most cases the growth of the thrush fungus is restricted to the cavity of the mouth; not infrequently, it may extend to the bordering structures of the throat, the (esophagus and also the nasopharynx (descending thrush).
The observation that the growth is limited by the eardia, the choame and the vocal cords led Berg to propound the hypothesis that the vegetation of the thrush fungus necessitates the presence of squamous epithelium (Berg's law). Although this singular behavior is certainly true as a rule, there are exceptions. To these belong the growth of the fungus on the turbinated bodies and nasal septum in infants afflicted with wolf's throat; also the discovery of Heller, who found that the thrush filaments may penetrate the intact cylindrical epithelium of the trachea. Usually, the thrush fungus begins its growth in the mouth and from this place spreads to neighboring organs. It is possible, however, for thrush to grow primarily on the tonsils, and the mouth be free from the disease. Then the tonsils may be covered by a white pseudomern brane and thus simulate genuine diphtheria (sprue-diphtheria).
General Symptoms.—The local changes are introduced by and attended by other symptoms. The infants drink less greedily; in fact, on account of the pain, food may be ingested in very small quantities. The body weight falls, which may be the result of a diarrlicea which usually attends the disease. Slight fever and vomiting are often present. If the thrush is propagated to the upper air-passages, hoarseness and a slight cough may supervene.
Course.—Thrush usually lasts for a short time only. Under proper treatment it disappears in one or two days and does not return. There are obstinate cases, however, which resist therapeutic measures for many days. Occasionally, thrush disappears temporarily to return again, perhaps during the night, as luxuriantly as ever. The infants in these cases are debilitated, atrophic or cachectic, in whom thrush is only a complication of another severe disease (cachectic thrush). The appear ance of thrush is always a serious symptom in these cases, because it often announces a general decline of the vitality. In these isolated cases
we see thrush descend to the deeper parts of the throat and the necropsy reveals an extensive thrush of the cesophagus (see Plate 42).
Thrush does not always remain a local infection; in rare cases the fungus may produce a specific general infection of the organism. This leads to a discussion of the severest complications of the "sprue-disease," to which an anatomical rather than a clinical interest must be attached, as they are recognized only after death, and do not manifest any characteristic symptoms during life.
The tendency of the thrush fungus to induce genuine metastases belongs above all to this class. These v,-ere first described by Zenker and Ribbert,—each reported a case of multiple cerebral abscesses; later, Schmorl, Guidi and Pineau saw embolic abscesses of the kidneys, lungs, and spleen. Recently, Heubner observed a similar case in an infant, in which during life a probable diagnosis of "general infection by thrush" could be made. The formation of metastases, as well as the general infection, is readily explained by the ability of the thrush fungus to penetrate into the blood vessels (see Plate 42).
The cases of thrush-sepsis may be more frequent than is usually assumed. Systematic puncture of the heart immediately after death at the clinic of Escherich many times revealed the fungus in the blood of the heart. The researches of Stooss have demonstrated that the thrush fungus in its passage is accompanied by other tnicroorganisms, especially the pyogenic streptococci and staphylococci, which are always abundantly present in the thrush membranes and in the deeper layer of the tissues into which the fungus has penetrated. Hence, it is not improbable that a mixed infection holds an important rffle in the for mation of metastases and general sepsis.
The pyogenic properties of the thrush fungus. proven by experi ment on animals, furthermore explain the finding of this microiirganism as a causative agent in purulent otitis media. The infection of the middle ear probably occurs through the short passage of the Eustachian tube.