Plate IIANATOMY OF THE EARThe illustration on the opposite page shows the interior structure of the ear. The concha andMeatus, or canal, comprise the external ear, which is separated from the middle ear by theDrum Membrane. Wax is secreted by glands located in the lining of the meatus, and should be detached by the motion of the jaws during talking and eating. If it adheres to the drum membrane it causes partial deafness.The internal ear, or labyrinth, a cavity in the bone, back of the middle ear, consists of three parts: theCochlea, theSemicircular Canals, and a middle portion, theVestibule. The middle ear is connected with the throat by theEustachian Tube.Sound vibrations, which strike the drum membrane, are conveyed by means of a chain of three small bones through the middle ear to the nervous apparatus of the internal ear. The Eustachian tube and middle ear are lined throughout with mucous membrane, and any severe inflammation of the throat may extend to and involve the tube and the middle ear, causing deafness.PLATE IIPLATE II
ANATOMY OF THE EAR
The illustration on the opposite page shows the interior structure of the ear. The concha andMeatus, or canal, comprise the external ear, which is separated from the middle ear by theDrum Membrane. Wax is secreted by glands located in the lining of the meatus, and should be detached by the motion of the jaws during talking and eating. If it adheres to the drum membrane it causes partial deafness.
The internal ear, or labyrinth, a cavity in the bone, back of the middle ear, consists of three parts: theCochlea, theSemicircular Canals, and a middle portion, theVestibule. The middle ear is connected with the throat by theEustachian Tube.
Sound vibrations, which strike the drum membrane, are conveyed by means of a chain of three small bones through the middle ear to the nervous apparatus of the internal ear. The Eustachian tube and middle ear are lined throughout with mucous membrane, and any severe inflammation of the throat may extend to and involve the tube and the middle ear, causing deafness.
PLATE IIPLATE II
MODERATE OR SLIGHT EARACHE.—A slight or moderate earache, which may, however, bevery persistent, not sufficient to incapacitate the patient or prevent sleep, is often caused by some obstruction in the Eustachian tube, either by swelling or mucous discharge. This condition gives rise to the train of effects noted in the section ondeafness. The air in the middle ear is absorbed to some extent, and therefore the pressure within the ear is less than that outside the drum, so that the latter is pressed inward with the result that pain, and perhaps noises and deafness ensue, and, if the condition is not relieved, inflammation of the middle ear as described above.
Treatment.—Treatment is directed toward cleaning the back of the nose and reducing swelling at the openings of the Eustachian tubes in this locality, and inflating the tubes with air. A spray of Seiler's solution[3]is thrown from an atomizer through the nostrils, with the head tipped backward, until it is felt in the back of the throat, and after the water has drained away the process is repeated a number of times. This treatment is pursued twice daily, and one hour after the fluid in the nose is well cleared away the Eustachian tubes may be inflated by the patient. To accomplish this the lips are closed tightly, and the nostrils also, by holding the nose; then an effort is made to blow the cheeks out till air is forced into the tubes and is felt entering both ears. This act is attended with danger of carrying up fluid into the tubes and greatlyaggravating the condition, unless the water from the spray has had time to drain away.
Blowing the nose, as has been pointed out, is unwise, but the water may be removed to some extent by "clearing the throat." The reduction of swelling at the entrance of the Eustachian tube in the back of the nose can be properly treated only by an expert, as some astringent (glycerite of tannin) must be applied on cotton wound on a curved applicator, and the instrument passed above and behind the roof of the mouth into the region back of the nose.
Rubbing the parts just in front of the external opening into the ear with the tip of one finger for a period of a few minutes several times a day will also favor recovery in this trouble.
FOOTNOTES:[1]See p.49.[2]Caution. Ask the doctor first.[3]Tablets for the preparation of Seiler's solution are to be found at most druggists.
[1]See p.49.
[1]See p.49.
[2]Caution. Ask the doctor first.
[2]Caution. Ask the doctor first.
[3]Tablets for the preparation of Seiler's solution are to be found at most druggists.
[3]Tablets for the preparation of Seiler's solution are to be found at most druggists.
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 anæmic 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 dangerousexcept 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 removethe body it is best to secure medical aid very speedily.
Plate IIITHE NASAL CAVITYIn the illustration on the opposite page, theRed Portionindicates theSeptumof 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.PLATE IIIPLATE III
THE NASAL CAVITY
In the illustration on the opposite page, theRed Portionindicates theSeptumof 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.
PLATE IIIPLATE III
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 offood 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 ofgrippe. 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 ingrippe. 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 nostrilswith 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 isnot 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 obstructionin 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 displacementof 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, inreality, 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. Uncleannipples 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, andgreat 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 fromthe 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.
Plate IVTHE LARYNXThe 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, theEpiglottislies 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 theCricoid 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."TheFalse Vocal Cordsare bands of ligament, and take no part in the production of sound.TheTrue Vocal Cordsmove 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.PLATE IVPLATE 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, theEpiglottislies 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 theCricoid 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."
TheFalse Vocal Cordsare bands of ligament, and take no part in the production of sound.
TheTrue Vocal Cordsmove 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.
PLATE IVPLATE IV
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 likegrippe, 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. Occasionallythere 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 whitespot 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° F.) than in tonsilitis, when it is frequently 101° to 103° 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 inthree- 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.
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 oneor 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° to 105° 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 producedby 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 (seeTonsilitis) 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° to 102° 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 childrenunder 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 andgrippe. It also follows overuse of the voice in public speakers and singers, and is seen after exposure to dust, tobacco, orother 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° to 101° 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 iscoughed 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 andtends 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° F., usually). The child goes to bed and to sleep, but awakens, generally between 9 and 12P.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 describedmay 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° to 105° 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° 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 remediesare 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 thefaucet, 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.