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.

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° to 102° F.), and the headache, backache, and pains in the limbs are not so marked as in tonsilitis.

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.

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° 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 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.

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.

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.

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.

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.

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.

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.