=The Nose and Throat=
_Cold in the Head--Mouth-Breathing--Toothache--Sore Mouth--Treatment
of Tonsilitis--Quinsy--Diphtheria._
=NOSEBLEED.=--Nosebleed is caused by blows or falls, or more
frequently by picking and violently blowing the nose. The cartilage of
the nasal septum, or partition which divides the two nostrils, very
often becomes sore in spots, owing to irritation of dust-laden air,
and these crust over and lead to itching. Then "picking the nose"
removes the crusts, and frequent nosebleed results. Nosebleed also is
common in both full-blooded and anaemic persons; in the former because
of the high pressure within the blood vessels, in the latter owing to
the thin walls of the arteries and capillaries which readily rupture.
Nosebleed is again an accompaniment of certain general disorders, as
heart disease and typhoid fever. The bleeding comes usually from one
nostril only, and is a general oozing from the mucous membrane, or
more commonly flows from one spot on the septum near the nostril, the
cause of which we have just noted. The blood may spout forth in a
stream, as after a blow, or trickle away drop by drop, but is rarely
dangerous except in infants and aged persons with weak blood vessels.
In the case of the latter the occurrence of bleeding from the nose is
thought to indicate brittle vessels and a tendency to apoplexy, which
may be averted by the nosebleed. This is uncertain. If nosebleed comes
on at night during sleep, the blood may flow into the stomach without
the patient's knowledge, and on being vomited may suggest bleeding
from the stomach.
=Treatment.=--The avoidance of excitement and of blowing the nose,
hawking, and coughing will assist recovery. The patient should sit
quietly with head erect, unless there is pallor and faintness, when he
may lie down on the side with the head held forward so that the blood
will flow out of the nose. There is no cause for alarm in most cases,
because the more blood lost the more readily does the remainder clot
and stop bleeding. As the blood generally comes from the lower part of
the partition separating the nostrils, the finger should be introduced
into the bleeding nostril and pressure made against this point, or the
whole lower part of the nose may be simply compressed between the
thumb and forefinger. If this does not suffice a lump of ice may be
held against the side of the bleeding nostril, and another placed in
the mouth. The injection into the nostril of ice water containing a
little salt is sometimes very serviceable in stopping nosebleed.
Blowing the nose must be avoided for some time after the bleeding
ceases.
If none of these methods arrest the bleeding the nostril must be
plugged. A piece of clean cotton cloth, about five inches square,
should be pushed gently but firmly into the nostril with a slender
cylinder of wood about as large as a slate pencil and blunt on the
end. This substitute for a probe is pressed against the center of the
cloth, which folds about the stick like a closed umbrella, and the
cotton is pressed into the nostril in a backward and slightly downward
direction, for two or three inches, while the head is held erect. Then
pledgets of cotton wool are packed into the bag formed by the cotton
cloth after the stick is withdrawn. The mouth of the bag is left
projecting slightly from the nostril, so that the whole can be
withdrawn in twenty-four hours.
The bleeding nostril may be more readily plugged by simply pressing
into it little pledgets of cotton with a slender stick, but it would
be impossible for an unskilled person to get them out again, and a
physician should withdraw them inside of forty-eight hours.
=FOREIGN BODIES IN THE NOSE.=--Children often put foreign bodies in
their nose, as shoe buttons, beans, and pebbles. They may not tell of
it, and the most conspicuous symptoms are the appearance of a thick
discharge from one nostril, having a bad odor, and some obstruction to
breathing on the same side. If the foreign body can be seen, the
nostril on the unobstructed side should be closed and the child made
to blow out of the other one. If blowing does not remove the body
it is best to secure medical aid very speedily.
[Illustration: PLATE III
=Plate III=
=THE NASAL CAVITY=
In the illustration on the opposite page, the =Red Portion= indicates
the =Septum= of the nose, the partition which separates the nostrils.
Inflammation of the membrane lining the nasal cavity is the condition
peculiar to catarrh or "cold in the head." Deformity of the septum may
obstruct the entrance of air into the nose and create suction on the
walls of the nasal cavity, causing an overfilling of the blood
vessels, or "congestion," with subsequent thickening of the mucous
membrane.
Polypi, small growths which form in the nose, or enlargement of the
glands in the upper part of the throat (just beyond dotted line at
inner edge of red portion) also block the air passages and give rise
to mouth-breathing and its attendant disorders.
Another cause of mouth-breathing is extreme swelling of the membrane
which covers the turbinated bones of the nose.]
=COLD IN THE HEAD FROM OVERHEATING.=--Chilling of the surface of the
body favors the occurrence of colds, in which lowered bodily vitality
allows the growth of certain germs always present upon the mucous
membrane lining the cavities of the nose. Dust and irritating vapors
also predispose to colds. Overwarm clothing makes a person susceptible
to colds, while the daily use of cold baths is an effective
preventive. There is no sufficient reason for dressing more warmly in
a heated house in winter than one would dress in summer. It is,
moreover, unwise to cover the chest more heavily than the rest of the
body. Some one has wisely said: "The best place for a chest protector
is on the soles of the feet." The rule should always be to keep the
feet dry and warm, and adapt the clothing to the surrounding
temperature. Among the germs which cause colds in the head, that of
pneumonia is the one commonly found in the discharge from the nose.
When pneumonia is epidemic it is therefore wise to take extra
precautions to avoid colds, and care for them when they occur.
The presence of chronic trouble in the throat and nose, such as
described under Mouth-Breathing, Adenoids, etc. (p. 60), is perhaps
the most frequent cause of colds, because the natural resistance of
the healthy mucous membrane to the attack of germs is diminished
thereby, and the catarrhal secretions form a source of food for the
germs to grow upon. It should also be kept in mind that cold in the
head is the first sign of measles and of _grippe_. Colds are more
common in the spring and fall.
=Symptoms.=--Colds begin with chilliness and sneezing, and, if severe,
there may be also headache, fever, and pain in the back and limbs, as
in _grippe_. The nose at first feels dry, but soon becomes more or
less stopped with secretion. The catarrh may extend from the back of
the nose through the Eustachian tube to the ear, causing earache,
noises in the ear, and deafness (see p. 41). This unfortunate result
may be averted by proper spraying of the nose, and avoidance of
blowing the nose violently.
=Treatment.=--Treatment must be begun at the first suspicion of an
attack to be of much service. The bowels should be opened with calomel
or other cathartic; two-fifths of a grain for an adult, half a grain
for a child. Rest in bed for a day or two, after taking a hot bath and
a glass of hot lemonade containing a tablespoonful or two of whisky,
is the most valuable treatment. The Turkish bath is also very
efficacious in cutting short colds, but involves great risk of
increasing the trouble unless the patient can return home in a closed
carriage directly from the bath. Of the numerous remedies which are
commonly used to arrest colds in the first stages are two which
possess special virtue; namely, quinine and Dover's powder, given in
single dose of ten grains of each for an adult. Both of these
remedies may be taken, but while the Dover's powder is most effective
it is often necessary for the patient to remain in bed twelve to
eighteen hours after taking it on account of nausea and faintness
which would be produced if the patient were up and moving about.
Rhinitis tablets should never be used. They are generally abused, and,
indeed, some fatal cases are on record in which they caused death.
Drugs are of little value except in the beginning of a cold, when they
are given with the hope of cutting short an attack.
The local applications of remedies to the inflamed region is of
service. At the onset of the cold, Seiler's solution (conveniently
made from tablets which are sold in the shops) or Dobell's solution
should be sprayed from an atomizer, into the nostrils, every half
hour, and, when the discharge becomes thick and copious, this is to be
discarded for a spray consisting of alboline (four ounces) and camphor
and menthol (each thirty grains), used in the same manner as long as
the cold lasts. Containing bottles should be stood in hot water, in
order that all sprays for the nostrils may be used warm.
It is well to give babies a teaspoonful of castor oil and a warm bath,
and keep them in bed. If there is fever with the cold, five drops of
sweet spirit of niter may be given in a teaspoonful of sweetened water
every two hours. Liquid vaseline, or the alboline mixture advised for
adults, may be dropped into the nostrils with a medicine dropper more
conveniently than applied by spray.
=TOOTHACHE.=--When there is a cavity in an aching tooth it should be
cleaned of food, and a little pledget of cotton wool wrapped on a
toothpick may be used to wipe the cavity dry. Then the cavity should
be loosely packed, by means of a toothpick or one prong of a hairpin,
with a small piece of absorbent cotton rolled between the fingers and
saturated with one of the following substances, preferably the first:
oil of cloves, wood creosote or chloroform.
If wood creosote is used the cotton must be well squeezed to get rid
of the excess of fluid, as it is poisonous if swallowed, and will burn
the gum and mouth if allowed to overflow from the tooth.
=ALVEOLAR ABSCESS= (_improperly called "Ulcerated Tooth"_).--An
"ulcerated tooth" begins as an inflammation in the socket of a tooth,
and, if near its deepest part, causes great pain, owing to the fact
that the pus formed can neither escape nor expand the unyielding bony
wall of the socket.
This explains why an abscess near the tooth is so much more painful
than a similar one of soft parts. There may be no cavity in the tooth,
but the tooth is commonly dead, or its nerve is dying, and the tooth
is frequently darker in color. It often happens that threatened
abscess at the root of a tooth, which has been filled, can be averted
by a dentist's boring down into the root of the tooth, or removing the
filling. It is not always possible to locate the troublesome tooth,
from the pain, but by tapping on the various teeth in turn with a
knife, or other metal instrument, special soreness will be discovered
in the "ulcerated" tooth. The ulcerated tooth frequently projects
beyond its fellows, and so gives pain when the jaws are brought
together in biting.
=Treatment.=--The treatment for threatened abscess near a tooth
consists in painting tincture of iodine, with a camel's hair brush,
upon the gum at the root of the painful tooth, and applying, every
hour or so, over the same spot a toothache plaster (sold by all
druggists). The gum must be wiped dry before applying the moistened
toothache plaster. Water, as hot as can be borne, should be held in
the mouth, and the process repeated for as long a time as possible.
Then the patient should lie with the painful side of the face upon a
hot-water bag or bottle. The trouble may subside under this treatment,
owing to disappearance of the inflammation, or to the unnoticed escape
of a small amount of pus through a minute opening in the gum. If the
inflammation continues the pain becomes intense and throbbing; there
is often entire loss of sleep and rest, fever, and even chills, owing
to a certain degree of blood poisoning. The gum and face swell on the
painful side, and the patient often suffers more than with many more
serious diseases.
After several days of distress, the bony socket of the tooth gives
way, and the pus makes its exit, and, bulging out the gum, finally
escapes through this also, to the immediate relief of the patient. But
serious results sometimes follow letting nature alone in such a case,
as the pus from an eyetooth may burrow its way into the internal parts
of the upper jaw, or into the chambers of the nose, while that from a
back tooth often breaks through the skin on the face, leaving an ugly
scar, or, if in the lower jaw, the pus may find its way between the
muscles of the neck, and not come to the surface till it escapes
through the skin above the collar bone. Pulling the tooth is the most
effective way of relieving the condition, the only objection being the
loss of the tooth, which is to be avoided if possible.
If the pain is bearable and there are no chills and fever, the patient
may save the tooth by remaining in bed with a hot-water bottle
continually on the face, and taking ten drops of laudanum to relieve
the pain at intervals of several hours. Then many hours of suffering
may be prevented if the gum is lanced with a sharp knife (previously
boiled for five minutes) as soon as the gum becomes swollen, to allow
of the escape of pus. The dentist is, of course, the proper person to
consult in all cases of toothache, and the means herein suggested are
to be followed only when it is impossible to obtain his services.
=MOUTH-BREATHING= (_including Adenoids, Chronic Tonsilitis, Deviation
of the Nasal Septum, Enlarged Turbinates, and Polypi_).--Any
obstruction in the nose causes mouth-breathing and gives rise to one
or more of a long train of unfortunate results. Among the disorders
producing mouth-breathing, enlargement of the glandular tissue in the
back of the nose and in the throat of children is most important.
Glandular growths in the upper part of the throat opposite the back of
the nasal cavities are known as "adenoids"; they often completely
block the air passage at this point, so that breathing through the
nose becomes difficult. Associated with this condition we usually see
enlargement of the tonsils, two projecting bodies, one on either side
of the entrance to the throat at the back of the mouth. In healthy
adult throats the tonsils should be hardly visible; in children they
are active glands and easily visible.
We are unable to see adenoids because of their position, but can be
reasonably sure of their presence in children where we find symptoms
resulting from mouth-breathing as described below. The surgeon assures
himself positively of the existence of adenoids by inserting a finger
into the mouth of the patient and hooking it up back of the roof of
the mouth, when they may be felt as a soft mass filling the back of
the nose passages.
Other less common causes of mouth-breathing, seen in adults as well as
children, are deviation of the nasal septum, swelling of the mucous
membrane covering certain bones in the nose (turbinates), and polypi.
Deviation of the nasal septum means displacement of the partition
dividing the two nostrils, so that more or less obstruction exists.
This condition may be occasioned by blows on the nose received in the
accidents common to childhood. The deformity which results leads in
time to further obstruction in the nose, because when air is drawn in
through the narrowed passages a certain degree of vacuum is produced
and suction on the walls of the nose, as would occur if we drew in air
from a large pair of bellows through a small thin rubber tube. This
induces an overfilling of the blood vessels in the walls of the
passages of the nose, and the continued congestion is followed by
increased thickness of the lining mucous membrane, thus still further
obstructing the entrance of air. A one-sided nasal obstruction in a
child with discharge from that side leads one to suspect that a
foreign body, as a shoe button, has been put in by the child.
Polypi are small pear-shaped growths which form on the membrane lining
the nasal passages and sometimes completely block them. They resemble
small grapes without skins.
These, then, are the usual causes of mouth-breathing, but of most
importance, on account of their frequency and bearing on the health
and development, are adenoids and enlarged throat tonsils in children.
Adenoids and enlarged tonsils are often due to inflammation of these
glands during the course of the contagious eruptive disorders, as
scarlet fever, measles, or diphtheria; probably, also, to constant
exposure to a germ-laden atmosphere, as in the case of children
herded together in tenements.
=Symptoms.=--The mouth-breathing is more noticeable during sleep;
snoring is common, and the breathing is of a snorting character with
prolonged pauses. Children suffering from enlarged tonsils and
adenoids are often backward in their studies, look dull, stupid, and
even idiotic, and are often cross and sullen; the mouth remains open,
and the lower lip is rolled down and prominent; the nose has a pinched
aspect, and the roof of the mouth is high. Air drawn into the lungs
should be first warmed and moistened by passing through the nose, but
when inspired through the mouth, produces so much irritation of the
throat and air passages that constant "colds," chronic catarrh of the
throat, laryngitis, and bronchitis ensue.
The constant irritation of the throat occurring in mouth-breathers
weakens the natural resistance against such diseases as acute
tonsilitis, scarlet fever, and diphtheria, so that they are especially
subject to these diseases. But these are not the only ailments to
which the mouth-breather is liable, for earache and deafness naturally
follow the catarrh, owing to obstruction of the Eustachian tubes (see
Earache, p. 40, and Deafness, p. 38). Deformity of the chest is
another result of obstruction to nose-breathing, the common form being
the "pigeon breast," where the breastbone is unduly prominent. The
voice is altered so that the patient, as the saying goes, "talks
through the nose," although, in reality, nasal resonance is reduced
and difficulty is experienced in pronouncing N and M correctly, while
stuttering is not uncommon. Nasal obstruction leads to poor nutrition,
and hence children with adenoids and enlarged tonsils are apt to be
puny and weakly specimens.
=Treatment.=--The treatment is purely surgical in all cases of nasal
obstruction: removal of the adenoid growths, enlarged tonsils, and
polypi, straightening the displaced nasal septum, and burning the
thickened mucous lining obstructing the air passages in the nose. None
of the operations are dangerous if skillfully performed, and should be
generally done, even in the case of delicate children, as the very
means of overcoming this delicacy. The after treatment is not
unimportant, consisting in the use of simple generous diet, as plenty
of milk, bread and butter, green vegetables and fresh meat, and the
avoidance of pastries, sweets, fried food, pork, salt fish and salt
meats, also the roots, as parsnips, turnips, carrots and beets, and
tea and coffee. Life in the open air, emulsion of cod-liver oil, daily
sponging with cold water while the patient stands in warm water,
followed by vigorous rubbing, will all assist the return to health.
=SORE MOUTH; INFLAMMATION OF THE MOUTH.=--There are various forms of
inflammation of the mouth, generally dependent upon the entrance of
germs, associated with indigestion or general weakness following some
fever or other disease. Unclean nipples of the mother or of the
bottle, or unclean bottles, allow entrance of germs, and are frequent
causes. Irritation of a sharp tooth, or from rubbing the gum, or from
too vigorous cleansing of the mouth, may start the disease. Some
chemicals, especially mercury improperly prescribed, produce the
disease. The germs may gain admission in impure milk in some cases.
Inflammation of the mouth is essentially a children's disease, only
the ulcerated form being common in adults.
=Symptoms.=--In general, the mouth is hot, very red, dry, and tender;
the child is fretful and has difficulty in nursing, often dropping the
nipple and crying; the tongue is coated, and there may be fever and
symptoms of indigestion, as vomiting; sometimes the disease occurs
during the course of fevers; later in the course of the disorder the
saliva often runs freely from the mouth.
=Simple Form.=--In this there are only redness, swelling, and
tenderness of the inside of the mouth. The tongue is at first dry and
white, but the white coating comes off, leaving it red in patches.
After a while the saliva becomes profuse. The treatment consists in
washing the mouth often in ice water containing about one-half drachm
of boric acid to four ounces of water by means of cotton tied on a
stick, and holding lumps of ice in the mouth wrapped in the corner of
a handkerchief. It is well also to give a teaspoonful of castor oil.
=Aphthous Form.=--In this there are yellow-white spots, resulting in
little shallow depressions or ulcers, on the inside of the cheeks and
lips, and on the tongue and roof of the mouth. These occur in crops
and last from ten to fourteen days. The disease is often preceded by
vomiting, constipation, and fever, with pain in the mouth and throat,
and is accompanied by lumps or swelling of the glands under the jaw
and in the neck. The treatment consists in the use of castor oil, and
swabbing the mouth, several times a day, after each feeding, with
boric-acid solution, as advised before, or better with permanganate of
potash solution, using ten grains to the cup of water.
=Thrush= (_Sprue_).--This form is due to the growth of a special
fungus in the mouth, causing the appearance of white spots on the
inside of the cheeks, lips, tongue, and roof of the mouth, looking
like flakes of curdled milk, but not easily removed. There are also
symptoms of indigestion, as vomiting, diarrhea, and colic. The disease
is contagious, and is due to some uncleanliness, often of the bottles,
nipples, or milk. Sometimes ulcers or sore depressions are left in the
mouth, and in weak children, in which the disease is apt to occur, the
result may be serious, and a physician's services are demanded. The
treatment consists in applying saleratus and water (one teaspoonful in
a cup of water) to the whole inside of the mouth, between feedings,
with a camel's-hair brush or with a soft cloth. A dose of castor oil
is also desirable, and great care as regards cleanliness of the
bottles and nipples should be exercised.
=Ulcerous Form.=--This does not occur in children under five, but may
attack persons of all greater ages. It is often seen following measles
and scarlet fever, and in the poor and ill nourished, and after the
unwise use of calomel. There are redness and swelling of the gum about
the base of the lower front teeth, and the gums bleed easily. Matter,
or pus, forms between the teeth and the gum, and the mouth has a foul
odor. The gum on the whole lower jaw may become inflamed, and a yellow
band of ulceration may appear along the gums. The glands under the jaw
and in the neck are enlarged, feeling like tender lumps, and saliva
flows freely. In severe cases the gums may become destroyed and eaten
away by the ulceration, and the bone of the jaw be diseased and
exposed. As in the graver cases it may become necessary to remove dead
bone and teeth, and the very dangerous form next described may
sometimes follow it, it will be seen that it is a disease requiring
skilled medical attention. The treatment consists in using, as a mouth
wash and gargle, a solution of chlorate of potash (fifteen grains to
the ounce) every two hours. Cases usually last at least a week.
=Gangrenous Form.=--This is a rare and fatal form of inflammation of
the mouth and occurs in children weak and debilitated from other
diseases, as from the contagious eruptive fevers, chronic diarrhea,
and scurvy. It is seen more often in hospitals and is contagious. A
foul odor is noticed about the mouth, in which will be seen an ulcer
on the gum or inside of the cheek. The cheek swells tremendously, with
or without pain, and becomes variously discolored--red, purple, black.
The larger proportion of patients die of exhaustion and blood
poisoning within one to three weeks, and the only hope is through
surgical interference at the earliest possible moment.
=CANKER.=--A small, shallow, yellow ulcer, appearing on the inside of
the lips or beneath the tongue during some disorder of the digestion.
It is very tender when touched and renders chewing or talking somewhat
painful. Treatment consists of touching the ulcer carefully with the
point of a wooden toothpick which has been dipped in pure carbolic
acid (a poison) and then rinsing the resulting white spot and the
whole mouth very carefully, so as not to swallow any of the acid.
Inflammation of the mouth occurs in two other general diseases, in
syphilis and rarely in diphtheria. In children born of syphilitic
parents, deep cracks often appear at either side of the mouth and do
not heal as readily as ordinary sores, but continue a long time, and
eventually leave deep scars. In diphtheria the membrane which covers
the tonsils sometimes spreads to the cheeks, tongue, and lips, but in
either case the general symptoms will serve to distinguish the
diseases, and neither can be treated by the layman.
=MILD SORE THROAT= (_Acute Pharyngitis_).--The milder sore throat is
commonly the beginning of an ordinary cold, although sometimes it is
caused by digestive disorders. Exposure to cold and wet is, however,
the most frequent source of this form of sore throat. Soreness,
dryness, and tickling first call attention to the trouble, together
with a feeling of chilliness and, perhaps, slight fever. There may be
some stiffness and soreness about the neck, owing to swelling of the
glands. If the back of the tongue is held down by a spoon handle, the
throat will be seen to be generally reddened, including the back, the
bands at the side forming the entrance to the throat at the back of
the mouth, and the uvula or small, soft body hanging down from the
middle of the soft palate at the very back of the roof of the mouth.
The tonsils are not large and red nor covered with white dots, as in
tonsilitis. Neither is there much pain in swallowing. The surface of
the throat is first dry, glistening, and streaked with stringy, sticky
mucus.
=Treatment.=--The disorder rarely lasts more than a few days. The
bowels should be moved in the beginning of the attack by some purge,
as two compound cathartic pills or three grains of calomel, and the
throat gargled, six times daily, with potassium chlorate solution
(one-quarter teaspoonful to the cup of water), or with Dobell's
solution. In gargling, simply throw back the head and allow the
fluid to flow back as far as possible into the throat without
swallowing it. The frequent use of one of these fluids in an atomizer
is even preferable to gargling. As an additional treatment, the
employment of a soothing and pleasant substance, as peppermints,
hoarhound or lemon drops, or marshmallows or gelatin lozenges, is
efficacious, and will prove an agreeable remedy to the patient in sad
contrast with many of our prescriptions. The use of tobacco must be
stopped while the throat is sore.
[Illustration: PLATE IV
=Plate IV=
=THE LARYNX=
The illustration on the opposite page shows the upper part of the
larynx and the base of the tongue.
During the inspiration of a full breath, or when singing a low note,
the =Epiglottis= lies forward and points upward, as shown in the cut,
with the glottis (the passage leading into the windpipe between the
vocal cords) wide open.
During the act of swallowing, the epiglottis is turned downward and
backward until it touches the =Cricoid Cartilage=, thus closing the
glottis. The cricoid cartilage, which forms the upper part of the
framework of the larynx, rests on the "Adam's apple."
The =False Vocal Cords= are bands of ligament, and take no part in the
production of sound.
The =True Vocal Cords= move during talking or singing, and relax or
contract when sounding, respectively, a low or high note. Hoarseness
and cough occurring during laryngitis, diphtheria, and croup, are the
result of inflammation of the mucous membrane lining the larynx.]
=TONSILITIS= (_Follicular Tonsilitis_).--Tonsilitis is a germ disease
and is contagious. Exposure to cold and wet and to germ-laden air
renders persons more liable to attacks. It is more likely to occur in
young people, especially those who have already suffered from the
disease and whose tonsils are chronically enlarged, and is most
prevalent in this country in spring. The disease appears to be often
associated with rheumatism. Tonsilitis begins much like _grippe_, with
fever, headache, backache and pain in the limbs, sore throat, and pain
in swallowing. On inspecting the throat (with the tongue held down
firmly by a spoon handle and the mouth widely open in a good light,
preferably sunlight) the tonsils will be seen to be swollen, much
reddened, and dotted over with pearl-white spots.
Sometimes only one tonsil is so affected, but the other is likely to
become inflamed also. Occasionally there may be only one spot of
white on the tonsil. The swelling differs in degree; in some cases the
tonsils may be so swollen as almost to meet together, but there is no
danger of suffocation from obstruction of the throat, as occurs in
diphtheria and very rarely in quinsy. The characteristic appearance
then consists in large, red tonsils covered with white spots. The
spots represent discharge which fills in the depressions in the
tonsil. The fever lasts three days to a week, generally, and then
subsides together with the other symptoms.
With apparent tonsilitis there must always be kept in mind the
possibility of diphtheria, and, unfortunately, it is at times
impossible for the most acute physician to distinguish between these
two diseases by the appearances of the throat alone. In order to do so
it is necessary to rub off some of the discharge from the tonsils, and
examine, microscopically, the kind of germs contained therein. The
general points of difference are: in diphtheria the tonsils are
usually completely covered with a gray membrane. In the early stage,
or in mild cases of diphtheria, there may be only a spot on one
tonsil, but it is apt to be yellow in color, and is thicker than the
white spots in tonsilitis. These are the difficult cases. Ordinarily,
in diphtheria, not only are the tonsils covered with a grayish
membrane, but this soon extends to the surrounding parts of the
throat, whereas in tonsilitis the spots are always found on the tonsil
alone. The white spot can be readily wiped off with a little
absorbent cotton wound on a stick, in the case of tonsilitis, but in
diphtheria the membrane can be removed in this way only with
difficulty, and leaves underneath a rough, bleeding surface. The
breath is apt to have a bad odor in diphtheria, and the temperature is
lower (not much over 100 deg. F.) than in tonsilitis, when it is
frequently 101 deg. to 103 deg. F. Notwithstanding these points, it is never
safe for a layman to undertake the diagnosis when a physician's
services are obtainable. On the other hand, when this is not possible
and the patient's tonsils present the white, dotted appearance
described, especially if subject to similar attacks, one may be
reasonably sure that the case is tonsilitis.
=Treatment.=--The patient should be put to bed and kept apart from
children and young persons, and, if living among large numbers of
people, should be strictly quarantined. For, although the disease is
not dangerous, it quickly spreads in institutions, boarding schools,
etc. If the tonsils are painted with a solution of silver nitrate (one
drachm to the ounce of water), applied carefully with a camel's-hair
brush, at the beginning of the attack, and making two applications
twelve hours apart, the disease may sometimes be arrested. It is well
also at the start to open the bowels with calomel, giving three grains
in a single dose, or divided doses of one-half grain each until three
grains have been taken. Pain is relieved by phenacetin in three- to
five-grain doses as required, but not taken oftener than once in three
hours, while at night five to ten grains of Dover's powder (for an
adult) will secure sleep. For children one-half drop doses of the
(poisonous) tincture of aconite is preferable to phenacetin. The
outside of the throat should be kept covered with wet flannel wrung
out in cold water and covered with oil silk, or an ice bag may be
conveniently used in its place. A half teaspoonful of the following
prescription is beneficial unless it disagrees with the stomach. It
must not be taken within half an hour of a meal, and is not to be
diluted with water, as it acts, partly through its local effect, on
the tonsils when allowed to flow from a spoon on the back of the
tongue.
[Rx] Glycerin 4 ounces
Tincture of chloride of iron 1/2 ounce
Mix. Directions, half teaspoonful every half hour.
A mixture of hydrogen dioxide, equal parts, with water can also be
used to advantage as a spray in an atomizer every two hours. The
phenacetin and Dover's powder must be discontinued as soon as the pain
and sleeplessness cease, but the iron preparation and spray should be
continued until the throat regains its usual condition. A liquid diet
is desirable during the first part of the attack, consisting of milk,
cocoa, eggnog (made of the white of egg), soups, and gruels; orange
juice may be allowed, also grapes. The bowels must be kept regular
with mild remedies, as a Seidlitz powder in a glass of water in the
morning, or one or two two-grain tablets of extract of cascara
sagrada at night.
=QUINSY.=--Quinsy is a peritonsilitis; that is, it is an inflammatory
disease of the tissues in which the tonsil is imbedded, an
inflammation around the tonsil. The swelling of these tissues thrusts
the tonsil out into the throat; but the tonsil is little affected.
Quinsy involves the surrounding structures of the throat, and usually
results in abscess. The disease is said to be frequently hereditary,
and often occurs in those subject to rheumatism and gout. It is seen
more often in spring and autumn and in those living an out-of-door
existence, and having once had quinsy the victim is liable to frequent
recurrences of the disease. Quinsy is characterized by much greater
pain in the throat and in swallowing than is the case in tonsilitis,
and the temperature is often higher--sometimes 104 deg. to 105 deg. F. When
the throat is inspected, one or both tonsils are seen to be enlarged
and crowded into its cavity from the swelling of the neighboring
parts. The tonsils may almost block the entrance to the throat. The
voice is thick and indistinct, the glands in the side of the neck
become swollen, and the neck is sore and stiff in consequence, while
the mouth can be only partially opened on account of pain. For the
same reason the patient can swallow neither solid nor liquid food, and
sits bent forward, with saliva running out of the mouth. The secretion
of saliva is increased, but is not swallowed on account of the pain
produced by the act. Sleep is also impossible, and altogether a more
piteous spectacle of pain and distress is rarely seen. Having reached
this stage the inflammation usually goes on to abscess (formation
behind or above or below the tonsil), and, after five to ten days from
the beginning of the attack, the pus finds its way to the surface of
the tonsil, and breaks into the mouth to the inexpressible relief of
the patient. This event is followed by quick subsidence of the
symptoms. Quinsy is rarely a dangerous disease, yet, occasionally, it
leads to so much obstruction in the throat that death from suffocation
ensues unless a surgeon opens the throat and inserts a tube.
Occasionally the pus from the ruptured abscess enters the larynx and
causes suffocation.
Quinsy differs from tonsilitis in the following respects: the swelling
affects the immediate surrounding area of the throat; there are no
white spots to be seen on the tonsil unless the trouble begins as an
ordinary tonsilitis; there is great pain on swallowing, and finally
abscess near the tonsil in most cases.
=Treatment.=--A thorough painting of the tonsils at the onset of a
threatened attack of quinsy with the silver-nitrate solution, as
recommended under tonsilitis, may cut short the disorder. A single
dose of calomel (three to five grains) is also useful for the same
purpose. The tincture of aconite should be taken hourly in three-drop
doses until five such have been swallowed, when the drug is to be no
longer used. The constant use of a hot flaxseed poultice (as large as
the whole hand and an inch thick, spread between thin layers of cotton
and applied as hot as can be borne, and changed every half hour) gives
more relief than anything else, and may possibly lead to disappearance
of the trouble if employed early enough. The use of the poultices is
to be kept up until recovery, although they need not be applied so
frequently as at first. A surgeon's services are especially desirable
in this disorder, as early puncture of the peritonsillar tissue may
save days of suffering in affording exit for pus as soon as it forms.
=DIPHTHERIA.=--The consideration of diphtheria will be limited to
emphasizing the importance of calling in expert medical advice at the
earliest possible moment in suspicious cases of throat trouble. For,
as we noted under tonsilitis, it is impossible in some cases to
decide, from the appearance of the throat, whether the disease is
diphtheria or tonsilitis. A specimen of secretion removed from the
throat for microscopical examination by a bacteriologist as to the
presence of diphtheria germs alone will determine the point. When such
an examination is impossible, it is always best to isolate the
patient, especially if a child, and treat the case as if it were
diphtheria. Diphtheria may invade the nose and be discoverable in the
nostrils. A chronic membranous rhinitis should be treated as a case of
walking diphtheria.
Antitoxin is the treatment above all other remedies. It has so
altered the outlook in diphtheria that, formerly regarded by
physicians with alarm and dismay, it is now rendered comparatively
harmless. The death rate has been reduced from an average of about
forty per cent, before the introduction of antitoxin, to only ten per
cent since its use, and, when it is used at the onset of the disease,
the results are much more favorable still. This latter fact is the
reason for obtaining medical advice at the earliest opportunity in all
doubtful cases of throat ailments; and, we might add, that the
diagnosis of any case of sore throat is doubtful, particularly in
children, whenever there is seen a whitish, yellowish-white, or gray
deposit on the throat. Antitoxin is an absolutely safe remedy, its ill
effects being sometimes the production of a nettlerash or some mild
form of joint pains. In small doses, it will prevent the occurrence of
diphtheria in those exposed, or liable to exposure, to the disease.
The proper dose and method of employing antitoxin it is impossible to
impart in a book of this kind. Paralysis of throat, of vocal cords, or
of arms or legs--partial or entire--is a frequent sequel of
diphtheria. It is not caused by antitoxin.
The points which it is desirable for everyone to know are, that any
sore throat--with only a single white spot on the tonsil--may be
diphtheria, but that when the white spot or deposit not only covers
the tonsil or tonsils (see Tonsilitis) but creeps up on to the
surrounding parts, as the palate (the soft curtain which shuts off
the back of the roof of mouth from the throat), the uvula (the little
body hanging from the middle of the palate in the back of the mouth),
and the bands on either side of the back of the mouth at its junction
with the throat, then the case is probably one of diphtheria. But it
is often a day or two before the white deposit forms, the throat at
first being simply reddened. The fever in diphtheria is usually not
high (often not over 100 deg. to 102 deg. F.), and the headache, backache, and
pains in the limbs are not so marked as in tonsilitis.
=MEMBRANOUS CROUP.=--Membranous croup is diphtheria of the lower part
of the throat (larynx), in the region of the Adam's apple. If in a
case of what appears to be ordinary croup (p. 83) the symptoms are not
soon relieved by treatment, or if any membrane is coughed up, or if,
on inspection of the throat, it is possible to see any evidence of
white spots or membrane, then a physician's services are imperative.
It is not very uncommon for patients with mild forms of diphtheria to
walk about and attend to their usual duties and, if children, to go to
school, and in that inviting field to spread the disease. These cases
may present a white spot on one tonsil, or in other cases have what
looks to be an ordinary sore throat with a simple redness of the
mucous membrane. Sore throats in persons who have been in any way
exposed to diphtheria, and especially sore throats in children under
such circumstances, should always be subjected to microscopical
examination in the way we have alluded to before, for the safety of
both the patient and the public.
There is still another point perhaps not generally known and that is
the fact that the germs of diphtheria may remain in the throat of a
patient for weeks, and even months, after all signs in the throat have
disappeared and the patient seems well. In such cases, however, the
disease can still be communicated in its most severe form to others.
Therefore, in all cases of diphtheria, examination of the secretion in
the throat must show the absence of diphtheria germs before the
patient can rightfully mix with other people.
Gargling and swabbing the throat with the (poisonous) solution of
bichloride of mercury, 1 part to 10,000 parts of water (none of which
must be swallowed), should be employed every three or four hours each
day till the germs are no longer found in the mucus of the tonsils.
=HOARSENESS= (_Acute Laryngitis_).--This is an acute inflammation of
the mucous membrane of the larynx. The larynx is that part of the
throat, in the region of the Adam's apple, which incloses the vocal
cords and other structures used in speaking. Hoarseness is commonly
due to extension of catarrh from the nose in cold in the head and
_grippe_. It also follows overuse of the voice in public speakers and
singers, and is seen after exposure to dust, tobacco, or other smoke,
and very commonly in those addicted to alcohol.
=Symptoms.=--Hoarseness is the first symptom noticed, and perhaps
slight chilliness, together with a prickling or tickling sensation in
the throat. There is a hacking cough and expectoration of a small
amount of thick secretion. There may be slight difficulty in breathing
and some pain in swallowing. The patient feels generally pretty well,
and is troubled chiefly by impairment of the voice, which is either
husky, reduced to a mere whisper, or entirely lost. This condition
lasts for some days or, rarely, even weeks. There may be a mild degree
of fever at the outset (100 deg. to 101 deg. F.). Very uncommonly the
breathing becomes hurried and embarrassed, and swallowing painful,
owing to excessive swelling and inflammation of the throat, so much so
that a surgeon's services become imperative to intube the throat or to
open the windpipe, in order to avoid suffocation. This serious form of
laryngitis may follow colds, but more often is brought about by
swallowing very hot or irritating liquids, or through exposure to fire
or steam. In children, after slight hoarseness for a day or two, if
the breathing becomes difficult and is accompanied by a crowing or
whistling sound, with blueness of the lips and signs of impending
suffocation, the condition is very suggestive of membranous croup (a
form of diphtheria), which certainly is the case if any white,
membranous deposit can be either seen in the throat or is coughed up.
Whenever there is difficulty of breathing and continuous hoarseness,
in children or adults, the services of a competent physician are
urgently demanded.
=Treatment.=--The use of cold is of advantage. Cracked ice may be held
in the mouth, ice cream can be employed as part of the diet, and an
ice bag may be applied to the outside of the throat. The application
of a linen or flannel cloth to the throat wrung out of cold water and
covered with oil silk or waterproof material, is also beneficial, and
often more convenient than an ice bag. The patient must absolutely
stop talking and smoking. If the attack is at all severe, he should
remain in bed. If not so, he must stay indoors. At the beginning of
the disorder a teaspoonful of paregoric and twenty grains of sodium
bromide are to be taken in water every three hours, by an adult, until
three doses are swallowed.
Inhalation of steam from a pitcher containing boiling water is to be
recommended. Fifteen drops of compound tincture of benzoin poured on
the surface of a cup of boiling water increases the efficacy of the
steam inhalation. The head is held above the pitcher, a towel covering
both the head and pitcher to retain the vapor.
The employment, every two hours, of a spray containing menthol and
camphor (of each, ten grains) dissolved in alboline (two ounces)
should be continued throughout the disease. If the hoarseness persists
and tends to become chronic, it is most advisable for the patient to
consult a physician skilled in such diseases for local examination and
special treatment.
=CROUP.=--Croup is an acute laryngitis of childhood, usually occurring
between the ages of two and six years. The nervous element is more
marked than in adults, so that the symptoms appear more alarming. The
trouble frequently arises as part of a cold, or as a forerunner of a
cold, and often is heralded by some hoarseness during the day,
increasing toward night. The child may then be slightly feverish
(temperature not over 102 deg. F., usually). The child goes to bed and to
sleep, but awakens, generally between 9 and 12 P.M., with a hard,
harsh, barking cough (croupy cough) and difficulty in breathing. The
breathing is noisy, and when the air is drawn into the chest there is
often a crowing or whistling sound produced from obstruction in the
throat, due to spasm of the muscles and to dried mucus coating the
lining membrane, or to swelling in the larynx. It is impossible to
separate these causes. The child is frightened, as well as his
parents, and cries and struggles, which only aggravates the trouble.
The worst part of the attack is, commonly, soon over, so that as a
rule the doctor arrives after it is past. While it does last, however,
the household is more alarmed than, perhaps, by any other common
ailment.
Death from an attack of croup, pure and simple, has probably never
occurred. The condition described may continue in a less urgent form
for two or three hours, and very rarely reappears on following nights
or days. The child falls asleep and awakens next morning with
evidences of a cold and cough, which may last several days or a week
or two.
The only other disease with which croup is likely to be confused is
membranous croup (diphtheria of the larynx), and in the latter
disorder the trouble comes on slowly, with hoarseness for two or three
days and gradually increasing fever (103 deg. to 105 deg. F.) and great
restlessness and difficulty in breathing, not shortly relieved by
treatment, as in simple croup. In fifty per cent of the cases of
membranous croup it is possible to see a white, membranous deposit on
the upper part of the throat by holding the tongue down with a spoon
handle and inspecting the parts with a good light.
Croup is more likely to occur in children suffering from adenoids,
enlarged tonsils, indigestion, and decayed teeth, and is favored by
dry, furnace heat, by exposure to cold, and by screaming and shouting
out of doors.
=Treatment.=--Place the child in a warm bath (101 deg. F.) and hold a
sponge soaked in hot water over the Adam's apple of the throat,
changing it as frequently as it cools. Hot camphorated oil rubbed over
the neck and chest aids recovery. If the bowels are not loose, give a
teaspoonful of castor oil or one or two grains of calomel. The most
successful remedies are ipecac and paregoric. It is wise to keep both
on hand with children in the house. A single dose of paregoric
(fifteen drops for child of two years; one teaspoonful for child of
seven years) and repeated doses of syrup of ipecac (one-quarter to
one-half teaspoonful) should be given every hour till the child vomits
and the cough loosens, and every two hours afterwards. The generation
of steam near the child also is exceedingly helpful in relieving the
symptoms. A kettle of water may be heated over a lamp. A rubber or tin
tube may be attached to the spout of the kettle and carried under a
sort of sheet tent, covering the child in bed. The tent must be
arranged so as to allow the entrance of plenty of fresh air. Very
rarely the character of the inflammation in croup changes, and the
difficulty in breathing, caused by swelling within the throat,
increases so that it is necessary to employ a surgeon to pass a tube
down the throat into the larynx, or to open the child's windpipe and
introduce a tube through the neck to prevent suffocation.
The patient recovering from croup should generally be kept in a warm,
well-ventilated room for a number of days after the attack, and
receive syrup of ipecac three or four times daily, until the cough is
loosened. If ipecac causes nausea or vomiting, the dose must be
reduced. The disease is prevented by a simple diet, especially at
night; by the removal of enlarged tonsils and adenoids; by daily
sponging, before breakfast, with water as cold as it comes from the
faucet, while the child stands, ankle deep, in hot water; and by an
out-of-door existence with moderate school hours; also by evaporating
water in the room during the winter when furnace heat is used. When
children show signs of an approaching attack of croup, give three
doses of sodium bromide (five grains for child two years old; ten
grains for one eight years old) during the day at two-hour intervals
and give a warm bath before bedtime, and rub chest and neck with hot
camphorated oil.