CHAPTER XXX.

STOMATITIS MATERNA-NURSING SORE MOUTH.

STOMATITIS MATERNA, OR NURSING SORE MOUTH-DEFINITION-NATURE AND ATTENDANT PATHOLOGICAL CONDITIONS-CAUSES AND TIME OF OCCURRENCE KIND OF PATIENTS-VARIETIES-SYMPTOMS, LOCAL AND GENERAL-TREATMENT, GENERAL AND LOCAL.

THIS, as its name implies, is a disease peculiar to those who are, or who are about to be, mothers, and is attended with painful inflammation of some portion of the lining membrane of the mouth.

Although inflammation of the mouth is a symptom considered necessary to the full development of the disease, it must be regarded only as a symptom attending a general condition of the whole system, or, at least, of some one of its elementary constituents, perhaps the blood, which, by its own peculiar modification, implicates the solid parts in an action which they would not otherwise take upon themselves.

This view of its pathological seat, it is believed, is the only one which will enable us satisfactorily to account for many of the phenomena presented, both in respect to the time of occurrence, and the particular solid tissue affected.

What this modification of the condition of the blood may be, we can only conjecture; as, in the present state of science, the investigations, which have extended only to the physical and chemical qualities of this fluid, do not afford the means of ascertaining with any exactitude many of the most important changes which occur in it.

What are its vital conditions under varied circumstances, or, indeed, in any case, perhaps is entirely beyond the reach of our philosophy; and, it may be, will ever elude the imperfect means of research attained by the ingenuity of man.

If the pathological condition of the system is that of anemia resulting from pregnancy and lactation, there must be some pecu

liarity about it, judging from its effects, differing from anemia arising from other causes.

Several cases have occurred in my practice in women who were pregnant with their first child, which continued throughout the remaining time of gestation and during lactation. I remarked that all the patients in whom these cases occurred were very young, of scrofulous diathesis, weakly, and labored under most of the symptoms of anemia resulting from other exhausting influences, such as pallor, languor, shrunken veins, &c.

I think that without other influences, pregnancy and lactation. are not sufficient, and hence I believe we must look for extrinsic causes; and these are, probably, endemic and epidemic. By the former, I mean such morbific agents as are operating in the immediate locality of the patient; for, so far as I can learn, it is not of very general prevalence.

By the epidemic influence, I mean the extensive change which has taken place in the general cast of the diseases of the West, especially along the course of the large rivers, from the ordinary endemic bilious fever, and other miasmatic diseases, to the ty phoidal, or continuous type, attended for the most part with affections of the mucous membranes, particularly of the alimentary canal.

There are three different varieties of this disease. The first includes the most simple variety, so far as local symptoms are concerned. It is characterized by a superficial and often diffused inflammation of the mucous membrane of the mouth, which may be confined to a small part, as the lips, or the end of the tongue; or it may spread throughout the whole cavity of the mouth and fauces.

The parts, upon examination, are found of a scarlet-red color, and dry; but as a general thing not much, if at all, swollen. This appearance may be of transient duration, lasting, probably, only for a few hours, more generally, however, for several days, when in a great many instances it completely subsides, leaving the patient to all appearance quite well, with the exception of a little debility.

In some cases the subsidence is not so complete, and amounts to only a very considerable remission of the soreness and distress. After an uncertain length of time-in slight cases longer, and

shorter in severe ones-the inflammation returns, and runs a similar course to the former paroxysm.

The paroxysms usually commence suddenly, with a sense of burning or scalding in some part of the mouth,-oftener, perhaps, on the end of the tongue than elsewhere, which rapidly spreads, involving the parts continuously, until the whole mouth feels as if it had been scalded, and the acts of mastication and deglutition are intolerably painful. The subsidence of the pain and suffering is as sudden and gratifying as its onset was unexpectedly afflicting.

The second variety seems to engraft itself, as it were, upon the diffuse and superficial inflammation of the first; for, in addition to the above appearances described, a crop of vesicles are scattered over the whole or a part of the inflamed surface. These are often so clear and transparent, that without attention they may be overlooked; sometimes, again, they have an aphthous appearance, and are quite obvious. The duration of this eruption is about eight or ten days; but it often lasts much longer, and then consists of successive crops.

Although the symptoms subside sometimes as completely as in the former variety, the respite from suffering is commonly shorter and less complete.

In the progress of a case, it is not unusual for the appearance described as the two varieties to alternate with each other.

In the third variety, the whole force of the paroxysm is concentrated upon a small part of the surface, always, in my experience, upon the tongue, either upon its side or inferior surface. I have seen it begin with a fissure gradually leading to an ulcer, from a hardened tubercle, from the bursting of a vesicle, or simply from an inflamed point. However it may commence, a rapid ulceration destroys the substance of the tongue, until a ragged notched line half completes its amputation. Suddenly it ceases, the cavity granulates, fills up, and heals, but the organ is left distorted. The patient flatters herself, upon the cessation of each paroxysm, that some newly applied remedy is an all-sufficient sanative against the ills which she knows by experience are in reserve for her. But, unfortunately, with a returning paroxysm, she finds her suffering unmitigated. Notwithstanding this fearful ulcerative process, this variety is less dangerous and affects the constitution more mildly than either of the other varieties.

A very important consideration in connection with the local manifestation of the disease is, that the first two varieties are migratory, travelling from the mouth along the surface of the mucous membrane to all the neighboring cavities, down through the pharynx and oesophagus to the stomach; and thence through the whole extent of the alimentary canal, frequently finding permanent lodgment in some section of the extensive tube, and destroying the patient by originating chronic gastritis, duodenitis, ileitis, &c., or passing through the larynx, trachea, and into the bronchia. And if it does not, by establishing inflammation in some portion of these tubes, exhaust the patient (by originating chronic gastritis or duodenitis), it may awaken into existence the more fearful affections of the substance of the lungs. It has also followed the nasal passages into the different cavities of the skull, or maxillary antrum, and there induced permanent inflammation. At other times it travels through the Eustachian tube to the tympanum, and thence to the mastoid cells. And I have seen one case where permanent deafness of one ear and exfoliation of bone from the mastoid process occurred. The most common course for it to take, is into the alimentary canal and lungs. It is very prone to fasten fatal disease upon the lungs, when it is allowed to run on for any considerable length of time.

The date of the commencement of the above local symptoms is various. Hitherto, I believe, it has been considered that they date from some time during the term of lactation, especially where the subject is young, and with the first child, but that they might reappear during subsequent pregnancies; and that they never are present in pregnancies, unless the patient has been subject to the disease during some previous term of lactation.

I am not certain that this is the general rule; but it is unquestionably the fact, that the woman will be more likely to experience such trouble after having once labored under the malady.

Accompanying the above array of symptoms are those of a general character. Perhaps, of all others, disorder of the digestive organs is the most prominent, as well as first in importance. Difficulty of deglutition, indigestion, and diarrhoea, form a part of these. All of these symptoms, like the local, are more or less paroxysmal,—the diarrhoea particularly. For some time it will harass the patient, exhaust the resources of her system, and then

disappear, and allow her to recruit strength, to be prostrated again by its return. Indigestion is, probably, more or less constantly present.

Difficulty of mastication and deglutition vary, of course, with the local symptoms. Emaciation is also often considerable, and generally keeps pace with the digestive disorders.

Many other general symptoms might be enumerated, but as they are not peculiar or so important, they will not be noticed.

Treatment. The first step in the cure of any disease, should be the removal of the cause when practicable. In cases where more than one cause contributes to the production of disease, the removal of one of them may so far interrupt the chain of impressions as to accomplish a cure.

Occasionally, this is found to be the case in the disease under consideration. The patient, by a change of her residence for the balance of the time of lactation, may get quite well. This, however, is not generally the case; and in all instances where the objections are not too weighty, the child should be weaned, or transferred to another nurse. I have seen so many cases of unfortunate terminations, and regard the condition of my patients so uncertain while laboring under this ubiquitous inflammation, in which, without any warning, some vital organ is involved, and it becomes the seat of destructive organic alteration, that I deem it a matter of great importance to take immediately the most effectual course within my knowledge to place the patient under the most favorable circumstances.

After an experience of many years' duration, I cannot feel quiet while my patient, if at all seriously affected, continues to nurse her child. I am thoroughly convinced that, in many instances which I have known to be followed by fatal secondary diseases, had the connection between the sore mouth and them been properly appreciated, and the causes of it understood, the mother's life would not have been sacrificed in a useless attempt at nursing; and I am well assured that, with the best management in grave cases, there is much more likelihood of the patient becoming worse than better while she nurses her child. I will also say that, in some cases, weaning will not of itself cure, although this is the general rule.

The most obvious and urgent indication for treatment will be