of Rhodes. Spurious works Andronicus.

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mucous membrane of the mouth into more or less thick horny
patches caused by a heaping up of the superficial horny layers
of the mucous membrane. The swards thus formed rested upon
the underlying mucous membrane whose veins were markedly
dilated and whose tissues showed a round-celled infiltration.
The papillae are markedly attenuated and apparently increased
in number.



Fig, 12. — Chronic recurrent aphthae.

Clinically these thickened rinds appear at first as smooth, dry,
milk-white patches — hence the name. The youngest of these
patches in point of development show a more rosy color and
appear at first as if the tongue had been streaked over with a
stick of lunar caustic. The underlying mucous membr,ane
shows through them and gives to the early patches a more rosy
hue. The older patches are scab-like in character and become
a pure white, sometimes bluish-white in color, and oftentimes
have a glistening appearance not unlike mother of pearl (plaques
nacr6es, Fournier). They are usually sharply separated from
the surrounding tissue by an area of inflammatory redness of
varying breadth, but as a rule less than i mm. broad. The
longer this rind has existed, the more dense and leathery it
becomes. At the same time, the edges are slightly loosened



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156 DE FOREST: THRUSH.

from their attachment and as a result the patch is often mechani-
cally torn from the tongue during mastication or by the tongue
rubbing against the teeth in an effort to move what seems to be
a foreign body in the mouth. If completely torn away, more or
less bleeding occurs and there are left irregular scars or deep and
painful fissures extending into the substance of the tongue itself.
If small hemorrhages occur beneath the growth the overlying
mass may become yellowish or even brown in color, but later, with
the absorption of the exuded blood, the white color returns.
All stages may be found in the mouth: from the delicate semi-
transparent patches to the thick milk-white papillary growths.

Leucoplakia is most apt to occur at the anterior portion of
the dorsum of the tongue, toward the tip and edges of the organ.
The patches at first are small, but as growth progresses they
coalesce to form larger islands separated by thin streaks or
areas of congested mucous membrane.

The same changes are occasionally found on the inner side
of the cheeks and lips. At the angle of the lips a particularly
characteristic three-cornered patch is often observed radiating
from the angle somewhat like the leaves of a fan. The formation
of fissures is most apt to occur upon the tongue itself because here
mechanical injury easily takes place.

The course of the process is an extremely chronic one, extending
over not merely years, but decades. It is most common in the
fifth or sixth decade of life and rarely appears before the fortieth
year. In women, leucoplakia is a great rarity. The many
names that have been applied to this condition from time to
time show the confusion which exists as to its true nature. It
is really a process peculiar to itself and has nothing to do with
either psoriasis, ichthyosis, or syphilis. The opinion expressed
by some writers that it is a late manifestation of syphilis is not
a tenable one. Many patients who have suffered from leuco-
plakia for years become primarily infected with syphilis and
secondary manifestations develop in the usual way.

The statistics of Erb and Neisser show that in a large number
of typical cases of leucoplakia the history of syphilis can be
excluded. The results of treatment of leucoplakia by anti-
syphilitic medication, too, is an argument against the syphilitic
origin of the disease: for such, treatment not only does no good,
but oftentimes makes the condition worse. Syphilis, therefore,
is not to be regarded as a direct cause of leucoplakia, but it is
without doubt an important predisposing cause of the disease.



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DE forest: thrush. 157

The cases reported by Schongarth show that in 65 per cent, of
the patients syphilis pre-existed.

Smoking, drinking of strong alcoholic beverages, and eating
of highly spiced food are also important etiological factors.
These habits, too, being much more common in men than in
women, account for the greater preponderance of leucoplakia in
men than in women. Various forms of digestive disturbances
either in the stomach or intestines predispose to leucoplakia, and
if they become worse the growth of the patches is increased.

In the majority of cases the discomfort experienced by the
patient is very slight; not infrequently the disease is discovered
quite accidentally. Deep fissures of the tongue usually cause
severe pain and interfere with mastication and with speech,
otherwise the sensation of the tongue over the affected areas is
diminished. As the growths rise above the surface, they give
the sensation of a foreign body in the mouth and this often
attracts the attention of the patient to the condition of the tongue
for the first time. If the man is suffering from syphilis, he often
regards these patches as a manifestation of this disease.
Other patients believe that cancer is about to develop. These
two conditions are generally regarded by the laity with great
apprehension and therefore many patients with leucoplakia
become hypochondriacs upon this subject. They magnify their
symptoms of discomfort in the mouth and attribute to the disease
much greater importance than really attaches to it. There is a
real reason for anxiety, however, for in not a few cases in which
leucoplakia was first observed, an epithelioma of the tongue
developed later, but it is not always easy to determine whether
the cancerous growth took its origin in the leucoplakial patch, or
in some other portion of the organ. The same causes of irrita-
tion of the tongue and mucous membrane favored the develop-
ment of this form of carcinoma as well as of leucoplakia itself.
The Atlas of Mikulicz reports a case in which epithelioma of the
tongue developed in a long-standing area of leucoplakia. It
would, however, be quite erroneous to maintain that every
case of leucoplakia ultimately terminates in carcinoma. Mod-
erate degrees of leucoplakia are far more frequently seen than
severe cases of the disease and in many cases the condition
remains stationary for years.

Unfortunately the disease is very resistent to all forms of
treatment thus far devised. In the milder cases, antiseptic
and slightly astringent mouth-washes can be used to keep the



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158 DE forest: thrush.

mucous membrane in good condition and to allay the patient's
apprehensions. Tincture of myrrh, tincture of nutgalls
flavored with a drop or two of oil of peppermint, peroxide of
hydrogen, and similar medications can be tried. No one of these
should be continued too long as the taste of the patient varies
materially from time to time. The use of tobacco in any form
must be prohibited. If the teeth are broken or decayed, the
pointed, useless roots should be extracted and the cavities
filled. If smoking cannot be entirely discontinued, the number
of cigars or cigarettes that are used daily should be limited to the
smallest number possible. In fact, all causes of irritation of the
mucous membrane of the mouth are to be removed.

The treatment of single patches of leucoplakia in obstinate
cases is best done by means of caustics. Pure lunar caustic,
a 50 per cent, solution of nitrate of silver, a 5 per cent, solution
of lactic acid gradually increased to 50 per cent., chromic acid
solutions, and, more recently, concentrated preparations of
peroxide of hydrogen are all to be recommended. Salicylic acid
is of value to aid in the dissolving and softening of the mucous
membrane. A 2 per cent, solution of resorcin has been used.
Rosenberg recommends the painting of the patches with pure
balsam of Peru, allowing it to stay in the mouth for from three to
five minutes.

Unfortunately in most cases, this entire list of medication
proves to be of no value, and often this very lack of result con-
firms the patient in his belief that he has an incurable disease
which will ultimately end in cancer. Many cases therefore give
rise to a severe form of hypochondriasis, although, as a rule, the
patient suffers but little discomfort. If speaking, eating, and
drinking are interfered with, mental disturbance is still more
apt to occur.

Some writers advocate that as soon as the patches of leuco-
plakia develop to any extent, they should be thoroughly curretted
away and the base cauterized with the thermocautery. Or
the tip of the tongue can be firmly grasped in a bit of gauze and
with a sharp scalpel the patch of leucoplakia can be shaved off
exactly as the skin is removed for transplantation.

Rinsohoff gives preference to the procedure of decortication
of the skin after first sprinkling the affected areas with crystals
of permanganate of potash. After this procedure there is
often left in place of the sensitive rind a soft insensitive scar.
Such a procedure can hardly be necessary in patches of small



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DE FOREST: THRUSH. 159

size, but at any rate it prevents the later development of larger
growths. The effect upon the patient's mental condition by the
absolute removal of the growths by any of thesej procedures is
usually a salutary one if the treatment be successful. On the
other hand, if it be unsuccessful, these precedures only make
the mental attitude of the patient worse. One is certainly



Fig. 13. — Leucoplakia oris (Psoriasis linguae, tylosis, Ichthyosis buccalis).

justified in regarding the condition as harmless so long as the
area of the lesion is not extensive.

The possibility of the ultimate development of an epithelioma
should in all cases be stated to the patient, and if such a growth
begins to develop, radical surgical procedures should be at once
instituted.

The illustration herewith presented is a composite one from
several sources and shows the various stages of leucoplakial
growth. (Fig. 13.)



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160 DE forest: thrush.

Prognosis, — In milder cases of thrush, where only the buccal
cavity is involved and where the growth has been quickly observed
and properly treated, the prognosis is good, and in this class are
included by far the larger number of cases of thrush that are
observed. Where the esophagus and stomach are involved and
the digestion as a whole is impaired by the activity of the organ-
ism, more serious illness may result.

In the excellent chapter upon Diseases of the Mouth, given by
Garrigues in his Text-book of Obstetrics, attention is called to
the fact that thrush, diarrhea, and green stools are practically
always associated with each other. The outcome is still more
serious when the growth extends and involves the entire pharynx^
larynx, and esophagus. In some cases reported the fungous
growth has been so profuse that the lumen of the esophagus
was obstructed, making the introduction of food impossible.
In other instances the larynx was involved, causing hoarseness
primarily and later mechanical dyspnea due to obstructive
growth in the trachea and bronchi. In still other instances
reported by Biihl and Virchow, the inspiration of masses of
thrush led to bronchitis and pneumonia.

If the growth extends through the epithelium and into the
underlying connective tissue, blood-vessels may be invaded
and the metastatic abscesses already mentioned may develop
in various vital organs. Thrush septicemia may also
occur.

In none of the cases thus far reported has the writer been able
to find a record of multiple miliary ulcers of the intestines result-
ing in numerous intestinal perforations and hemorrhage such as
caused the death of the child in Case I.

Cases of such severity are fortunately rare, but in view of the
possibility that the disease may assume a severe type, the prog-
nosis must always be guarded if the growth of the fungus be
extensive or if severe constitutional disease co-exist.

Treatment. — ^To use an hibernianism, the best treatment for
thrush is to prevent its occurrence. A definite routine should
be begun as soon as the child is first put to the breast and this
should be continued throughout the first year of life.

The details of this treatment, so far as the care of the mouth
is concerned, are as follows: A bag of cheesecloth holding a
large handful of powdered boric acid is placed in a clean fruit
jar; the jar is filled with boiling water and thoroughly shaken.
After standing for a short time, a clear saturated solution of



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DE FOREST: THRUSH. 161

boric acid results which can be replenished daily by filling up
the jar with boiling water so long as any powder remains in the
bag.

At the time of each feeding, whether from the breast or from
a bottle, a small amount of the solution is poured into a clean
tumbler. A wisp of absorbent cotton is wrapped about the
little finger and, wet with the solution, is used to thoroughly
cleanse the baby's mouth. If a small quantity be swallowed, it
does no harm, although to prevent this it is better to hold the
child on the lap face downward while the oral toilet is performed.
After feeding the procedure is repeated.

The nipple is then wiped oflF with cotton soaked in the solution
and the child put to the breast. When nursing is over, the
nipple is again wiped off and a small annular mass of dry cotton
is placed around it. On this mass, from an ordinary salt shaker,
a little dry boric acid is dusted, and this absorbent and antiseptic
dressing is held in place by means of a breast binder. Not only
does this treatment prevent thrush in the child, but it also
practically prevents maceration of the nipple epithelium by
being kept wet with milk. Erosions or fissures rarely occur, and
where this routine is carried out during the entire period of
lactation, abscesses of the breast become practically unknown.
Unfortunately, mothers thus escaping many of the alleged
difficulties of nursing become careless, neglect these precautions,
and, as a result, abscesses of the breast and thrush are both
more common several months after labor than when the baby
is only a few days old.

If nursing bottles are used, the rubber nipples should be habit-
ually kept in a covered glass of boric acid solution when not in
use.

If cases of thrush are seen where prophylaxis has been neglected,
the same routine of treatment should be commenced at once.
A moderate dose of castor oil should precede local treatment.
To destroy colonies already established in the mouth and along
the alimentary canal, some palatable antiseptic solution of
boric acid should be administered before each feeding.

If the disease has become well established before treatment
has begun, the mechanical removal of the masses of thrush
from the mouth is not always easy, is apt to disturb the child
already restless and irritable, and not infrequently is attended by
bleeding from the mucous membrane upon which the growth
has taken place. In such cases the suggestion made by Escherich



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162 DE forest: thrush.

is an excellent one. He recommends that in young children a
small mass of cotton be filled with powdered boric acid. This
is enclosed in a layer of fine linen in the form of the "sugar-
teat" so often used by mothers. This is then dipped into a
I per cent, solution of saccharin and is given to the child to suck
for a moment or two before and after each nursing. The child
will suck the sweet mass readily and enough of the boric acid is
carried in solution to act as an excellent mouth and intestinal
disinfectant. If this procedure be followed the mucous mem-
brane of the mouth can hardly be abraded.

The treatment of thrush must be chiefly prophylactic. Good
, air, good food, and above all, the removal of any fermentable
substances from the nursery and the proper cleaning of the mouth
after eating or drinking. If the fungus has already colonized,
it must be combated by applying alkalines as, in common with
other bud fungi, it does not flourish in an alkaline medium.
This may be accomplished by a repeated wiping out of the mouth
with a swab of cotton dipped into a 5 to lo per cent, solution of
bicarbonate of soda.

In more serious cases, various antiseptic mouth-washes have
been advocated : a i per cent, solution of formalin or a 4 per cent,
solution of permanganate of potash; some prefer the tincture of
the chloride of iron.

In still more serious cases hourly painting with a solution of
nitrate of silver in the strength of from 1-20 to 1-50 is prescribed.

Preparations containing honey or sugar are to be avoided as
they furnish an excellent food for fungous growth. The borax
and honey mixture so often used as a domestic remedy is to be
prohibited.

For internal medication, a i per cent, solution of resorcin may
be given in teaspoonf ul doses three or four times daily.

vSmall doses of salol are often effective, especially if intestinal
fermentation co-exists.

Teaspoonful doses of a i per cent, solution of chlorate of
potash every two hours has its advocates.

Garrigues gives the following excellent formula to use in those
cases in which a green and fetid diarrhea exists :

I^ Bismuthi subnitrat., gr. xv (i gram)

Resorcin, gr. v (30 centigrams)

Glycerin! , 3ij (8 grams)

Aquae dest., q. s. ad, Sij (60 grams). — Misce.

Signa. — Shake well. A teaspoonful every two hours.



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DE forest: thrush. 163

In those severe cases in which the growth of the fungus in the
esophagus threatens to obstruct free ingestion of food, emetics
should be used.

It is apparent that the roots of the fungus reaching into and
even below the epithelial layer are not reached by any of these
applications and from the remaining mycelia a new growth
of fungus continually develops. For this reason the use of
antiseptics which can be used with safety in the mouth is not
always followed by a certain cure. Taken all in all, the saturated
solution of boric acid, either used as has been directed in the
prophylactic care of the mouth or after the manner advocated
by Escherich, is the one most apt to give the best results. This
should be combined with alternate swabbing of the mouth
with the alkaline solution of bicarbonate of soda already men-
tioned.

Since thrush usually occurs secondary to some constitutional
impairment or definite disease, it is apparent that treatment
must also be directed toward the underlying cause of the trouble.
If this be removed, the thrush itself may disappear without any
special treatment.

The fact that thrush may occur in the mouth of any child
during the first year of life should always be borne in mind, and
the prophylactic measures just described should be made a
part of the routine of all children coming under the care of a
physician. Where prophylactic measures are systematically
used, the disease practically is unknown; where they are ne-
glected, it may occur at any time in either private or hospital
practice and, far from being a negligible factor, may, under fa-
vorable conditions, lead to severe intestinal disturbances. In
rare instances, as the history of the cases herewith reported
shows, it may terminate fatally. It, therefore, deserves a wider
recognition and consideration than is generally accorded it.

150 West Forty-seventh Street.

bibliography: thrush.

Ashby, Henry. Diseases of Children. London: Longmans,
Green & Co., 1889, p. 47.

Baginsky. Deutsche' med. Wochenschr., xi, 866, 1885.

Davis, Edward P. Treatise on Obstetrics. Philadelphia:
Lea Bros., 1896, p. 473.

David. Les Mikrobes de la bouche. S. 161, Alcan, Paris, 1 890

de Rothschild, H. I^ Progrh Medical y Mar. 3, 1900.



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164 DE forest: thrush.

Edgar, J. Clifton. Practice of Obstetrics. Philadelphia:
Blakiston, 1904, p. 913.

Fliigge. Loc. cit., siehe S. 119.

Freudenberg, A. CentralbLf, klin. Med., vii, Nr. 40, 1886.

Frflhwald. Jahrbuchf. Kinderklinik, xxix, 200, 1889.

Garrigues, Henry J. Text-book of the Science and the Art
of Obstetrics. Philadelphia: Lippincott, 1902, p. 806. Es-
pecially good.

Grawitz. Virchow's Archiv., Ixx, 566, 1877, und Ixxiii, 147,
1878.

Hirst, Barton C. Text-book of Obstetrics. Philadelphia:
Saunders & Co., 1903, p. 863.

Jewett, Charles. Practice of Obstetrics. New York and
Philadelphia: Lea Bros., 1901, p. 644.

Kehrer. Ueber den Soorpilz. Heidelberg, 1885 (with very
complete bibliography).

Klemperer. Ceniralbl. f. klin. Med., vi, 849, 1885.

Mikulicz, J., and Michelson, P. Atlas der Krankheiten der
Mund- und Rachenhohle. Berlin : Hirschwald, 1892, plate XXX,

Fig. 4.

Mikulicz-Radetzky, J., und Kummel, W. Die Krankheiten
des Mundes. Zweite Auflage, neu bearbeitet von W. Kummel,
mit 77 Zum Teil farbigen Abbildungen im Text. Jena: Verlag
von Gustav Fischer, 1909, p. 61. One illustration of thrush.

Miller, W. D. Mikroorganismen der Mundhohle. Leipsic:
Georg Thieme, 1892, 8vo, p. 448. 111. Fig. 131.

Plant. Baumgarte ft* s Jahresberichi, etc., loc. cit., i, 149, 1886.

Plant. Centralbl. f. Bakieriol. u. Parasitenkunde, i, 527
(Referat), 1887.

Quain, Richard. Dictionary of Medicine. 8vo., p. 1816.
Article by W. Fairlie Clarke. One illustration of fungus. D.
Appleton & Co., 1884.

Ranke, H. Jahrbuch f. Kinderheilkunde, xxvii, 309, 1888.

Rees. Verzleichende Morphologic und Biologic der Pilze. S.
405. Leipzig, 1884.

Reynolds, Edward, and Newell, Franklin. Practical Obstetrics.
Philadelphia: Lea Bros., 1902, p. 467.

Tweedy, E. Hastings, and Wrench, G. T. Rotunda Practical
Midwifery. London : Frowde, 1908, p. 417.

von Jaksch, Rudolf. Klinische Diagnostik. Wien und
Leipzig: Urban & Schwarzenberg, 1892, pp. 92, 100, 174, 455.

Weichselbaum, Anton. Pathologische Histologic. Leipzig,
Wien: Deuticke, 1892, p. 183.

Wesener, Felix. Medicinisch-klinische Diagnostik. Berlin :
Springer, 1892, p. 222, 334.

Wrench, G. T. Rotunda Midwifery for Nurses and Midwives.
London : Frowde, 1908, pp. 287.

Wright, Adam H. Text-book of Obstetrics. New York &
London: Appleton & Co., 1905, p. 494.



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transactions of the new york academy of medicine. 165

bibliography: sprue (psilosis).

Brown, W. Carnegie. Sprue and its Treatment. London:
J. Bule, 1908, xiii, 259 pp., i pi., i cht. (Psilosis.)

Manson, Sir Patrick. Tropical Diseases. New York: Wood
& Co., 1909, p. 465. (Psilosis.)

Thin, George. Psilosis or Sprue: Its Nature and Treatment,
with Observations on Various Forms of Diarrhea Acquired in
the Tropics. London: J. & A. Churchill, 1897, xii, 270 pp., 3 pi.



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON PEDIATRICS.

Meeting of November 11, 1909.
Eli Long, M. D., in the Chair.

CEREBRAL DIPLEGIA WITH OBSTETRIC PALSY.

Dr. Matthias Nicoll, Jr., presented a boy three years old,
a mulatto, who was admitted to an institution when seven
months of age. The first recorded history was in May, 1908,
when he was eighteen months of age; then the statement was
rendered, '* subluxation of shoulder, anterior poliomyelitis,
rachitis.'* The subluxation was marked and there was slight
power in extension of the wrist and in supination. He had a
marked rachitis and a lumbar kyphosis probably due to the
latter condition. The history obtained from the outside nurse
was that the child had an attack of whooping-cough when about
nine months old when it was noted that he did not move his arm.
Both legs were also involved, although apparently gaining in
motion. The reflexes were exaggerated. The child talked but
little and his intelligence was limited.

CEREBRAL DIPLEGIA.

Dr. Nicoll also presented a girl six years old, who had been
admitted to the hospital when three weeks of age. Her birth
history was not known. The paralysis was first noticed by the
wet nurse when the child was eight months of age; the child
was then returned to the hospital and had been under obser-
vation since. Until the past year she had not made any attempts
to stand even with support. Her intelligence had developed
slowly but steadily and was now of a fair order. Both patella
reflexes were exaggerated. Her method of walking was demon-
strated.



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166 TRANSACTIONS OF THE



DISCUSSION.



Dr. William P. Northrup said that the second case presented
by Dr. NicoU he had lectured on for three years in his clinic.
During that time he had not been able to help her very much.
He was glad to note some improvement in her condition now.
This was one of the most pathetic cases he had ever known.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 17 of 109)