena and the lesion of the digestive function, and next by the sympathetic relations of other parts, by the sym- pathies of the respiratory system, of the circulation of the skin, and of the nervous system. I shall enumerate the local phenomena and functional lesions : vomiting, anorexia, thirst, jaundice, pain, tenderness on pressure, tympanitis, changes in the character and quality of the discharges, constipation. Here are a set of functional lesions and local phenomena ; let us now consider the sympathetic relations ; these are fever, heat of skin, suppression of the cutane- ous secretion, suppression of the secretion of urine, morbid states of the tongue and pulse, pains in the chest and cough, hurried breathing, and palpitations of the heart. In the next place, we may have prostration of strength, delirium, coma, convulsions, tetanic spasms, and other symptoms of functional disease of the brain; these are all sympathies of relation. Now, in the first place, I have to remark, that there is a great deal of variety in the combi- nation of these symptoms. On what does this depend? on a variety of circumstances ; sometimes on the intensity or extent of the in- flammation : sometimes on the situation of the disease: sometimes on the complication of the affection ; sometimes on the various modes and degrees of susceptibility of the individual. All these causes tend to produce a great variety in the disease, and an exten- sive modification of the sympathetic relations. For instance, in some cases inflammation of the stomach and intestines is so slight that the patient is not prevented from going about and pursuing his ordinary avocations; in others, on the contrary, the patients are struck down at once by the violence of the disease, and are carried off by the fever which accompanies it before the inflamma- tion is completely developed. It varies also according to situation ; there is a difference between gastritis and dysentery : in the former
34 DISEASES OF THE DIGESTIVE SYSTEM.
we have an inactive state of the street intestine, and consequent constipation; in the latter, the colon is thrown into violent action, and there are frequent dejections. Disease of the duodenum is attended with a very remarkable peculiarity, being very frequently complicated with jaundice; here is a modification produced by situation. Again, inflammation of the ileum is attended with a very curious peculiarity, namely, the absence of pain. The patient states, that he feels unwell, he has obscure symptoms of intestinal disease, but it is neither dysentery nor gastritis; you investigate it with care, and find that the ileum is in a state of inflammation. Yet the patient does not complain of any pain; and this is another peculiarity depending on situation.*
But in considering the differences which depend upon intensity, extent, and situation of disease of the intestinal canal, we must not omit those which depend upon tissue. If disease be confined to the mucous membrane of the intestines alone, we may have an extremely diffused and extensive inflammation, sufficient to destroy life, without any pain being complained of by the patient; it is a painless though fatal disease. Recollect this, — extensive and fatal inflammation without pain. In former times the ideas of pain and inflammation were inseparable. Thanks to the light which patho- logy has shed upon modern medical science, we are now acquainted with this seeming anomaly, and can conceive the existence of ex- tensive disease of mucous surfaces unaccompanied by pain. But let the inflammation seize on the muscular tissue, the character of the disease is instantly changed, and the pain is dreadful. Here is a case in which difference of tissue is to be taken into consider- ation, f
The phenomena and sympathetic relations of intestinal disease may vary also according to its complication, and here we come to investigate one of the most beautiful laws of the human economy, namely, that the more complicated a disease is, the more latent will be any local lesion. This is a point that should never be forgotten. For instance, enteritis by itself is much more easily recognised than when complicated with pneumonia, or with irritation of the brain, and gastritis is but too often completely masked by beinc
* [The physiological explanation consists in the fact of the ner- vous supply to the ileum, coming from the sympathetic ; a fact of importance, which should be borne in mind in making our prognosis' of typhoid fever. The absence of pain might induce belief that there was no organic lesion. — B.]
t [The position is, perhaps, rather too broadly laid down in the text. The sensations of the patient will depend very much on the portion of intestine affected; whether duodenum, for example, or jejunum, and whether even the upper or the lower part of the ileum. The first and last portions of the intestinal canal receive branches of the cerebro-spinal nerves, — the middle is supplied almost entirely by the sympathetic. — B.]
DISEASES OF THE MOUTH AND PHARYNX. 35
combined with irritation of the bronchial mucous membrane. Lastly, we have the varieties which depend on different degrees of susceptibility. In one person we may have only slight cerebral irritation, in another high excitement, in a third delirium and ex- traordinary convulsions. The variety, then, in the modifications of diseases, and the combination of sympathies, is very great, and is referable to the extent and the intensity of the inflammation, difference of situation, complication of disease, difference of tissue, and different degrees of susceptibility.
LECTURE III.
DR. BELL.
Diseases of the Mouth and Pharynx. — Connexion in structure and function between them and diseases of the stomach and bowels — Stomatitis — its different species — Simple erythematic stomatitis — Its nature, causes and treatment — Follicular or aphthous stomatitis — Its varieties, complications; pathology, analogous to follicular gastritis and enteritis — Connexion with dyspepsy in adults, and in children with cholera and diarrhoea — Remedies, general and local — Importance of hygienic measures — Ulcerous stomatitis — Pultaceous stomatitis, or muguet — Its pathology— Treatment.
Doctor Stokes passes directly from a general view of the patho- logy of the digestive system to a consideration of gastritis, its pathology and treatment. But before taking up this subject, it will be well to describe to you some of the chief morbid alterations in the upper portion of the alimentary canal, or the buccal and pharyngeal regions. This proceeding is in conformity with an affinity between these regions and the stomach, which is manifested both by a continuity and general resemblance of tissue, (the mu- cous,) and by a resemblance and sympathy between them in their morbid states. In fact, just as we look at the tongue for an index to the state of the stomach, so may we expect to see often in the diseases of the mucous membrane of the mouth and pharynx a reflexion of those of the gastric mucous membrane. I do not by any means assert, that there is uniformity in this respect; but that there is so frequent a connexion between the inflammation and irritation of the stomach and the upper cavities already mentioned, that we shall be not a little remiss in our diagnosis, and needlessly conjectural in our prognosis, of the diseases of the digestive system, if we do not, with a knowledge of the frequency of this connexion, institute a careful inquiry into the state of both regions, even when our attention is invoked solely for one of them. In practice, we shall be much more successful by taking this enlarged view, than if we restrict ourselves to an investigation of either alone, and fail to see more than a mere local disease in the morbid alterations of the mucous mem- brane of the mouth ; or are aware that a chronic affection of the
36 DISEASES OF THE DIGESTIVE SYSTEM.
stomach assumes a much more serious, not to say alarming aspect* when accompanied with some degree of pharyngitis, and still more with aphthae and ulcers of the mouth and palate.
Stomatitis. —The morbid states of the buccal mucous membrane have been variously designated, not only in reference to I heir varieties, but to each of these separately. They have engaged the attention of medical men more when they appear in the infantile subject than in the adult; on account of their greater frequency of occurrence in the former than in the latter. The general and popular term for designating the sore mouth of infants is thrush ; the technical one aphthce. Of late years a new title is given to the whole class of diseases of the mucous membrane of the mouth, which, as far as its radicle is concerned, is perfectly appropriate, but as in all cases implying inflammation is not so accurate. The title is Stomatitis, from wop*, mouth ; and this is the generic name which is now adopted by the French and some English and American writers for diseases of the lining membrane of the mouth. The specific titles are more or less numerous with different authors. Those of M. Andral (Cours de Pathohgie Interne) seem to me to designate with sufficient distinctness the several morbid states of this region, and I shall therefore adopt them, with the addition of the ulcerous species. They are — 1. Simple Stomatitis; 2. Aphthous (Follicu- lar) Stomatitis ; 3. Ulcerous Stomatitis ; 4. Pultaceous Stomatitis ; 5. Pseudo-membranous, or Pellicular ; and 6. Gangrenous Stomatitis.
1. Simple or Ery thematic Stomatitis. — This species is common, but in a mild degree, in newly-born children, who are predisposed to it by the congested state of the mucous membrane of the mouth at birth. It is usually marked by redness, heat, and some degree of dryness of the mouth and tongue. Sometimes, as M. Billard de- scribes it, the inflammation is confined to one part of the buccal surface, at others it covers the whole and spreads to the lips, which tumefy, excoriate, crack, and frequently become the seat of herpes labialis. Often it accompanies inflammation of the stomach or bowels, but rarely causes fever in very young infants, whereas this is a common addition in children from seven to nine years of a»e. The functions of the mouth, or those in which it participates, such as mastication, deglutition, and speech, are performed with difficulty and pain; and sometimes there is a copious ptyalism. The dura- tion of the disease is from three to eight days; and the termination is commonly by resolution. This description is applicable to in- fantile stomatitis, but when the erythematic variety occurs, as it every now and then does, in adults, associated with dyspepsia, and is aggravated by the use of tobacco, and particularly smoking this poisonous weed, the prognosis is not by any means so clear. Nor must we expect, even in children, always to find this kind of inflammation of the mouth retain its simple erythematic character* for, sometimes, it is followed by ulcerations and even gangrene; and it is not uncommon, says M. Andral, for us to see after tins dis- ease an induration of the sub-mucous tissue of the mouth.
FOLLICULAR OR APHTHOUS STOMATITIS. 37
Causes. — Of the causes of simple stomatitis, dentition is the first and most common one; others are enumerated, such as very hot drinks taken into the mouth : acrid, caustic, and poisonous substances of various kinds ; contusions, operations on the teeth, and the accu- mulation of tartar. Sometimes, as already intimated, it is sympto- matic of inflammation of the digestive canal.
Treatment. — The cure of simple stomatitis is generally trusted to mild means, such as simplicity of regimen, mucilaginous drinks, consisting of gum water, or a decoction of slippery-elm or sassafras pith, alone, or mixed with milk. If the inflammation run higher, and fever be present, a few leeches should be applied at the base of the jaw, or even to the gums themselves, provided the child be not of a scorbutic habit, or badly nourished and with little habitual ac- tivity of capillary circulation. In this latter case, counter-irritation by moderately stimulating liniments is to be practised on the skin of the base of the jaw and mouth, extending back to the angles of the former. Saline or slightly acidulated gargles will be of ser- vice, and in nearly all cases of any intensity the bowels should be excited to increased exoneration by castor oil, magnesia and rhubarb, or, with reserve adapted to the temperament of the child, a small dose or two of calomel. This medicine will be most serviceable in the sanguine or nervoso-sanguine ; but much less so, if allowable at all, in the decidedly lymphatic with much sluggishness of the functions generally. The warm bath is a useful adjunct to the treatment in this as it is in most of the diseases of children, and in many cases it will, with a little change of air, and a simple, and even reduced milk diet, suffice for the cure.
2. Follicular or Aphthous Stomatitis — Aphtha — Thrush. — This is the most common kind of sore mouth in children ; and it is that which is a frequent accompaniment of chronic diseases of the gastro- intestinal mucous surface in subjects of all ages, as of gastritis, gastro-enteritis, cholera infantum, and dysentery ; also of typhous fever, and diseases of the lungs, and particularly of pulmonary phthisis in its third stage.
Three varieties are described of aphthous stomatitis, viz. — 1. papular; 2, vesicular; 3, pustular. These are often met with constituting successive stages rather than separate varieties of the disease. Whatever may be the form under which it exhibits itself, it more especially attacks the parts in which the epithelium is the most apparent. It usually appears first in the angles of the lips, and then on the tongue and the lining membrane of the lips and cheeks, and on the velum palati, in the form of little papular, vesicular, or pustular white specks, which some writers have denominated ulcers; but this term is not applicable until the specks burst, — a termination which usually occurs between the second and third day.
The eruption may be either discreet or confluent. The former is happily the most common ; but sometimes the other, or con- fluent variety, is met with, and it may prevail epidemically. It is no uncommon thing to meet with, in persons., and particularly
VOL. I. 4
33 DISEASES OF THE DIGESTIVE SYSTEM.
children, who have long suffered from bowel disease, an increase in the number and size of the specks, which run together and com- pose a thin white crust, that at length lines the whole inside of the mouth, from the lips even to the oesophagus. In this stage there is fever, headache, and often vomiting and other disorder of gastric function. But when this kind of sore mouth, or thrush, is a pri- mary disease, there is not, says Underwood, (Treatise on the Diseases of Children,) in nine out of ten cases, the least fever, though the mouth is often so much heated as to excoriate the nip- ples of the nurse, and so tender that the child is often observed to suck with reluctance and caution.
It is a popular opinion that the eruption and ulceration of thrush are continued down the oesophagus, and thence into the stomach, and along the entire course of the intestinal canal, showing itself in a redness about the anus. No doubt there is often coincident and sometimes preceding disease of the stomach and other parts of the digestive tube in stomatitis; but the continuity as above described seldom exists. Nothing is more common than this redness and erythematic inflammation about the anus in diseases of the diges- tive system of children; and it is worthy of remark, that certain poisons will spend their whole force, as far as this system is im- plicated, on the stomach, pharynx, and rectum, leaving the inter- mediate regions intact, or but slightly affected.
The duration of this disease in its milder or simpler forms will vary from three or four days to as many weeks; sometimes returning at different intervals. Underwood states, that he has seen this so very often the case, that when he found a child to have the complaint very slightly, and that it did not increase after two or three days, he ventured to pronounce it likely to continue a long time, but that it will be of no consequence.
Pathology. — It would be an erroneous notion respecting aph- tha?, if we regarded them as an ulcerative termination of com- mon inflammation. Callisen has described them as small tumours, from a change of the muciparous glands. Billard,with more pro- bability, considers them to be a morbid development of these bodies, or follicles of the mouth, sometimes in a state of simple tumefaction, at other times in a state of ulceration. " The muciparous follicles of the mucous membrane of the mouth are invisible in their ordinary state, and remain hidden in the thickness of the membrane, and compensate by their infinite number for the smallness of their size; but when they begin to inflame and tumefy, they appear on the internal surface of the lips and cheeks, on the pillars of the velum and the palatine arch, on the inferior surface and lateral parts of the base of the tongue, under the form of small white points, some- times exhibiting a coloured spot in their centre, slightly prominent, and often surrounded by a slight inflammatory circle. These fol- licles are either isolated, and few in number, or multiplied and spread over every part of the mouth. Sometimes they may be felt with the finger, when they are not sufficiently distinct to be seen. They
FOLLICULAR OR APHTHOUS STOMATITIS. 3ft
often do not stop at the mouth, but spread to the oesophagus, sto- mach, and intestinal tube." (Billard — Treatise on the Diseases of Infants, Dr. Stewart's Translation.) — The follicular points enlarge, preserving still their primitive circular form ; and from their central aperture there soon issues a white matter, which, being squeezed by the surrounding epithelium, itself soon beginning to ulcerate, there is an exudation of white puriform matter over all the parts.
Numerous aphthae and their proximity soon allow of the spread- ing of the excreted curdy matter so as to form a continuous coat of greater or less thickness, as already mentioned. In this state the aphthous is often confounded with the pultaceous stomatitis, or muguet, hereafter to be described ; but they may be distinguished by inspection of the inflamed follicles, and a solution of continuity, which is not met with in the latter disease. This is most common within the month ; aphtha? during dentition.
Aphtha? do not always exhibit the same characters in different spots. Sometimes, when the follicles are about to ulcerate, the edges of the ulcers, instead of being covered with a slight curdy ex- cretion, exhale a small quantity of blood, which concretes under the form of a slight brown scab, mistaken, says Billard, by some authors, for a gangrenous eschar.
The causes of follicular or aphthous stomatitis are predisposing and exciting; and of these the first is the most important and tho least controllable, because consisting in an excess of the white tissues, or a predominance of the lymphatic temperament. This may be greatly increased by bad or defective food and im- pure air, under the influence of slight causes, such as indigestion, common bowel complaint, or changes in the milk or other food. As evincive of predisposition in certain subjects over others, the practitioner must doubtless be able, from his own observa- tion, to confirm the remarks of Underwood, that " the thrush is sometimes found to seize every infant in certain families, in what- ever way the children may be managed." Illustrating the effect of dietetic regimen, is the additional observation of this experienced physician, though inelegant writer, that want of a proper attention to the state of the alimentary canal will bring on the disease, as " where the mother happening to be ill, the whole attention of the family has been thereby engaged ; or where one infant has been put to nurse, while all the rest of the children have been carefully brought up at home."
Aphthous stomatitis is mainly induced and kept up by disordered digestion and impeded nutrition ; and hence its common occur- rence in those children who are brought up by the hand, and espe- cially in those who, in addition to the deprivation of their mother's or nurse's milk, are cooped up together in hospitals, and deprived of fresh air, and illy attended to in the means for preserving a clean and fresh state of the skin. " The fact is, the thrush is a disease of debility, and therefore, attacks very young and very old subjects, especially if otherwise weakened." Whoever has watched the
40 DISEASES OF THE DIGESTIVE SYSTEM.
progress of protracted cases of cholera infantum, and seen the spread and severity of aphtha?, increasing as the disease advanced, and the little patient become weaker and more emaciated, will con- firm the accuracy of this remark.
Reference has been before made to some of the symptoms ac- companying aphthae. Those most marked are produced by the morbid state of digestion, such as eructations of an acid smell, sometimes vomiting and irregular action of the bowels; heat ot skin and fever; but you have been already told that this last is by no means a common complication of simple or discreet aphthae. On this point, however, we must remember that the ex- citement of the heart and bloodvessel system is relatively low in subjects of a lymphatic temperament, and hence we are not to lay stress on this as the only measure of inflammation or febrile action in them. If we were to judge from the cries, wakefulness and restlessness of children affected with aphthae, we should infer that they experience pain. When the disease extends to the pharynx and produces a swelling of the glands and inflammation of the trachea, which is among its alleged effects, the cry of the child is sensibly altered, and it manifests pain, but more by a harsh or hissing cry than by its tears. (Gardien, Traite Complet d'Accouchemens.)
Treatment. — We cannot judiciously apply our remedies in aph- thous stomatitis, without a due knowledge and consideration of its precursory and concomitant disorders. Thus, if it exists with den- tition, and there be much tumefaction and redness of the gums, with irritative fever at the same time, the treatment will be directed to the relief of this morbid state, and nearly all the medicines used for the aphthae will be of a topical kind, and these the most simple, such as a linctus made of mucilage of gum arabic and syrup, with a little acetic acid ; or if the heat and irritation of the mucous mem- brane be considerable, a weak solution of sugar of lead may be lightly applied to the parts by means of a fine brush or a piece of lint tied to the end of a small, rounded stick. The sub-lingual, or the sub-maxillary glands, taking on secondary disease by the irri- tation transmitted from the mucous membrane of the mouth, may- require the application to them of a few leeches, followed by a poultice and camphorated spirituous lotions so applied as to pro- duce evaporation.
Patches of aphthae or scattered ones in the regions already men- tioned, without apparent complication of pain or fever, may be treated by, at first, mild mucilaginous linctus applied cold, and the administrationof adoseof castoroil,or rhubarb and magnesia, to pro- cure a moderate but yet tolerably complete evacuation of the bowels. The disease still persisting, recourse will be had to a somewhat sti- mulating substance, such as borax, or alum ; the former in a linctus with sugar and mucilage, or with honey and water; the latter dis- solved in sweetened barley water, in the proportion of ten grains to the ounce. The preparation of borax which I prefer myself, after frequent trials of its efficacy, is a solution with sugar in water and
FOLLICULAR OR APHTHOUS STOMATITIS. 41
alcohol ; to which sometimes a little laudanum is added, as follows : R. Sodoe sub-borat. $u; Aquae fluvialis, f ?ij; Alcohol, f^ss; Sacchar. albi, 3ij. M. ft. Solutio. As there is great difference in the com- mon, as well as the morbid, sensibility of the parts, the quantity of borax will be increased or diminished accordingly. If it be thought advisable to circumscribe more accurately, and to retain the sub- stance longer on the part to which it is applied than can be done by a simple solution, gum arabic may be mixed in adequate quan- tity. But of the preparations which combine power with mildness, I know none equal to a solution of chloride of soda, as it is sold in the shops, and diluted with water, and to be applied as a gargle, in the proportion of one drachm to an ounce. In place of this, the chloride of lime in solution may be used. The fetor is removed, and the sores cleansed and excited to heal by these chlorides. I need not enlarge on the use of other topical remedies in this disease, as I shall have occasion to recur to this kind of medication, when treating of pultaceous and pseudo-membranous stomatites.
But, whenever we are called to a case of aphthous stomatitis which has lasted more than a few days in a child of very lymphatic tem- perament, and whose regimen has been faulty, we must regard all local remedies, indeed all treatment purely medicinal, a& of secon- dary importance ; and direct our measures to a change in the food, the air, and the applicata, both as regards clothing and bathing. If a child has been weaned, we ought to restore it to the breast; or, if this cannot be done, to give it nutriment nearly analogous to that derived from the maternal bosom. Sometimes, indeed, we are compelled to prescribe the substitute in preference to the original supply, as where the mother is pregnant, and her milk evidently disagrees with, and disorders the child. Cow's milk, fresh, and with a little farinaceous matter, as ground rice, pounded crackers, arrow root, or barley flour, mixed with it, and sweetened, is the best succedaneum for the mother's milk, and will, when given at proper intervals, in quantity not too great at a time, nourish, and correct, at the same time controul, previous looseness and concomi- tant disturbance of the bowels. Fresh air is to be admitted to the little patient in the room, if circumstances prevent its being taken out; but the latter course is still better, and will alone exert a bene- ficially controling power over the disease. Frequent changes of body-clothes, which must be of a suitable warmth, but not oppres- sive by their weight and thickness, — and the daily, or twice daily, use of the warm bath, at from 90° to 94° F., according to the temperature of the skin and activity of circulation, will greatly contribute to the cure. During the time in which the appropriate regimen is employed attention is to be paid to the state of the bowels. Sometimes they will be acted on by castor oil, or rhubarb and magnesia ; sometimes with chalk mixture, and at other times again with minute or fractional doses of calomel, mixed with gum- arabic, or still farther reduced in strength by mixture with chalk. For the most part vou will discover complications of visceral
4*
42 DISEASES OF THE DIGESTIVE SYSTEM.
disorder with aphthae of sufficient moment to prompt you to the remedies just indicated; and it is on this account that 1 en- large the more on the treatment of the disease of which aphthae are but a part, perhaps only a symptom, as in gastritis, or in gastro- enteritis of children, constituting what is generally called cholera infantum, or it may be to analogous irritation in the digestive tube, kept up by teething.
If I insist on the paramount importance of regimen in aphthous stomatitis, and dwell on the wants of nutrition, as indicated by the causes, and precursory as well as associated phenomena, I would wish to be understood as recommending renovation, but not that kind of excitement procured by stimulating remedies; and hence the pre- ference I give of regiminal over medicinal means. I would now, in harmony with this view of the nature of the disease, add that, after the therapeutic treatment, which I have stated to you, has been tried, and the febricula which may have been present removed, or so much abated as to excite no uneasiness in your mind, you may then administer with advantage a mild tonic. Of this class, a simple watery cold infusion of chamomile flower, or of wild- cherry tree bark, or if the skin be cold and circulation feeble, sulphate of quinia, are to be preferred. Stress has been laid by some on preparations of iron, and I have myself used the muriated tincture with advantage in that feebleness of frame, in which pros- tration and derangement of digestion and aphth.Ee were the predo- minant disorders.
3. Ulcerous Stomatitis. — This may be readily confounded with the former kind, but it differs in its not being restricted to the folli- cles. The ulcers occupy indifferently every part of the buccal cavity, viz., the frenum of the tongue, its base, the internal surface of the cheeks, and the palatine arch.
Under this head we may properly introduce mercurial stomatitis, the existence of which is not always announced nor accompanied by the characteristic mercurial fetor. I have seen ulcers of the. mouth and gums following the use of calomel in large doses in young children, at a time when they who administered them thought that the medicine produced no effect.
The treatment of ulcerous stomatitis requires nothing of a spe- cific character, — at any rate different from that of follicular stoma- titis. The same attention should be given, as in this latter disease, to the state of the general health, and the means recommended for renovating the digestion and quickening nutrition, concurrently with topical applications, used in the one, as were thought advisable in the other.
Pustular Stomatitis is a name given by M. Billard to the inflam- mation developed during the course of small-pox, and is analogous to the circumscribed pustular ulceration of the skin, and identical pre- cisely with that variolous ulceration which attacks all parts of the mu- cous surface (pharyngeal and tracheo-bronchial) that are reached by the atmospheric air. Nor do the aphthae which accompany scarlet
PULTACEOUS STOMATITIS. 43
fever or measles, require any specific notice in this place, consti- tuting as they do a part of these formidable diseases, and to be no- ticed with the other symptoms and the treatment hereafter.
4. Pultaceous or Curdy Stomatitis, or Stomatitis with altered Secre- tion— Muguet — White Thrush. — This species has a greater affinity to the first described one, or the erythematic, than any other. It is peculiarly a disease which attacks, in preference, infants soon after birth, and those still at the breast. " It is characterized by a con- cretion of mucus on the surface of inflamed mucous membrane, whether this be an epithelium or not. This concretion may be ob- served in the mouth, assophagus, stomach, and small or large intes- tines" (Billard).
Pultaceous stomatitis begins with small specks on the surface of the inflamed membrane ; they are seen on the inside of the lips and at the tip of the tongue. Gradually they are increased, enlarge, and unite together as irregular, thin lamina?, which sometimes remain separate, then exfoliate, and are replaced by others in successive se- ries. Sometimes, on the other hand, they become thicker and more diffused, so as to run into one another and form a continuous mem- brane, which lines the cavity of the mouth and covers the surface of the tongue, extending even over the pharynx and oesophagus, and* as M. Billard asserts, continued into the stomach and the whole intestinal canal. In the first or simpler form the disease is called discreet, in the latter confluent.
Pathology. — Pultaceous stomatitis consists in an inflammation of the buccal mucous membrane, which soon produces a morbid secre- tion of mucus, of a white or curd-like appearance, that afterwards concretes, and covers a surface of more or less extent. This pelli- cular or curdy production takes the place of the mucus which moistens and lubricates the mouth. Concretion in laminar shape, external to the epithelium and unaccompanied by ulceration, and its repeated removal and reproduction until the inflammation is ex- hausted, distinguish this kind of stomatitis, the true muguet of French writers, from the aphthous or ulcerous species.
The causes of this disease, as laid down by M. Billard, are, " the first period of infancy — bad nutrition — the assemblage of a great number of children in the same place — debility — inflammation of the buccal membrane, — and lastly, the disposition which the mucous membrane exhibits in young children to be covered, when they are inflamed, with thick, curdy, and membraniform concretions."
" As to general symptoms, they scarcely exist in very young in- fants ; fever is hardly ever manifested. I counted," says M. Billard, " the pulse and the beatings of the heart in forty children, aged from one to twenty days, affected with it, and found fifty, sixty, sixty- five, eighty, and in one instance one hundred pulsations in a minute* With the exception of the last case, the number of pulsations did not differ from the natural state of the pulse." M. Billard, you ought to be apprised, does not believe that there is greater frequency of pulse in infants than in adults ; but in this opinion he is not sus-
44 DISEASES OF THE DIGESTIVE SYSTEM.
tained bv the experimental observations of other physicians. The skin is usually hot and drv. When the membraniform concretions spread to the tonsils, and cover the pillars of the velum palati, the cry is husky. Sometimes, and the fact merits your attention, pultaceous stomatitis is complicated with other phlegmasia?. In fifty cases, fatal either from the disease or its complications, there was disease of the digestive apparatus in thirty-two.
Season is said not to exert ,any marked modifying influence in causing muguet. It prevailed, according to M. Billard, with almost equal intensity, and at all limes, at the Hospice des Enfans Trouves (Foundling Hospital). But the statement which he gives is not in unison with this assertion. In the quarter ending in March, 1826, out of two hundred and ninety patients, there were thirty-four cases of this disease. In the quarter ending in June, out of two hundred and thirty-five patients, there were thirty-five cases; in the three months ending in September, out of two hundred and thirteen sick, there were one hundred and one cases ; and forty-eight cases in the quarter ending in December among one hundred and eighty-nine patients. Thus we see that the actual numbers in each quarter were respectively, 34, 35, 101 and 48, showing nearly three times as many in the third or summer quarter, as in the winter and spring, and more than twice as many as in the autumn. The proportion of the sick with muguet to other diseases in the Hospital, were as 1 to 8£ in the winter ; 1 to not quite 7 in the spring; 1 to a little more than 2 in the summer, and 1 to not quite 4 in the autumn.
The contagiousness of this kind of stomatitis, believed by many, is denied by M. Billard, who refers to, while confirming, the expe- rience of M. Baron. This gentleman has often seen children drink from the cup used by those who have been affected without their contracting the disease.
Treatment. — The remedies for this kind of sore mouth are nearly the same as those recommended in other kinds of stomatitis. In simple or discreet muguet, it will be sufficient to cleanse the mouth with a little piece of sponge, or of lint, tied to the end of a quill, after dipping it either in a simple mucilage, or in one slightly quickened with vegetable acid ; and to alter somewhat the intestinal secretions by a mild laxative. But in confluent or diffused pultaceous sto- matitis, or muguet, we should apply fomentations or cataplasms to the neck, and cooling saline gargles to the mouth, and purge with a small dose of calomel, followed by castor oil and magnesia. The farther treatment will be regulated by the state of the stomach, ac- cession of fever, and the appearance of the mouth. Minute doses of the alkalies, — carbonates of potassa and of soda, in solution with ipecacuanha wine; or ipecacuanha and chalk, the warm bath, and mildly astringent or stimulating washes or linctus to the mouth and fauces, will be brought into requisition, in the more violent cases of the kind of stomatitis now under notice. Of gargles, my prefer- ence is still in favour of fluid chloride of soda, to which, on occa-
PSEUDO-MEMBRANOUS STOMATITIS. 45
sions, in this, as well as in aphthous stomatitis, may be added tinc- ture of myrrh, as in the following prescription: — R. Liq. chlorid. sodae, Tinct. myrrhae, aa f gss. ; Aqua3 fiuvialis, f^vi.; Aquas Ro- sar. f §i. M. This gargle to be applied at intervals, as may be deemed necessary.
LECTURE IV.
DR. BELL.
Pseudo-membranous Stomatitis. — Its complications with visceral disease — insidious approach — Pathology — ■ sometimes prevails epidemically — Treat- ment, modified by the state of the digestive system and degree of local excite- ment— Local applications — Means of properly applying mineral acids and lunar caustic — Sulphate of copper — Iodine, topically and internally — Warm bath — Gangrenous stomatitis — As a result of other kinds of stomatitis, and as a separate disease — Different opinions as to its violence and danger — Two stages of gangrene of the mouth — Its Pathology — common origin in the gums — Treatment, general and local — Emetics, tonics, and the warm bath and frictions — Iodine — Topical remedies — numerous — The chief one is sul- phate of copper.
In continuing my observatious on the different kinds of sore mouth, with inflammation, I shall in this lecture speak of the one which is characterized by a membranous or pellicular secretion, somewhat re- sembling that in croup, and identical with that which lines the fauces and pharynx in certain varieties of angina. After this, your attention will be directed to the gangrenous sore mouth, the most violent and unmanageable of all the species of stomatitis. Let me again im- press on your minds the necessity of constantly being aware of the dependence of the local disease on the state of the general system, and especially on interrupted and perverted nutrition ; and the im- possibility of removing the former unless the latter be corrected, and the permanent stimulants of pure air, wholesome food, and some exercise, be brought into operation on the frame of the little suf- ferer.
5. Pseudo-Membranous Stomatitis — Buccal Diphtheritis. — This is the most dangerous of all the stomatites. It occurs not only alone but in connexion with inflammation and a similar exudation on the pharynx, tonsils, or soft palate of children. Its seat is com- monly on the gums, angles of the lips, and on their inner surface, and the lining of the cheeks, or the tip and sides of the tongue. It is more usually seen on one side only : at first appearing as small patches of a grayish-white, irregularly rounded, it afterwards extends by the running of these together, and their becoming gray, dark, and livid : they appear depressed, owing to the projection on their mar- gin of the surrounding mucous membrane. Laminae of the false membrane are, after awhile, detached to be replaced by others. At this epoch of the disease, the membranous formation extends over
46 DISEASES OF THE DIGESTIVE SYSTEM.
a part of the tongue, the gums, and the internal surface of the cheeks. During some days it is nearly stationary, after which there is a change, either by resolution or gangrene. In the first contingency the patches at their centres, or their borders, begin to be absorbed, and there only remains a simple whitish streak, which gradually disappears, leaving no trace of disease. But when gangrene super- venes, we see some points on which absorption takes place, whilst the rest of the tissue is completely mortified.
This kind of stomatitis is complicated at times with bronchitis, pneumonia, or inflammation of the digestive canal. Regarded as a pellicular inflammation, or one attended with exudation, for such is the etymological signification of diphtherite, this disease is not com- mon, but occasionally, as Drs. Evanson and Maunsell observes (A Practical Treatise on the Management and Diseases of Children), " we have seen and removed from the velum or back of the pharynx a thick pellicle of lymph ; the mucous membrane beneath being in- flamed, but free from ulcer or slough. On the contrary, we have found from the first the inflamed surface beneath converted wholly into an ash-coloured slough or studded with patches of such." Happily this form of diphtherite is not so common as might be sup- posed from the remarks of some writers who apply this term to any spreading ulceration at the back part of the throat. It is always dangerous, and often the more so from the insidiousness of its ap- proach, and its having made extensive progress without any unea- siness in the throat, pain in swallowing, or other symptom to indicate the real nature of the disease. Sloughing in gangrene may be the result of any of the morbid conditions of the mouth or fauces of which we have spoken ; but it is most liable to occur in affections of the tonsils, soft palate, or back of the throat ; perhaps more particularly when attended by false membranes.
" When inflammation of the tonsils or pharynx is very intense, ac- companied by false membranes, or occurring during scarlatina or any livid-coloured eruption, we may apprehend gangrene, parti- cularly if the child be very delicate, badly nourished, or exposed to contagion, (as when gangrenous sore throat prevails,) or if gan- grene of other parts of the body be present. We judge of the ap- proach of gangrene by the local appearances and general symptoms, as when much or sudden prostration attends, or is induced by a disproportionate degree of depletion ; while the colour of the in- flamed part changes from a lively red to pale, or appears from the first of a livid or dusky red hue." (Op. citat.) When the isthmus of the fauces is affected the appearance of the parts betrays this state, accompanied by a sense of suffocation, and difficulty of de- glutition ; which last becomes impossible, if the gangrene has ex- tended to the oesophagus; and when it has passed into the air tubes, there is a remarkable alteration in the cry or voice, which becomes hoarse or inaudible, with a peculiar cough, or wheezing respiration.
Symptoms. — In the beginning of this disease, increased heat of the mouth is felt and complained of, and also pain, aggravated by
PSEUDO-MEMBRANOUS STOMATITIS. 47
the contact of any foreign body. The breath is fetid, and the sub- maxillary glands are engorged and painful. After a while the lips and gums are tumid and bleed, and a sanious saliva flows copiously from the half open mouth; the breath becomes more and more of- fensive, the face red and swelled, and the fever more or less intense ; there are, also, headache, restlessness and vigilance. Gradually, when absorption has begun, these symptoms abate, and the con- valescence sets in.
Causes. — Membranous stomatitis attacks persons of all ages, but more frequently children than adults. It is most apt to occur in cold and damp weather, and where attention has not been paid to cleanliness and ventilation, as where a number of children are crowded together in hospital wards, or small and close rooms. Sometimes this kind of stomatitis prevails epidemically, but it does not appear to be contagious. It has been known to follow mercu- rial ptyalism, and it has been observed in fevers called by some continental writers mucous, and at the termination of certain chronic maladies.
Treatment. — The remedial measures to which we have re- course in pseudo-membranous stomatitis are nearly the same with those in aphthous stomatitis. The same prompt attention is required to remove the external and other causes by which nutri- tion is deteriorated, viz., impure air, bad and insufficient food, and personal filth ; and to substitute in their stead wholesome and appro- priate aliment, pure air, bathing, and clean and frequently changed body linen. The condition of the digestive system must be ame- liorated, it cannot all at once be relieved of disease, by mild laxatives, with the first dose of which we may combine a grain or two of calo- mel ; and afterwards simple bitters, or a weak solution of sulphate of quinia. Concurrently with these means we attempt an abatement of the local malady, by leeches beneath the chin or under the jaw, if the glands be sympathetically swollen and inflamed. But, if good is expected from even local depletion, it must be in the first stage of the disease, and ere the system becomes prostratea, as if under the influence of a poison. In a more advanced stage, when the skin is cold and the circulation feeble, we may place considerable reliance on the effects of oil of turpentine, given at first in a dose of 3i» with castor oil 3'j- to 5ss., according to the age of the child, and afterwards alone in a dose of 3ss. three times in the twenty-four hours, mixed wiih sugar and gum, — or, in extreme cases, with carbonate of ammonia. At this time a stimulating liniment, with turpentine oil as its basis, will be usefully applied, by rubbing, and by means of a piece of flannel dipped in the same to the throat and lower jaw.
More stress is laid upon early recourse to local applications, and especially to those of a stimulant nature to the mouth, in this, than in the other kinds of stomatitis; and above all, if the subject of it has been exposed to the deleterious influences so prevalent in hos- pitals and crowded and illy ventilated rooms. In the selection of
43 DISEASES OF THE DIGESTIVE SYSTEM.
these it is most prudent to begin with the milder ones, such as vineo-ar and water, fluid chloride of soda and water, tincture of myrrh, or a solution of borax, or even of common salt, which last is a very good detergent ; and afterwards, if the excitement is feeble or rapidly diminishing, we use those of a more potential character. Foremost in the good opinion of many, are the mineral acids, and of these the preferred one is the hydrochloric or muriatic acid. It may be used either as a common detersive gargle, sufficiently diluted or mixed with honey, in the proportion of one drachm of the acid to an ounce of the vehicle, or used as an escharotic undiluted, in which case it may be applied by a glass capillary tube, which, when immersed in the acid, takes up two or three drops, and after- wards put on the diseased surface, allows of their escape. In the common method of applying the acid with a sponge or dossil of lint tied to a quill, or a small rod of ivory or other stick, the acid is apt to be diffused over a greater surface than was originally intended. At all times, without great care, the teeth may suffer from this acid. On this account, as well as owing to its compara- tively less stimulating nature, and a belief that the mode of action which it induces, approaches nearer to the healthy one of the mucous tissue, lunar caustic is preferred by some judicious practi- tioners. It is recommended in solution — from a scruple to half a drachm, to the ounce of water — as a gargle or rather collutory. Preferably, however, to this, is rubbing quickly and lightly the diseased surface with a pencil of lunar caustic. There is one great advantage attending this latter method, — that it must be done by the physician himself, and hence that it will be properly done : whereas gargles left to be used by the mother or nurse are seldom applied as they ought to be, either through ignorance and timidity, or a false tenderness and fear of hurting the child. In discreet aphthae it is also employed in substance ; but pains are taken to touch each separate aphtha, in place of rubbing it over the whole diseased surface as is done in diphtheritis, and also in confluent aphthae, particularly when the back part of the throat is the seat of either of these diseases.
A still more favourite remedy with several who have written on this subject, and also tested its efficacy, is. sulphate of copper, in solu- tion or as a linctus, in which ten grains, or even twenty and thirty, of this salt are added to an ounce of water or of honey; or this salt alone may be employed in many obstinate cases. Testimony in favour of this practice is borne by Drs. Maunsell and Evanson, in the following terms : " From no other application have we derived equal benefit in the treatment of aphthae, muguet, cancrum oris, ulcerated sore throat, &c, &c. According to its strength, the solution of copper acts as a stimulant or escharotic, while its astrin- gent power is of a higher order. Hence its applicability to a great variety of cases; while it is remarkable that under its use the sur- rounding inflammation is lessened, as well as the ulceration im- proved.."
PSEUDO-MEMBRANOUS STOMATITIS. 49
Powdered alum, blown into the back part of the throat, has been recommended by Bretonneau, when diphtheritis has extended that far: — " When sloughing has actually taken place, the most decided escharotics may be required to destroy the sloughing parts, and arrest the progress of the disease. For this purpose the muriate, or butter of antimony, is perhaps the most effectual and manageable of the escharotics, as its action does not extend beyond the part to which it is applied, nor is its use attended by inflammation of the surrounding parts."
There is yet another article of considerable activity, not hitherto mentioned by writers in this disease, but one in which I am dis- posed to put no little confidence. I refer now to iodine, and par- ticularly to the tincture and the compound solution of the iodide of potassium, — the first prepared by dissolving two scruples of iodine in an ounce of rectified spirit; the latter by dissolving a drachm of iodine with two drachms of iodide of potassium (hydriodate of potassa) in one ounce of water. With either of these the diseased surface may be painted over with a brush dipped in it ; repeat- ing the application after the lapse of twelve hours, — in less urgent cases in twenty-four hours. The tincture or the compound solution may be reduced in strength by dilution, — of the first with rectified spirit, and of the second with water, — in cases in which the pelli- cular exudation is not very thick, or the vitality of the mucous mem- brane is yet active, or where the stronger preparation has been found to be too severe. The advantages of the iodine used in this way are, that the morbid exudation is absorbed ; sloughs, if they have taken place, are thrown off, and healthy granulations formed.
At the same time that we use the iodine topically, we should, with no small reliance in its therapeutical virtues, direct its adminis- tration internally. With this view we give a simple solution of the iodide of potassium in a watery infusion of a bitter, at intervals of from four to six hours. The dose of the iodide will be from a sixth of a grain to half a grain, for young children. Its effects will, of course, be carefully watched, and if it prove irritating to the stomach, or cause any oppression of breathing, or restlessness and vigilance, for all these are occasional and unwelcome effects of this medicine, we must either suspend its employment or greatly reduce the dose.
Carbonate of ammonia in full doses, of from five to ten grains, is also highly spoken of in this disease.
Reference has been already made to bathing as a preliminary or incipient part of the treatment of this disease, in order to cleanse the skin of impurities, and to restore, in a measure at least, its func- tion, suspended by accumulation of perspirable matter and want of common ablution, as is the case under circumstances already explained. In the progress of the disease the warm bath ought to constitute a part of the regular treatment, and be used twice a-day, for about ten minutes at a time. In extreme cases and stages of the disease, stimulating pediluvia should be frequently had recourse
VOL. I. — 5
50 DISEASES OF THE DIGESTIVE SYSTEM.
to, as answering all the purposes of counter-irritation, without the annoyance and troublesome sores, even of a gangrenous nature, which sometimes ensue on the application of blisters and even sinapisms to the extremities of subjects in whom capillary circula- tion is feeble, and the tissues prone to disorganization, owing to their lax temperament and imperfect and depraved nutrition.
6. Gangrenous Stomatitis. — This kind of stomatitis corresponds more nearly with gangrenous aphthae than with gangrene of the mouth (cancrum oris), or gangrenous erosion of the cheek; names, these two last, given to a formidable and generally fatal disease.
Gangrenous stomatitis may be the consequence or termination of any of the kinds of sore mouth already mentioned, and it is fre- quently spoken of and described in this light; as, for example, by Andral (Cours de Pathologie Interne). Aphthae are liable to de- generate into deep chancrous and eating ulcers, which soon be- come sphacelated in subjects whose vital energy from defective nutrition is feeble. The supervention of this state in common aphthae, or other kinds of stomatitis, requires a change of treatment, and a suspension of the liberal use of stimulating and caustic appli- cations which may have been used before. Emollients, such as mucilaginous and slightly warm fluids, are to be applied to the parts ; and not until gangrene is fairly begun ought we to attempt to aid them to throw off the now foreign and dead matter by stimulating substances, already mentioned.
The other and more important, and unfortunately still less ma- nageable variety of gangrenous sore mouth, is that which spends much of its force on the cheek, and hence one of its names, gan- grenous erosion of the cheek. It is also peculiar in being preceded by very slight inflammation ; indeed the chief and almost the sole evidence of this morbid state of the capillaries of the part is oedema and congestion, which soon yields to disorganization of the tissue. In this respect it is analogous to anthrax or carbuncle. Antece- dently, however, to these changes in the substance of the cheek, are others in the mucous tissue lining this part, and also in the gums, which are designated under the title of cancrum oris — canker of the mouth.
_ Owing to the different degrees of intensity of this last mentioned disease depending on' the difference in constitution and circum- stances of the patients, writers are not at all agreed in their opinion of its violence and danger. " The common canker," Underwood tells us, " is rarely troublesome to cure." It sometimes, he con- tinues, makes its appearance in the month ; at others, about the time of teething ; and frequently at the age of six or seven years, when children are shedding their first teeth, and the second are making their way through the gums, which are covered with little foul sores, extending sometimes to the inside of the lips and cheeks. The worst variety of this disease which he saw was durino- the second period of dentition, when a child has been shedding a dum- ber of teeth together, leaving the rotten stumps behind, which have
GANGRENOUS STOMATITIS. 51
been neglected to be drawn out. The whole gums will then be- come spongy, or dissolve into foul spreading ulcers ; and small apertures will be formed, communicating from one part to another, accompanied with an oozing of a fetid and some purulent discharge.
Gangrene of the Mouth. — Very different from this is the gan- grene of the mouth, properly so called, in which, with M. Baron, we recognise two well-marked stages of the disease: — 1. An oedema- tous circumscribed swelling, characterized by a shining, and, as it were, oily appearance of the skin, and by a central body of more or less hardness, in which there is sometimes an obscure red spot, either on the internal or external surface of the buccal parietes. In this first stage in young infants we do not meet with fever, or any symptom of reaction. 2. This central part presents an eschar which usually forms from within; the mucous membrane becomes disorganized, the bones are laid bare, all the soft parts, even to the periosteum, mortify and separate in shreds, at the same time that the mucous or bloody matter, mixed with the remains of the gums or sides of the mouth, flows out, exhaling an infectious odour. (M. Billard, op. cit.)
Pathology. — Dr. B. H. Coates (N. Amer. Med. and Surg. Journ., Vol. IL), in a valuable paper on the "Gangrenous Sore Mouth of Children," says, coincidently with M. Billard, that its access was frequently preceded by no marks of visible disease, or at least none that attracted attention. The little subjects were, apparently, in merely a drooping or enfeebled state. Those met with in the Doctor's clinic, at the Asylum for Children below the city, in a low and unhealthy situation, were generally of feeble and anemic habit, that which is one of the chief, if not the chief predisposing cause of the disease. Sometimes the ulceration followed a common remit- tent or intermittent fever; insomuch that, at one time, whenever a child was brought to the asylum it was expected, as a matter of course, that its mouth would become sore. Dr. Hall (Edinb. Med. and Su?g. Journ., Vol. XV.) states that, in all the cases which have come to his knowledge, this affection had been preceded by fever, acute disorder of the digestive organs, typhus, inflammation of the lungs, variola, rubeola, or scarlatina. In illustration of the effects of debilitating causes, may be mentioned the great proportion, at times, of children congregated in an asylum who are attacked with this disease. Thus, out of 240 at one time in the institution, Dr. Coates tells us that 70 were more or less affected with the ulcera- tion in question.
The ulceration may begin in many parts of the mouth, but Dr. Coates tells us that, in by far the greatest number of cases, it commences immediately at the edges of the gums in contact with the necks of the teeth, and most generally of the two incisors. The spread of the disease is, he thinks, uniformly from the gums to the cheek. When gangrene is formed, a fever of irritation is generally developed. It is aggravated by loss of rest, want of nourishment, and probably by putrid matter finding its way to the stomach. To this latter cause, Dr. C. refers a diarrhoea which almost uniformly
52 DISEASES OF THE DIGESTIVE SYSTEM.
comes on towards the close. We must not, however, forget the probability of a morbid state of the intestinal mucous follicles and membrane being coincident with that of the same tissue in the mouth, as has been already adverted to when speaking of follicular stomatitis.
Dr. Cuming {Dublin Hospital Reports, Vol. IV.), in his " Obser- vations on an Affection of the Mouth in Children," as it occurred in the Dublin Institution for the Diseases of Children, says, that, in most instances, the ulceration, commencing in the gums, extends by continuity of surface to the lips and cheek, but sometimes it com- mences in the lining membrane of the lips or cheek, and extends from thence to the gums. This disease is most liable to attack during the period of the first dentition. It is, however, he adds, frequently met with in children between three and seven years of age. The greater number of cases under Dr. Coates's observation occurred between two and five years of age, but some as late as eight or ten. Dr. Cuming has frequently seen it when the child had only six or eight teeth ; and he constantly observed, that when it occurs thus early it is always the upper gum that is first and principally attacked. This he conceives to be the mildest and most manageable form of the disease. The most formidable variety, in his experience, is that which occurs in children between twenty months and seven years of age.
Thickness and hardness have always occurred in the other situations, besides the cheek, where this gangrene has approached the external cellular masses of the face. After reaching this stage a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly, and has always, in Dr. Coates's experience, been the immediate harbinger of death. I have seen the skin of the cheek and chin all black, or of a brownish hue, hard like tanned leather, in a fatal case of this kind of gangrene shortly before death.
Billard directs attention to the coexistence of the affections of the teeth, the congestions of the gums, and the cedematous swelling of the face on the diseased side ; and he adds, this agreement esta- blishes the existence of some connexion between the diseases of the gums and of the teeth, and gangrene of the mouth ; and he expresses his belief, that this latter.disease may follow swelling and disorgani- zation of the gums. If it should occur in a child in whom the second dentition had commenced, the consequences would be very serious, and might result in the loss of the teeth for the remainder of life.
Treatment. — Before prescribing, we ought to be aware that the prognosis in gangrene of the mouth is unfavourable, as we might suppose from the class of subjects who are chiefly affected, and the gravity of the disease itself, as well as of its complications If fully apprised, as we ought to be, of the antecedents of this disease, inter- mittent or remittent fever, or bowel disease, we must address our- selves earnestly and early to all the means adapted to alter this morbid condition ; and whilst doing so, to modify at once the func
GANGRENOUS STOMATITIS. 53
tions of nutrition. With this view, a mild emetic of ipecacuanha will often be of service, followed at once by tonics, and among these the sulphate of quinia, infusion of calumba or of quassia, are to be preferred. Alternating with the quinia, and administered conjointly with the simple bitter, should be minute doses of iodine in its state of iodide of potassium, at intervals of four to six hours. Carbonate of ammonia is also to be used. Warm salt water bath, twice or thrice daily for a few minutes each time, followed by assiduous frictions, will contribute to the restorative effects of the preceding treatment. On purgatives we must not lay stress after an evacuation of the bowels has been obtained by castor oil with oil of turpentine, in the proportions already indicated. Mercury finds advocates in this form of gan- grene as well as in aphthous stomatitis, but we cannot rely on its local action to the exclusion of the interference by its impression on the general system with nutrition. The same remark applies, with still more force, to arsenic, which is directly adverse to nutrition, and on all occasions like that now under consideration, we cannot afford an hour for vitality to retrograde, as would be the case by the dimi- nished activity of nutritive life. Some may object, that iodine also attacks nutrition; but it is only in large doses that it acts in this way, and it does not produce that morbid impression on the nutri- tive centre, the digestive system, that arsenic does, and even mer- cury also not unfrequently. In small or moderate doses iodine quickens digestion and nutritive absorption, and increases, instead of diminishing, the bulk of the tissues and of the frame generally.
Much and not unmerited stress is laid upon the local treatment in gangrenous sore mouth ; but if we hope for more than tempo- rary relief from this means, it must be when fully aided and sus- tained by the general remedies just indicated.
Dr. Stewart {Practical Treatise on the Diseases of Children) very properly advises, in the forming stage of infiltration, the appli- cation of stimulating frictions to excite the absorbent vessels. Lini- ment of hartshorne may be used for this purpose, or a solution of muriate of ammonia, applied to the cheek by means of pledgets saturated with the solution. The disease being farther advanced, various substances, of a more or less stimulant and escharotic na- ture, are recommended ; such as lunar caustic, butter of anti- mony, the chlorides, as already mentioned in the treatment of other kinds of stomatitis ; also caustic potassa, and the actual cautery, the last a favourite remedy with some of the French practitioners. In the use of these powerful agents we ought, however, to be regu- lated by the extent of action of the tissues around the gangrened spot : if they be inflamed, and indicate a readiness to separate themselves from the mortified matter, we ought not to be too pro- digal of astringents and stimulants, or escharotics; but rather use mild applications, such as the carrot or yeast poultice, or the slightly stimulating wash of a solution of common salt, or powdered borax, on the part.
5*
54 DISEASES OF THE DIGESTIVE SYSTEM.
There is one remedy which latterly unites more suffrages in its favour than any other, as a local stimulant and detergent, in gan- grenous sore mouth : it is sulphate of copper, the eulogy on which, by Dr. Evanson and Maunsell, in the worst and aphthous forms of sore mouth, I have already placed before you. 1 shall now add the unequivocally expressed testimony of Dr. Coates, who is also joined in opinion by some recent French writers, probably as a re- sult, in a measure, of his experience, which was recorded some fifteen years ago (JV. A. Med. and Surg. Jour., 1826). Dr. Coates's formula is as follows : —
R. Sulph. cupn, Jij. Pulv. cinchonae, ^ss. Aquae, £ v. M.
"To be applied twice a-day, very carefully, to the full extent of the ulcerations and excoriations. The cinchona here is not absolutely necessary, but operates by retaining the sulphate longer in contact with the edges of the gums." Sulphate of zinc, in solution with tincture of myrrh, was useful ; also, a simple solution of this salt, 3i. to an ounce of water. Extraction of the diseased teeth, or of the teeth of the diseased gums, early, is an important part of the cure. For the reasons already assigned^we might, with some con- fidence, use topically the compound solution of iodine, as a suitable stimulant to the parts.
There is yet a kind of sore mouth which, as far as our present knowledge extends, is seen only in women during lactation, and hence I shall call it
Stomatitis JVutricum. — The first notice of this disease which has met my eye is in a short communication from Dr. Backus, of Rochester, New York (American Journal of the Medical Sciences, Jan. 1841). But a more detailed description had been previously given by Dr. E. Hale (1830) in the Medical Communications of the Massachusetts Medical Society, Vol. V., also Am. Journ. April. J 842. h '
The disease commonly begins with a hard pimple upon the ed^e of the tongue, generally at a little distance from the tip, which is very red and extremely painful. After a few returns, and not unfrequently after a first attack of this nature, the central spot ulcerates. The ulcer is deep, with hard elevated edges surrounded by an inflamed circle, and is still exquisitely painful. The location of these ulcers is gener- ally the same as in the stomatites of children, viz., on the tongue and inside of the cheeks, but rarely, if ever, upon the gums or the° palate. J- he inflammation, however, extends to the fauces, and, as we have seen in the case of muguet or pellicular stomatitis, is continued on tne esophagus, stomach, and intestines, and is then accompa- nied with diarrhoea. The ulcerations increase in depth, though their extent of surface is not great. Dr. Hale has seen a consider- able loss of substance in the edge of the tongue, which was only partially supplied when the ulcer healed, leaving the Part7a 3 and uneven. The accession of the disease is presented by Dr
STOMATITIS NUTBICUM. 55
Backus to be very sudden ; " in three hours time after seeing your patient in health, you may find her with a scalded tongue and fauces, and unable to co'nverse or to take food." The appetite is good throughout the whole course of the disease, but the pain from taking food is so great that nothing but the mildest liquids can be borne. Although the patient becomes greatly emaciated, and her strength wastes rapidly, the secretion of milk is little if at all diminished, and the child continues vigorous and healthy.
The subjects of this disease are, as before stated, women during the period of lactation. Sometimes, indeed, Dr. Hale has seen it during pregnancy; but never in the first pregnancy, nor in a sub- sequent one, unless the woman had previously suffered from it while nursing; and even when it appeared at this time it readily yielded to remedies without any considerable constitutional irritation. Dr. Backus also admits that it sometimes appears during the latter months of pregnancy. Its attacks are not confined to any parti- cular constitution or temperament ; but are made at times on the most robust who have always enjoyed good health. Dr. Backus is inclined, however, to believe " that females of a leucophlegmatic temperament and of dyspeptic habits, with habitually slow bowels, are perhaps more liable to its attacks than others." A woman who has once had this disease is always liable to a recurrence of it in every subsequent period of nursing.
The prognosis is generally favourable, if too long a period be not allowed to pass after symptoms of debility and exhaustion have been manifested : and it is chiefly where there is a predisposition to phthisis pulmonalis that such appearances should excite solicitude, lest the constitution should be fatally undermined. Of course, under these circumstances we must be more urgent in our recommenda- tion that the mother or nurse should wean the child, or hand it over to another and healthier person.
Treatment. — This last measure is the most certain and speedy means of cure of this kind of stomatitis, and in some instances it is indispensable. The symptoms which require that the nursing should be suspended, are the violence of the diarrhcea and general exhaustion, more than the increased soreness of the mouth.
As the stomach is sometimes disordered, an emetic of ipecacuanha will be of service. But this, although an occasionally useful pre- liminary to other partsof the treatment, isnotindispensably necessary. Dr. Hale rests the cure chiefly on tonics, such as the lime-water in- fusion of bark, given in the dose of a wine-glassful two or three times a day. Carbonic acid, as in bottled beer and porter, and the effervescing salts, was found to be serviceable. When a laxative is proper, it is best given with some effervescing mixture, as, for example, powdered rhubarb mixed in water with the bicarbonate of potassa, to which a little lemon-juice or vinegar is added at the moment of taking it. When the porter has stimulated too much, and the effervescing salts were agreeable to the patient, Dr. Hale gave a fermented solution of tartaric acid and sugar, as follows :
56 DISEASES OF THE DIGESTIVE SYSTEM.
An ounce of tartaric acid is put into about three gallons of water, with white sugar in quantity to please the taste : to this add two or three spoonfuls of good yeast, and stir it well when first mixed, and again after two or three hours; at which time, if necessary, add more yeast: let it stand quietly in a cool cellar about twenty-tour hours; then draw it off and carefully bottle it. Sulphate of quinia is well adapted to some cases, and more particularly to those in which the debility is considerable. All stimulating tonics are inju- rious, and tinctures of all kinds are inadmissible. Dr. H. found it necessary to direct a discontinuance in the use of wine, a pro- hibition which ought to be the rule with mothers while nursing their children ; and the use of wine or of any fermented liquors the ex- ception during this same period.
Coincident with this view of the treatment of sore mouth of nurses is that of Dr. Backus, who places his chief reliance in cha- lybeates, combined with rhubarb and aloes, as in the following pre- scription : — R. Carb. ferri, grs. lxv. ; Pulv. rhei et Gum aloes, aa grs. xv. M. ft. mass, in pil 50 dividend. " Two of these pills should be taken twice or three times a day, or often enough to keep the bowels very open"
Little value is attached to local remedies by Dr. Hale. When they are had recourse to, some of those heretofore mentioned, such as the chlorides, or a weak solution of the nitrate of silver, may be used.
LECTURE V.
DR. BELL.
Glossitis — Its varieties and causes — Symptoms — Termination — Diagnosis — Treatment — Importance of scarifications — Symptomatic or secondary glos- sitis— Treatment modified by the nature of the primary disease. — Parotitis ■ — Primary — Supposed contagion of — Terminations — Metastasis to other organs — Treatment — Secondary or symptomatic parotitis — That caused by mercury, — its treatment. — Diseases of Dentition — Predisposition to nu- merous diseases in early infancy — Causes besides dentition — The suscepti- bility of the organs of the child, and peculiar exposure to external agents — Sympathies of the dental apparatus — Direct and remote — Treatment during dentition — hygienic and medicinal — The measures chiefly demanded.
In the description of the various species of stomatitis in the last two lectures, you have learned that the tongue is frequently affect- ed, and, indeed, that the disease sometimes first manifests itself by aphthous or pellicular inflammation of its mucous membrane. But, in addition to these affections, which it has in common with other parts of the mouth, the tongue every now and then becomes the sole seat of inflammation. This morbid state of the or°-an is termed glossitis, from >xa.<r<r*, the tongue.
Glossitis, though a term strictly applicable to partial inflamma- tion of the tongue, induced by bruises from foreign bodies, or com-
GLOSSITIS. 57
pression between the teeth, as in convulsions, or by irritants or corrosives taken into the mouth, or to symptomatic disease, as in violent ptyalism, small-pox, scarlatina, &c, yet we seldom think of applying it formally, or carrying out a specially devised plan of treatment for it, except in cases of idiopathic or primary phlogosis of the organ. Before speaking of the probable causes and pheno- mena of this disease, I will just repeat the paragraph in which Schill in his Semeiology describes the circumstances under which it becomes enlarged, and the prognosis in consequence.
" 454. Enlargement of the tongue may be occasioned by hyper- trophy, inflammation, or congestion. Inflammatory swelling of the tongue, if it occur in other acute diseases, as angina, pulmonary inflammation, measles, plague, or variola, yields an unfavourable prognosis. Even non-inflammatory swelling of the tongue is a dangerous phenomenon, in acute diseases, especially in cerebral diseases which are combined with coma. If it be the consequence of mercury, of the abuse of spirituous drinks, of gastric inflamma- tion, of chlorosis, of syphilis, or if it occur in hysteria and epilepsy, the prognosis is not dangerous ; but the disease is always more tedious where the tongue swells, than where it does not. It is enlarged also by degenerescence and cancer." p. 169 — Philadelphia Edition.
Sanguine temperament and plethora, kept up by excessive and stimulating aliment, are spoken of as among the predisposing causes of glossitis, — the exciting ones being suppressed perspiration or other natural or accustomed discharges, and the immoderate use of spirituous liquors. But there must be some other circumstance which escapes our observation, and on which the occurrence of this disease depends; for we find, happily, no proportion between the combined operation of all the assigned causes and the frequency of the disease. Idiopathic inflammation of the tongue is a rare dis- ease, and, I must add, as formidable as it is rare. The situation and connexions of this organ are such that, apart from the morbid changes in its own tissues consequent on its phlogosis, its enlarge- ment exerts a pernicious influence on respiration and deglutition, by the impediments which it offers to these two functions ; and espe- cially to the former.
Glossitis has been divided into superficial and deep-seated ; the first attacking the mucous membrane and tissue immediately subjacent; the second extending to the substance of the tongue. The first is the least dangerous. It is ushered in by the common symptoms of inflammation, accompanied with some difficulty of deglutition; the tongue is painful, and the patient is sensible of its enlargement, which is evident on inspection. The pain is not great ; the surface is dry and red, and after a while becomes coated with a thick tenacious mucus, sometimes mixed with blood, except at its tip and borders. There is an abundant flow of saliva, which, mixed with the mucus of the mouth, dribbles out continually from the angles of the mouth. Sometimes the sides of the tongue are studded
53 DISEASES OF THE DIGESTIVE SYSTEM.
with small ulcers, of a grayish colour, and excessively painful, which, in some cases, are quite deep, and exhibit schirrous margins.
If the glossitis persist, or become deep-seated, the swelling in- creases rapidly ; speech, and the natural movements, are more and more impeded ; the tongue assumes a bluish hue, and its size is such, that it throws back the velum of the palate, presses upon the glottis and larynx, and hence causes a troublesome cough, and, be- coming toolarge for the mouth, protrudes externally. The mechani- cal impediment thus existing to a free return of blood from the head, causes a lividness of complexion, a protrusion of the eyeballs, and in fact most of the phenomena of strangulation, which are rendered the more obvious and alarming by the imminence of asphyxia, owing to the impediment to respiration. In addition to some dis- order of the senses, — vertigo, pain in the ears, indistinct vision, com- plaint is often made of pain in the tract of the spinal cord and parts adjacent, from the cervix downwards.
The constitutional symptoms are such as might be inferred from the violence of the local ones ; the pulse is frequent, full and hard, but smaller, as the respiration becomes more difficult ; the skin which in the early stage is dry and burning, is at length bathed in a cold sweat ; the thirst is excessive, and the urine deposits a late- ritious sediment. Among the occasional effects of inflammation of the mucous membrane of the tongue, and, in a measure, a symptom of the disease, is a membranous exudation like that in buccal or pharyngeal diphtherite, and in croup.
The termination of glossitis is by resolution, suppuration, or gan- grene. The first of these is sometimes manifested as early as the second or third day, but seldom before the fifth or sixth : that in sup- puration is announced by diminished excitement of the system, with an accession of coldness over the surface of the body, or by a com- plete rigor, some diminution of pain if the abscess be superficial, an increase of swelling in some particular part, and finally a point- ing which indicates more distinctly the place and the termination of the malady. Different is the case when the pus is deeply im- bedded in the substance of the tongue, the muscular fibres of which, although forced apart, as by a wedge, do not yield as they would do if the supply of cellular tissue were more abundant; and hence the relief by suppuration is small in such a case. The termination of glossitis in gangrene is fortunately rare, and has happened only in constitutions extremely debilitated by intemperance or prior disease.
Between idiopathic or primary glossitis and symptomatic or secon- dary, the diagnosis is made with tolerable ease. When occurring from acrid substances or poisons, the cause is obvious ; and when following, or associated with pharyngitis, gastritis, or variola, typhous fever, the sequence and connexion indicate its source : the same may be said of metastasis of gout or rheumatism to the tongue, the inflammation of which follows the subsidence of irrita- tion in other parts, and promptly disappears with its return to, or reappearance in, these or analogous parts. Iu all these cases we
GLOSSITIS. 59
can have little solicitude respecting the swelling and inflammation of the tongue, which, as a symptom, is readily palliated and seldom is of itself dangerous.
Treatment. — In primary glossitis of the profound kind, on the other hand, our prognosis will be guarded, even if it is not unfa- vourable. The remedies must be active and promptly used, and not desisted from until a marked impression is produced, by some abatement, at least, of the violence of the disease. Foremost of these is venesection, either from the arm or from the external jugular, to such an extent as to produce faintness ; and to be repeated in four or six hours afterwards if the violence of the inflammation is not manifestly abated. Aiding the effects produced by the use of the lancet, is the application of leeches to the tongue itself, at the under surface : the oozing of blood from their bites should be encou- raged by warm water held in the mouth, or, if this cannot be done, by warm moist cloths, or a sponge saturated with warm water fre- quently applied to the bleeding surface. If any difficulty be experi- enced on the application of leeches to the organ itself, they should be put on the skin between the border of the lower jaw and the cricoid cartilage, meeting at the median line just under the skin. Derivation is to be procured, as well as evacuations to diminish vascular excitement, by active purgatives, such as calomel and jalap, infu- sion of senna with salts, and stimulating enemata, — so as to cause the bowels to be freely and repeatedly evacuated. In a case of extreme difficulty of deglutition, a drop or two of croton oil placed on the back of the tongue will often be carried down with the saliva and produce its wonted purgative effect. It would be a waste of time to rely on the common routine of diaphoretics; but re- course ought to be had at once, after venesection and leeching, to the potassio-tartrate of antimony or emetic tartar, in such doses and so repeated as to cause a powerful sedative or depressing effect. With it we may conjoin either tincture of digitalis or of colchicum in adequate doses, to be repeated every hour until their peculiar and full impression is produced, or the disease is mitigated by their administration. For the purpose of counter-irritation hot pediluvia, or if there be a tendency to perspiration the warm bath, will be good adjuvants to the preceding remedies; but we must not regard them in any other light than as aids to more active means. In the early stage of glossitis, before congestion is so established as to threaten gangrene, ice to the tongue is sometimes serviceable — after bloodletting and leeching.
But if the swelling remains unabated, and the parts assume a more livid hue, indicating what some have termed apoplectic con- gestion, and the respiration continues violently impeded, then must we have recourse to free and deep scarification of the tongue, in the direction of its length, from the base to its apex, and penetrating to its very centre. Several cases are on record, in which the dan- ger was great, and death imminent, until this operation was per- formed. Its first and obvious effect is a free discharge of blood,
60 DISEASES OF THE DIGESTIVE SYSTEM.
which is sometimes followed at once by a lessened bulk of the tongue. But to insure the full efficiency of scarifications, they ought to be employed early, at least so soon as we find that no decided impression is made on the inflammation by the means already in- dicated. Delay subjects the patient to peril, by laborious and im- peded respiration, and also to oppression and engorgement of the brain, which may go so far as to destroy life even after the partial abatement of the primary cause, the local disease. And, besides, the organ becomes so fixedly engorged, that the blood seems to form an integral part of its tissue, and after incision escapes by drops without any abatement of its induration. There is a risk also, of acute inflammation supervening on this state of congestion, and of the tongue being struck with gangrene. In making the in- cisions, the only danger is of wounding the arteries, ranince. It has been noticed, that large and deep as the scarifications may be, the retraction of parts by the tongue resuming its natural size is such, that they leave only scratches or imperfect traces of a wound.
In cases in which suppuration has taken place in the centre of the tongue, but yet in which, although certain symptoms, as already enumerated, indicate this occurrence, there is hardly any fluctua- tion or pointing, we must not stop short of very deep incisions to give vent to the confined pus. As illustrative of the advantages of perseverance in this part of the treatment, I shall repeat what Dr. Kerr, in a well written article on Glossitis, in the Cyclopaedia of Practical Medicine, tells us on this point, when quoting from the Glasgow Medical Journal. The case occurred to Mr. Orgill. The patient, a farmer, fifty years of age, had suffered for some days from glossitis, and, besides other treatment, had undergone local bleeding by cupping and leeches, as well as incisions, half an inch deep, from as far as the scalpel could be made to reach to the tip of the tongue. The incised wounds bled freely, and the swelling was a good deal reduced, but in the evening of the same day it became as great as ever; it was scarified still more deeply, and a castor oil enema prescribed ; this also gave great relief ; but next morning the swelling had returned, with a peculiar lividity at the tip of the diseased half of the organ. An incision an inch deep was made with a scalpel, which gave exit to a gush of pus in a very offensive state ; and in eight days the patient was well. The sensibility of the organ on the affected side remained imperfect for a year after- wards, but at length was restored.
Few, if any, washes or gargles other than simple or slightly acidulated water are required to aid the healing of the wounds caused by the incisions or of the cavity from which the pus had escaped. r
There are cases in which the tongue is much swollen and inflamed in consequence of the constitutional and extreme effects of mercury ending in violent ptyalism. An antiphlogistic treatment will generally suffice for the cure ; but it may be necessary to have recourse to incisions in the manner already mentioned. Ice applied
PAROTITIS. 61
to the tongue has been before spoken of as one of the means of abat- ing the violence of the inflammation after V.S. and leeching.
In symptomatic glossitis the treatment will readily suggest itself with, and indeed as forming a part of, that of the original disease.
Gangrene, and particularly where it assumes the appearance of carbuncle, is to be promptly met by free incisions, followed by the actual cautery and stimulating washes, such as solutions of the chlo- rides spoken of in my last lectures, and a solution of nitrate of silver. All the customary means are to be employed for supporting with- out exciting the general system. With this view, sulphate of quinia, wine whey, and light nourishing food will be administered.
Parotitis — Cynanche Parotidcea — Mumps. — The term paro- titis, designating inflammation of the parotid gland, is derived from irapamr, the Greek name of this gland. There are two varieties of this disease, primary or idiopathic ; or, as called by some, specific, and the other accidental or secondary and symptomatic. To the first only the English term mumps is applicable. It is most apt to attack young persons, especially those of the male sex, just before the approach to puberty : but it seldom appears after the age of 25 or 30 years. It rarely attacks the same person more than once in his life; and on this account, as well as its sometimes appearing about the same time, or in quick succession in several persons, it is commonly alleged to be contagious. As yet no morbific matter of a peculiar nature, and capable of causing the disease in another and healthy person, has been secreted by, or at least has been detected on a patient with parotitis. There are also abundance of cases in which no trace of contagion could be ascertained, but which originated from exposure to cold or analogous causes. Sometimes it has prevailed epidemically.
Parotitis is ushered in, generally, by the symptoms common to inflammation, such as rigors, lassitude, acceleration of pulse, and hot and dry skin. To this succeeds a feeling of uneasiness, and then shooting pain in the parotid gland, some swelling under the ear and impediment in mastication. More commonly, the swelling is on both sides, and increases to the third or fourth day, accompanied with hard and frequent pulse, thirst, headache, loss of appetite, and at times a great heaviness. When the inflammation, or at least tumefaction, is participated in by the sub-maxillary glands, velum palati, tonsils and pharynx, deglutition becomes excessively painful, and for a period impossible. In other cases, again, the swelling is more oedematous than inflammatory, and the constitu- tional symptoms are very slight.
The most usual termination of mumps is by resolution, which occurs in most subjects on the fourth or fifth day from the begin- ning of the swelling. The accompanying, or as some might regard it, critical evacuation, is by sweat over the region of the gland and adjoining portion of the neck and head, and sometimes over the whole body. Suppuration is a termination of rare occurrence in primary parotitis; when it does occur, it is announced by the
vol. i. — 6
62 DISEASES. OF THE DIGESTIVE SYSTEM.
customary symptoms, — prominence of the swelling at a particular point, and softness and fluctuation, with a bluish hue and sluggish circulation of the skin above the tumour.
More generally, however, as I have just said, resolution takes place, and there is a prompt diminution and almost disappearance of the swelling. But, at the same time, another and remote organ, the testicle in males and the mamma or external parts of generation in females, becomes, by metastasis, the seat of inflammation. When the disease is confined to one parotid, the testicle or mamma of the same side is affected. Sometimes the disease is retransferred from the genital organ to the gland, a change which may be fol- lowed by a second metastasis from this latter to the former.
Treatment. — The remedial means, in general, are quite simple in parotitis. A saline laxative, reduced regimen for a few days, and an avoidance of dampness and cold, will suffice in most cases. If the fever should, however, be high, and the pain and difficulty of deglutition considerable, a small bleeding from the arm, or a few leeches over the gland, followed by a cathartic of calomel and jalap, and antimonials, will meet the requirements of the case. Metastasis to the testicle will be treated by cooling applications to this part, and a suspensory bandage if the patient should be up and move about; and also by a stimulating liniment rubbed over the parotid gland, or a sinapism of mustard applied to this part, with a view of restoring the inflammation to its original seat. Fever accompanying the metastasis will be obviated by the same reme- dies as are adapted to the original disease.
Secondary or Symptomatic Parotitis requires little else than topical remedies, such as cataplasms in the first stage, and deter- gent washes if suppuration is declared, — other than the treatment adapted to the particular disease in which the parotitis manifests itself. Inflammation and abscess of the parotid are occasionally met with in fevers, such as typhus and plague, and in the eruptive ones, as in scarlatina and measles. I have seen the gland entirely exposed by the breaking of an abscess and loss of the teguments, in the case of a child with scarlatina. My little patient recovered not- withstanding, and the opening gradually closed without much dis- figuration. The chief dressing was of lint and solution of chloride of lime.
A variety of parotitis once quite common, in connection with similar inflammation of the other salivary glands, from the exces- sive use of mercury, is now, happily, of rare occurrence. The sali- vation in these cases, which was merely a symptom or an effect of the morbid excitement of the salivary glands, was spoken of as the disease, against which the remedies were chiefly directed. But if we fix our attention on the parts really diseased, viz., the buccal mucous membrane, and the glands connected with it bv their excretory ducts, we shall have little difficulty in devising a' treat- ment adapted to the exigency. Fever if high, and accompanied by parotitis, stomatitis, and even sometimes glossitis, will be removed by
DISEASES OF DENTITION. 63
venesection or leeches over the parotid and sub-maxillary glands, to be followed by fomentations to these parts ; or, if the state of the patient, owing to the nature of the antecedent disease for which the mercury had been given, forbid, the detraction of blood, we have recourse to purging by saline medicines, and to potassio-tartrate of antimony, at first conjoined with nitre or, in dilution, with pur- gative salts, and afterwards with opium. The extremes of cold or of heat should be avoided, and the feelings of the patient be the guide as to the amount of clothing, fire in the room, &c: but the ad- mission of cool air, so as not to blow on the patient, will be ser- viceable. The warm bath daily is one of the best means of keeping up a moderate action of the skin, by which the cure will be greatly accelerated. Of the various gargles recommended on these occa- sions, the milder or mucilaginous are the best in the acute stage, and afterwards an infusion of green tea, or a weak solution of sugar of lead. The last is apt to cause a temporary discoloration of the teeth. If there be mercurial ulceration of the mouth, hydrochloric acid, or the nitrate of silver may be employed in the manner re- commended in a preceding lecture.
In the treatment of a case of mercurial salivation, we cannot propose to ourselves, nor promise our patient, that it will be ar- rested at once by any kind of treatment. On the contrary, like all kinds of poisoning, of which this is one, time is required both for an elimination of the deleterious agent from the system and for a subsidence of the morbid phenomena, such as depraved secretions, and perverted innervation to which it has given rise.
Diseases of Dentition. — There must, almost of necessity, be some vagueness in the ideas associated with the expression Dis- eases of Dentition. They are often confounded with the diseases of the period of dentition, and particularly of that which elapses from six months after birth to the appearance of the deciduous teeth- This is the period of the greatest mortality, as it is that in whicli the probability of life is less than in the years immediately succeeding it. Dentition is one of the contributing causes; but it is only one, and even though it were the chief, there would remain many diseases, the origin of which must be traced to other sources. The excessive activity of the organs of nutrition, and impressi- bility of the nervous system in early infancy, and the excitement, so apt to become morbid in consequence of the change of food from that of the mother's breast to various articles of a more stimulating and heterogenous nature, throw the system of the young being open, in a peculiar degree, to irritation of any kind, and d, fortiori to that from teething. If, to these we add the extremes of heat and cold, to which, from the ignorance of parents and the carelessness of nurses, infants are so much exposed, we can have some idea of the strain upon the tender organization and naturally great suscep- tibility of the child during the period of first dentition.
You need hardly be told of the great vascular and nervous supply to the dental apparatus, and of the excitement* of both the
64 DISEASES OF THE DIGESTIVE SYSTEM.
nerves and bloodvessels during the growth of the teeth. The direct sympathies, by means of the great and important sensitive nerves of the fifth pair, between the dental arches and all the senses, and the readiness with which febrile reaction must occur under the excitement of these parts during their nutritive erethism, are inferences which, irrespective of positive experience, might almost be drawn h priori from a survey of the anatomical relations between the teeth and adjoining organs of the face and head. The indirect and reflex sympathies by which, through the irritation of the brain consequent upon morbid excitement of the dental appa- ratus, remote organs suffer, is also explicable though not so imme- diately obvious. In this way the stomach and digestive apparatus generally, the respiratory and secretory organs, including under this latter the skin, are so often affected during painful and laborious digestion. It may be made a question, whether the functions of these organs are deranged in consequence of the primary excite- ment transmitted by the dental apparatus, or are predisposed to be morbidly excited by other and common agents, such as cold and moisture giving rise to catarrh, bronchitis and pneumonia, great heat to gastric and intestinal diseases, wrong food to similar affec- tions, and diseases of the skin, &c. On a review of all the premises, we should lean to the latter of these two opinions, while we cannot deny that at times dentition seems to be the direct exciting cause, since the disease is developed without any notable or sometimes any obvious or appreciable change in the qualities of the ingesta or sensible slates of the atmosphere.
Your physiology will have taught the obedience of the muscular to the nervous system, and that any undue excitement of the latter is immediately followed by violent and irregular action, spasmodic or convulsive, of the former. Now, with an irritation of large branches of the fifth nerve continued for many months, acting on a susceptible brain, we cannot be surprised that at any moment of this period a slight exacerbation of the irritation should cause a reflex action on the muscles, manifested by convulsions. Not seldom, during this period, the cerebral irritation and its reflexion on the muscles are the consequence of morbid impressions transmitted from an excitable stomach or intestine, and caused by food irrita- ting either by its indigestibility or its excess.
With this view of the subject we cannot either be ignorant of the nature of the morbid phenomena as they present themselves during dentition, or negligent of the appropriate means of relief. Topical irritation is manifested by increased heat and swelling of the gums, and its extension to the salivary glands causing an increased flow of saliva, one of the most common and generally accredited symptoms of teething. There are great differences among children as to the time when this process begins, as well as the ease with which it is accomplished. Dr. Ashburne (Med. Gaz 1833-4) gives the following table, as exhibiting the average order of the appearance of the teeth of the first dentition : —
DISEASES OF DENTITION. 65
Periods. Teeth.
Seventh month from birth . . Two central lower incisors.
Eighth " M " . Two central upper incisors.
Ninth " «« " . Two lateral lower incisors.
About ninth or tenth . . Two lateral upper incisors.
11 twelfth or fourteenth . . Four first molars.
„ seventeenth eighteenth, ) TwQ canine>
nineteenth or twentieth ) rr
Twenty-third to thirtieth . . Four last molars.
There are many examples of children born with some of their teeth cut ; and some of those who had not any till they were twenty months old : Duges (Diet, de Med. and de Chir. Prat.) states his having seen a young person who did not cut them until she had reached the eleventh year of her age ; and Smellie cites a case in which they were not even visible until the twenty-first year.
The child experiences a troublesome itching of the gums prior to the eruption of the teeth, which prompts to rubbing them with its own, and to willingly submit to this being done by others' fingers, or by hard bodies, such as coral, &c. Morbid heat of the gums and mouth alsa makes the application of cold bodies to them, or mouthfuls of cold water, grateful to the child. The irrita- tion at this time is often transmitted to the nose, and by the Eu- stachian tube to the ear, causing symptoms of coryza and pain in the ear, and a frequent turning and tossing of the head, and also to the eyes, as manifested by their watering. Starting in the sleep, and occasional twitches of the muscles of the face or contraction of the hands, are not uncommon during this period. Alternations of drowsiness and morbid vigilance succeed each other. Sympa- thetic disorder of the digestive canal is indicated by occasional ejection of the contents of the stomach, and sour and bilious dis- charges from the bowels. The skin is often hot and the pulse fre- quent, constituting a state of things approaching to the febrile, — the more evident if the heat and redness of the gums be increased and salivation suspended. The urinary secretion is very irregular; more commonly less, sometimes more copious than natural. There is often a circumscribed redness of the cheeks, and blotches or papular erythema? on this part of the face, and on the thighs, hips, &c, and eruptions on the scalp. "A symptom less common than any of the foregoing, and appearing in certain habits, is," as Underwood apprises us, " a swelling of the tops of the feet and hands: it is seldom, however, of much importance, and goes away upon the appearance of the teeth." Where this symptom persists with aggravation, dentition is slow and painful; and there is a greater call for purgative medicines to remove the frequently ac- companying costiveness. Another occasional effect of, or at least associated disease with dentition, is laryngismus stridulus, or spasm of the glottis, on which I shall have occasion to address you more fully hereafter. Bronchitis is at times developed apparently under
6*
6(3 DISEASES OF THE DIGESTIVE SYSTEM.
the direct excitation of teething ; but more frequently the bronchia and pulmonary mucous membrane acquire a morbid irritability from this cause, which renders them peculiarly sensible to atmo- spheric changes.
Lancing the Gums. — The treatment of the diseases of dentition must of course be modified by the organ or the apparatus which sutlers most and the degree of morbid excitement. As in the case of all symptomatic fever of irritation, we attempt a removal, or if this is impossible, a mitigation of the force of the local and exciting cause. On the present occasion, we direct our attention first to the gums, and if we find them redder than natural, swelled, and painful or spongy, we can have little hesitation in lancing them, either writh the shoulders of a common lancet or with a gum lancet. In per- forming the operation we cut down direct on the tooth, and do not stop until we feel the edge of the instrument grating on it: nor can we be content with one incision, but must make another intersecting the first, at an angle more or less approaching a right one. In cutting down on the tooth, the incision should be not entirely on the summit of the gum, but also somewhat on the ante- rior face of this latter, — very much as the swelling points and the tooth is seen to protrude, when it does rise from the gum. The fears entertained by some that, if the tooth does not soon appear after scarifications of the gum, the cicatrix will be an additional obstacle to its progress outwards, are groundless; for this, like all newly formed parts, is more readily absorbed than the original structure. Ulcerations of the gum, spoken of as a sequence of lancing it, are thought by experienced writers, such as Underwood and Hamilton, to be more frequent in cases in which this operation had never been performed, than in those in which recourse has been had to it.
There are cases in which, even though the gums be not swelled or protruded by the tooth, it will be advisable to cut down on this latter. The resistance to the passage of the tooth, as where denti- tion is backward, may be greater from a hard and not inflamed, than from a prominent and inflamed gum, and there may be greater necessity for removing this resistance, and renewing the irritation by pressure, which the confined tooth produces in the subjacent nerve. Hence, when we are called to a child from eight months to twenty months old, and are required to prescribe for the relief of some violent disorder, such as vomiting and purging, or high fever, or great restlessness, spasms, and general convulsions, it will be prudent, on inspection of the mouth, to lance the elevated gum when this presents; or if it does not, to make our incisions in that part corresponding with or covering the expected tooth or teeth. Even if we have not thought it necessary to begin the treatment in this way, it will be highly advisable to have recourse to it, if we find that the disease for which our assistance was invited does not yield soon to the common and generally recognised appropriate remedies. JNot unfrequently, no other treatment is required for
DISEASES OF DENTITION. 67
convulsions of violent and frequent recurrence before we are called, than free lancing of the gums and a warm bath.
The persistence of heat, and flushing of the face and preter- natural excitement about the head in dentition, will justify, in addi- tion to scarifying the gums, the application of a few leeches under the angles of "the lower jaw or behind the ear, and the administra- tion of laxative medicines, and cooling drinks and a restricted regi- men ; and also warm pediluvia. Convulsions when violent, and recurring after the gums are lanced, will require venesection, the warm bath and opium. This last, after we are assured that the stomach and bowels are cleared of any indigestible or other irritating matter in them, is essentially required for preventing the return of convulsions, by allaying the exquisitely morbid irritability in some children of a nervoso-lymphatic temperament, when vascular and local determination to any important organ are not evident. With the same view tonics, such as the sulphate of quinia and the simple bitters, are useful ; they should be given early in the day, — and the warm bath or a mild opiate, such as a portion of Dover's powder, in the evening.
Diseases of the stomach and bowels, manifested by vomiting and purging, and depraved secretions, will be met by the treatment adapted to them in other cases. But both in these, and in the affections of the thoracic viscera during the period of dentition, we must not expect a reduction of the morbid excitement by the same direct and frank treatment as we would in subjects more advanced in life, and in whom the nervous system is not so con- tinually excited. The predominance of nervous symptoms, or rather the greater share which the nervous has than the vascular in the diseases of dentition, require of us to address our remedies more to the first than the second. In our hygienic as well as therapeutical treatment, we must constantly bear this fact in mind; and accordingly we shall avoid exposing the child either to extreme cold or high heat, both of which are inimical to the nervous sys- tem ; and endeavour to give it tone by tepid bathing and fresh air. In its dietetic regimen, care must be taken not to confound nutri- tive with diffusible stimulants. The former are tonic; the latter, whilst they excite fever, also tend to provoke and keep up nervous disturbances of various kinds.
Among the most troublesome diseases of dentition are, eruptions on the face and scalp, sores of the ears, &c. These are really less alarming than other internal diseases, but they often excite more soli- citude on the part of the mother, — by the disfiguration of features which they cause to her little favourite, — mixed with anxiety and impatience to have them removed. Now, if it be ever required of us to avoid the charge of nimia medicina, or an impertinent inter- ference with nature at the risk of the patient's life, it is in these cutaneous affections of children. Not that we are forbidden to use remedies on the occasion; but these must be directed to an improve- ment of the digestive and nutritive systems by general treatment.
6S DISEASES OF THE DIGESTIVE SYSTEM.
rather than any specific one, to carry off the eruption or dry up sores. I shall "not pretend to particularise the different eruptions which harass infants during dentition, but proceed to the more important part of my subject, an indication of the best measures to be pursued for their treatment. If we bear in mind the fact, that the remote irritation which keeps up those diseases of the skin being that of dentition, must last for a considerable period, we shall be less tempted to urge the use of heroical or violent remedies; but rather content ourselves with moderating its intensity, and calling off' the secondary irritation of the skin by derivation to the bowels and increasing the natural secretions, than have recourse to repel- lent remedies of any description.
The warm or tepid bath, according to the degree of excitement and the powers of reaction in the little patient, with mucilaginous applications to the skin, occasionally laxatives to maintain a regular state of the bowels, the use of small doses of calomel with chalk, and the chalk mixture or chalk powder, alternating with small doses of bitters and iron, will constitute the outline of the therapeutical treatment. The hygienic will consist in taking the patient out in the fresh air, giving it good cow's milk diluted with water, and in which some farinaceous powder has been mixed, in addition to, or in place of the breast of the mother, according to the period of lactation. But if the child be puny, and without suffering from fever or phlogosis, and its teething slow and painful, in addition to the cutaneous disorder, we may every now and then with advan- tage direct a somewhat more nutritive and varied diet, — such as animal jellies and broths, and counter-irritation to the skin on parts remote from that which is the seat of the eruption.
In the preceding remarks you will see that no attempt is made to lay down a specific plan of treatment for children during the period of dentition. This must vary with the constitution of the child and the particular disease, as well as the stage of disease under which it may be suffering. Your intercourse will often be with those who are overfed, and in whom a plethoric state is in- duced by this means, which throws them open to inflammation of the brain and convulsions, or to gastric and intestinal disorder, and troublesome pustular eruptions. The mother will sometimes boast of the quantity of milk, in addition to that furnished from her own breast, which her child takes daily, as if the measure of capacity for liquid aliment were in fact the measure of strength. It will be difficult to persuade her, in advance, that she is doing wrong to her offspring; and even when disease, such as bowel complaint, comes on, she will be prone to give broths in addition to milk, and condiments to flour in order to strengthen the digestion of the little sufferer, whose bowels she supposes to be disordered because they are weak. All thnt is necessary often in such a case, is a reduction to a third of the original quantity of food, and an increase of exercise, or of airing at least, in order to restore health and obviate many impending and alarming maladies. r 5
DISEASES OF DENTITION. 69
Dr. John Clarke, in his Commentaries on the Diseases of Children, is disposed to attribute most of the diseases of dentition to over- feeding and consequent plethora, and to improper kinds of food which produce irritation. To these he adds another cause, too often overlooked by experienced medical men in their attendance on sick children, bul which is undoubtedly one of a serious nature. It is keeping the head too warm. I have had frequent occasion, as indeed almost every observing practitioner must have had, to notice the sores and eruptions on the scalp and behind the ears kept up by the unnatural and unreasonable and cruel fashion of wear- ing caps, and these often worked and embroidered so as to render them still more rough and irritating to the tender heads of infants. There are few instances of more expressive natural language, than that of the little being in its desire to tear off its cap under the annoyance of itching, heat, and other irritation caused by this covering, or in its pleasure when freed for a while from this incum- brance. I have found it, in some cases, impossible to cure sores and scalding of the ears so long as a cap was worn ; but in a few days after it was laid aside the disease was almost entirely well, without there having been scarcely anything applied, to quicken the curative process.
Contrasted with the practice of keeping the head too warm by giving it a covering in the house which it does not require, since, independently of its natural covering of hair, the abundant supply of blood to this region and its great vascularity insure a con- tinued evolution of animal heat, is that of leaving the limbs, and particularly the lower ones, without adequate protection by cloth- ing. Vitality in this part is relatively feeble, and extrinsic aid is required by friction, bathing, and warm covering for the feet and legs, the latter of which are so commonly exposed when the child is in the nurse's or mother's arms. After the little being is old enough to run about, the circulation is rendered more active in the lower limbs, and there is then less call for the precautions just stated, which are indispensably necessary before this time. Of one elementary principle of physiology there is very general ignorance among the community, and oversight by too many physicians. I refer now to the established fact, that animal heat requires for its evolution a certain degree of energy of function of the nervous as well as the vascular systems, and that one of the best means of ex- citation of these two systems for such evolution is external heat and retention of animal heat itself by warm clothing. In the young of all animals there is less activity of calorification than in older and adult ones; and hence the necessity of additional means of pro- tecting the former from the depressing influence of external cold, and of fostering by external aids the generation of animal heat. The young of birds are covered in a close nest by their mother's body and wings until they have acquired their own natural cover- ing and protection, down and feathers, against atmospheric ex- tremes, and especially that of cold and moisture. Provision is
70 DISEASES OF THE DIGESTIVE SYSTEM.
made by the parent for imparting some of its own warmth to its young, in the case of the young of the mammalia which are not born with a hairy covering adequate to their wants in this parti- cular. It is only in the young of our own species that instinct does not meet the exigency of the case, and false reasoning fails to supply the omission. During the night the child is covered in excess with