The nature of thrush being thus precisely made out, we shall now describe the different forms of this morbid product, its seat, its mode of production, and the phenomena which accompany its development; we shall then speak of the causes which favour its appearance, and the means which should be employed for its destruction.

Form, seat, and characters of thrush. Cryptogamia of thrush coalesce to form small whitish specks of a curdy appearance. At first, disseminated and isolated, of roundish shape, they coalesce so as to constitute larger and irregular patches, pellicles of a greater or less thickness which form a layer, like the membranous exudations. They sometimes present a yellowish colour, which may even assume a brownish tint; but this modification appears to be of no importance. Their consistence is at first rather great; they afterwards become softened, and are easily crushed under the finger, like the pultaceous concretions. They soon become moveable, and are easily detached by a slight friction, which does not implicate the subjacent tissues.

They are developed in the follicles of the mucous membrane, as one of my friends, M. Gubler, has quite recently observed. Originating in a glandular cavity, which they easily fill, they then extend through the orifice to spread externally, under the form of a small rounded eminence of a milky whiteness, so that the whole of the production very much resembles the form of a pomegranate.

If the orifice is too narrow, the byssoid filaments distend the glands beyond measure, and thin their walls to such an extent that they appear to form sub-epithelial tumours. M. Gubler has never clearly perceived specks of thrush situated between the raised epithelium and the mucous dermis; but he does not deny the possibility of this special development.

Thrush, then, is developed on the surface of the epithelium, with the aid of the contract of air; and observation here confirms the truth of the laws laid down by H. Dutrochet on the intervention of air in the spontaneous generation of vegetable infusoria. But there is no air beneath the epithelium; thrush, then, can only be observed on the surface.

However, if the epithelium of the mucous membrane is not locally destroyed by the vegetation of thrush, the membrane itself presents a general modification which it is well to know. It must be one of the conditions necessary to the development of this product, the appearance of which it always precedes; it is constant and especially appreciable in adults; it is more apparent during life than after death.

This modification consists in a state of softening of the epithelium, of dryness and acidity of the mucous membrane. This always presents an unnatural shining appearance, principally on the tongue, which appears to be stripped of its usual covering.

The cryptogamia of thrush are at first developed in the mouth, on the edges and posterior surface of the tongue; on the internal surface of the cheeks; on the hard and soft palate; on the internal surface of the lips ; and lastly, in the pharynx and œsophagus.

Juay 64I have had the opportunity of observing in the practice of Professor Trousseau, a really curious example of thrush in the oesophagus. The tend to cryptogamic vegetations were so confluent that, soon coalescing, they

formed a canaliculated layer spread over the mucous membrane of the w Eseph. œsophagus; this tube adhered but very slightly to the subjacent tissues, aus.

and received the food in its interior.

[Virchow (Verhandlungen der Phys. Med.; 1852) gives the particulars of a case of a child seven weeks old, in whom the oesophagus was completely blocked up by a solid cylinder of apthous product. On transverse section there could not be found any trace of a central canal, the mass reached as far as the cardiac orifice. Under the microscope it showed the well known numerous threads and spaces, with remnants of ingesta, milk, epithelial formations, &c. In the lungs, some masses were also found.-P.H.B.]

It is also said that thrush has been observed in the stomach, in the small and large intestine. Facts of this kind have been reported in the the works of MM. Lediberder, Billard, and Valleix. In a child which

presented the productions of thrush in the large intestine, I have tracedari the extension of the disease to the mucous membrane around the anus.

In the intestine, thrush detaches itself very readily from the mucous and la membrane, and becomes mixed with excrementitious matters, with which it is ejected. It is difficult to recognize, in consequence of the musline. analogy it presents with the fragments of caseum, so numerous in the digestive tube of young infants. Microscopical examination is the only means by which it can be recognized, and by which all error on this head can be prevented.

In conjunction with thrush, a series of very varied pathological ind changes is met with. The buccal mucous membrane is usually red,

and sometimes presents ulcerations of a greater or less depth. Changes

of the same nature exist in the stomach and intestine; they are always u observed more frequently in the latter of these viscera, the mucous membrane of which is injected, softened, and ulcerated in various parts; pale, on the contrary, hypertrophied, and presenting traces of old cicatrices in the case of chronic inflammation.

Tubercular or granular phthisis, chronic pneumonia, white swellings, &c., may also, in their last stage, be complicated by thrush. Such conditions I have many times observed. They then develop themselves rortipe in a subject weakened and exhausted by hectic fever, a very favourable Lu CL circumstance to the germination of cryptogamia.

In a word, in order to specify all which relates to the concomitant lesions of thrush, it must be observed that this phenomenon may develop

itself in all the organic changes capable of producing cachexia and death, of which it is often the precursory symptom.

CAUSES.

It is difficult to appreciate the circumstances which favour the germination of thrush, if it is necessary to detail precisely the causes which bring on the general disposition necessary to the development of this product.

Thrush is a disease of the children of the lower orders, and of children imperfectly attended to, badly cared for, and nourished by hand or by the sucking bottle, rather than by a good nurse. It is a very frequent disease in the hospitals for children, and especially in the wards appropriated to infants, which require more attention than the other children.

It is observed more frequently in winter and in damp weather, in consequence of the catarrhal affections which originate in these seasons. Thrush is a disease of all ages; it is, however, more frequent amongst children at the breast than at any other epoch of existence. It is occasionally met with in the adult; in this case it is always symptomatic. The possibility of its development in the child, whilst in the mother's womb, has been mentioned, but this assertion is erroneous. The presence of air is necessary to the development of this cryptogamic plant. Its generation, then, in the centre of the liquor amnii, is impossible, inasmuch as the child has not been in a condition capable of respiring.

Thrush only reigns in an epidemic manner when the diseases, in the course of which it develops itself, are of this nature. Idiopathic thrush never appears in the epidemic form.

It is always symptomatic thrush which takes on this form; it is also only assumed in the hospitals, the sojourn in which is such a Faily, aily source for all the diseases in children, and especially of entero-colitis.

Thrush is not contagious after the manner of infectious diseases, like smallpox for instance; but it propagates itself like certain cutaneous diseases-itch or favus, for example. It is transmitted by direct contact : this is also the opinion of Baron, Billard, MM. Valleix, Trousseau, Guersant; and the last of these authors states that he has seen the thrush of the nursling communicated to the breast of the nurse.

This opinion is not that which Dugès has adopted. He considered thrush transmissible by indirect contact, like smallpox or scarlet fever, relying on this fact, that a child in good health had acquired the disease by sucking a nurse who had given the breast to another child affected with thrush. This fact may be true, but its interpretation is vicious, and besides, is not sufficient to sanction an opinion so opposed to the results of the most common observation.

SYMPTOMS.

Whatever may be the nature of thrush, it is evident that this product constitutes a morbid state, with the concomitant phenomena of which it is useful to be acquainted. To this end the conditions in which it develops itself must be appreciated; the lesions of the mouth and the lesions of the organism in general must be separately studied in order to compare them together, and to discover the evidence which separates them or which allies them.

Important modifications take place in the mouth which render the

spontaneous generation of thrush possible. Here is a material fact, 'M, M. Raz

easy to appreciate, one which cannot be mistaken, and which should be regarded as that preparation of the tissues, indispensable to the development of the cryptogamic plant.

These changes are less easily appreciated in the mouth of children than in that of adults. They are characterized by a transformation and Shi of the epithelium, which becomes shining, dry, glutinous, and apparently destroyed. The mucous membrane acquires an unnatural redness and heat, becomes the seat of a very painful smarting; the tongue

hing 4x is especially altered in its appearance. It becomes red, and its papillæ 7 apparuit, destroy!!

are more apparent than in a natural state. Its coating tends to disappear, and according to the observations of M. Gubler, it constantly presents the signs of a very decided acid reaction; it is even to this acid state of the mucous membrane that the development of the cryptogamia must be attributed.

These alterations are those of stomatitis; but they would not suffice to favour the germination of thrush, did not another cause of a more elevated kind come in aid. In fact, stomatitis exists very frequently without thrush appearing. The intervention of a second influence is then necessary; and this it is which fertilizes the soil and renders it~ fit for the development of the parasite. What then is the influence which becomes added to the alterations LIGN of the mouth? This, the study of the lesions of the organism which coincide with thrush will readily demonstrate. Let us state it in advance it is on the one hand, the state of health which bad hygiene determines, and on the other, the cachexia which follows inflammation of the viscera.

The cryptogamia of thrush are sometimes developed in children who are apparently in good health, and do not present any appreciable organic lesion, but who are in a decided state of weakness, bordering on a chloro-anæmic disposition; this is what is called idiopathic thrush. I have collected several examples of this in the practice of M. Trousseau. In this case, the lesions of the mouth are the only ones which are appreciable. There is no fever nor gastric irritation. The patches of thrush are developed on the tongue, the internal surface of the

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cheeks and lips never become confluent, and disappear in some days under the influence of the most simple attention.

This variety of thrush is but very seldom developed in town; it is especially met with in hospitals. The children in whom I have observed it belonged to very poor families; they had suffered for a greater or less length of time from the indifferent nourishment of the mother; they were badly cared for, imperfectly nourished, deprived of those attentions which surround the rich; the only air they breathed was the indifferent quality enclosed in the rooms of the children of the poor, or in the long and dismal wards of our hospitals. All were feeble, attenuated, slightly developed for their age. In my opinion, there was not one of them who could be looked upon as enjoying a good constitution and a perfect state of health.

Thrush is much more frequently observed amongst children labouring under an acute or chronic disease. This variety is termed symptomatic Custom. thrush; it is, in fact, the expression of several morbid states, which, 1716 without having any relation between them, constitute the general influence necessary to its development.

Symptomatic thrush is observed in the course of all the chronic diseases of children, and especially at the approach of the fatal termination of these diseases. The production of the cryptogamic plant is very rapid and the patches very numerous. At first small and isolated, they rapidly increase in volume, coalesce, and form a very confluent eruption. It is sometimes met with in very thick layers, capable of obstructing deglutition if they extend as far back as the pharynx. It is in symptomatic thrush that small, not very numerous ulcerations, with an ash-coloured base, are met with on the surface of the buccal mucous membrane, which much resemble those produced by aphthæ.

Whatever may have been stated, symptomatic thrush has no general symptoms which are peculiar to it. It can only possess the symptoms of the diseases in the course of which it is developed. As these diseases are numerous, it consequently follows that its symptomatic expression is very varied.

There is, however, one disease which especially appears more favourable than many others to the generation of thrush, this is entero-colitis.

All the symptoms of intestinal inflammation are successively observed. These symptoms are diarrhoea, vomiting, erythema, and ulcerations of the buttocks, groin, and malleoli; fever, with a quotidian remission in conjunction with a rapid emaciation; the buccal mucous membrane becomes dry, inflames, and possesses an acid reaction; thrush is developed; it invades the mouth, determining obstruction to suction and deglutition; it does not alter the symptomatic expression of the