The throat and the voice

Front matter

The first SIX volumes are now ready, others will follow at intervals of about once a mouth.

I. Hearing, and How to Keep It,

By CHAS. H. BURNETT, M.D., of Philadelphia,

Part I. The Throat

CHAPTER PAGE

I. General Construction of the Throat . 9 II. Care of the Throat 19

III. Acute Sore Throats 30

IV. Diphtheria 42

V. Croup 49

VI. Acute Laryngitis 53

VII. Chronic Sore Throats 56

VIII. Enlarged Tonsils 66

IX. Chronic Laryngitis 68

X. Foreign Bodies in the Throat and Windpipe 72

XI. Morbid Growths in the Throat and Windpipe . . . \ . . . .74

XII. Paralysis of the Throat . . . .75

XIII. Spasm of the Throat yy

XIV. Neuralgia of the Throat . . . .82

XV. Naso-Pharyngeal Catarrh . . . .83 1 * v

VI

CONTENTS.

Part II. The Voice

CHAPTER

I. The Voice II. Acoustics of Voice

III. Varieties of Voice

IV. The Vocal Organ V. Vocal Culture

VI. Improper Use of the Voice VII. Vocal Gymnastics VIII. Defects of Voice.

IX. Care of the Voice

87 89

Preface

THERE is no pretension, in the following pages, to teach either the art of practising medicine or the art of cultivating the voice. The aim of the writer has been to direct the attention of the general reader to some scientific facts concerning the throat and the voice, and to present for consideration some opinions and advice based upon an intelligent appreciation of those facts.

Should the perusal of this little volume incite desire for fuller expositions than have been displayed in the " Primer," ample material is accessible in various treatises on Anatomy, Physiology, Physics, and Vocal Culture. Study from these sources will be the more profitable, the more it is supplemented by personal investigation.

Fig. I, — Diagrammatic Anatomical Sketch of the Throat and Adjoining Structures, in Vertical Section ; to Indicate the Course of the Air and Food Tracks.

vui

THE

THROAT AND THE VOICE.

PART I.

THE THROAT.

Chapter I. General Construction Of The Throat

THE throat is the common highway, so to speak, for the passage of air to the lungs and of food to the stomach.

It is protected and enclosed by various muscular and bony structures, chiefly occupying the neck, along which, too, course the great blood-vessels that nourish the head and the brain, as well as the great nerve-trunks that pass from the brain to the lungs, heart, stomach and intestines, and other organs ; while the strong bones at the back of the neck enclose the most important, or most vital, part of the spinal cord.

Thus the throat and neck, together, are very important regions of the body. The neck is directly exposed to atmospheric changes of wind and moisture, which sometimes induce disease in the throat or in the lungs; and the interior of the throat is exposed, in addition, to the baneful influences of whatever deleterious substances may happen to be floating in the atmosphere.

Fig. I. (see Frontispiece) is a diagramatic, anatomical sketch, showing the double route taken by the air through the nose and the mouth to the air-tube, as designated by the dotted lines, and the single route taken by the food through the mouth into the gullet behind the air-tube, indicated by the unbroken line.

Keeping the relations of the food- and air-tracts in mind, let the reader look into the throat of an individual whose tongue is kept flat down on the floor of the mouth by a paper-cutter, spoon-handle, or something of that kind. This will expose to view the interior of that portion of the throat (the middle portion of the pharynx) which is common to the two great avenues by which air and food are conveyed into the interior of the body. The avenue for air, or the respiratory tract, is a double one at top, air reaching the pharynx by the interior of the nose above, as in ordinary breathing, or by the mouth in front, as in occasional breathing. Passing through the pharynx, the air next passes through a rigid tube {larynx and trachea), the windpipe, open on top, — except at moments of swallowing and during certain accidents, —

■H

GENERAL CONSTRUCTION OF THE THROAT. II and always distended by means of stiff plates and rings of gristle {cartilage), which surround it more or less completely. Thence, the air passes along the subdividing continuations of the air-tube or windpipe {primitive, diminutive, and terminative or ultimate bronchial tubes) until it reaches the air-cells of the lungs, which are grouped in series around each ultimate extremity of this series of air-passages. These successive divisions of the air-tube are, progressively, smaller and smaller, the terminal ones being about one-fortieth of an inch in diameter.

The avenue for food, or the alimentary tract, passes through the mouth into the pharynx, which it follows down directly into the gullet (food-pipe, oesophagus), continuous with the pharynx, and leading into the stomach. This gullet is located behind the upper part of the air-tube (larynx and trachea), and rests against the spinal column, or back-bone. The gullet, however, is a flaccid tube, its anterior and posterior walls being in contact, except when separated by the entrance of morsels of food or swallows of liquid.

Now, although air may enter the body by two avenues — nose and mouth, — it is to be remembered that respiration through the nose is the natural method. Consequently, whenever respiration takes place habitually through the mouth, that method of breathing is indicative of some obstruction in the nasal passages or in the upper portion of the pharynx, temporary or permanent, as may be.

If the reader will examine the image of his mouth and throat as reflected in a well-illuminated mirror, such as a hand-mirror, which he can move in such a manner as to throw the rays of light upon the various portions he is observing, he will notice a movable curtain, the soft palate, hanging from the back portion of the roof of the mouth, or hard palate. When a deep inspiration is taken through the mouth, it will be noticed that this soft palate is forced backward until it touches the back wall of the throat, the pharynx ; but when the inspiration is taken through the nose, it will be seen that the soft palate moves forward somewhat, so as to leave a considerable space between it and the pharynx, in order that the air can pass by that route into the larynx, and thence through the windpipe into the lungs. This soft palate is composed chiefly of muscles, covered by the general lining membrane (mucous membrane) of the mouth and throat. Its lower border is crescentic on each side, the central portion being prolonged into a tapering extremity, the uvula, which, when elongated, is apt to touch the base of the tongue or the valve {epiglottis) on top of the larynx, and thus produce a sense of tickling, or other annoyance, which gives frequent rise to " hemming" or to a slight cough to relieve the disagreeable sensation. The soft palate on each side of the

GENERAL CONSTRUCTION OF THE THROAT 1 3 uvula is seen to divide into two folds, the front and narrower one of which reaches downward to the side of the root of the tongue, while the back and broader one reaches farther down to the side of the throat or pharynx. Between each of these pair of folds, a small body, the to?isil, is seen to project slightly. Each tonsil is a mass of glands, very apt to become enlarged in acute and chronic sore throat. Acute inflammation of the tonsil constitutes the prominent feature of the affection known as quinsy. The tonsils are apt to become permanently enlarged in scrofulous people, and then sometimes interfere so much with respiration as to require removal of a considerable portion of their bulk. They rarely enlarge for the first time after about the thirtieth year of age. Children with chronically enlarged tonsils are liable to a deformity of the chest, on account of the position they are compelled to assume in order to breathe with any degree of comfort. This likewise interferes with due expansion of the lungs, and proper aeration of the blood, and thus often leads to serious ill-health. It is therefore of the greatest importance to future well-being that diseased tonsils be properly treated, — the sooner the better. Confidence in the popular opinion that children " will grow out of it " will only end in prolonged suffering, to be finally terminated by the interference which should have been instituted long before.

The back portion of the throat is the posterior wall of the pharynx, and is continuous with the back wall of the gullet or food-pipe, the oesophagus. Like the palate, it is chiefly muscular in structure, and is covered by a continuation of the same lining or mucous membrane. It is loosely attached to the spinal column and can be moved upon it. In diseases of the bones of the spinal column in this location, and in diseases of the glands between the gullet and the spinal column, this posterior wall of the throat is apt to become pushed forward into the free space of the throat by an abscess, or collection of pus, which interferes with respiration and with swallowing. As this disease occurs most frequently in children, the condition is often confounded with croup.

The pharynx continues upward along the spinal column behind the palate until it reaches the base of the skull, when it bends forward into a vaulted roof, which has much the shape of the crooked forefinger, or the top of a buggy wagon or phaeton. It is often easy to pass the finger up behind the palate of an individual and feel this roof of the pharynx. Being quite near the nerves from the brain, diseases of this portion of the pharynx are apt to be attended with a peculiar form of headache located just behind the upper portion of the root of the nose. If the forefinger carried up behind the palate is directed forward, a sharp ridge will be felt in front at the

GENERAL CONSTRUCTION OF THE THROAT 1 5 middle line. This is the hindermost portion of the septum or partition of the nose. On each side of it is an opening, which is the posterior orifice or outlet of the nasal passage a To each side of these openings, on the side wall of the pharynx, is a small protuberance, in the centre of which is a depression which leads into a delicate tube reaching to the drum portion of the ear, being in fact the vent-hole of that drum. When the nose is blown during the existence of a cold in the head, a crackling is heard in the ear, due to the driving of air through a collection of mucus which has accumulated at the mouth of this tube. Diseases of the back portion of the nose and of the sides of the pharynx are very apt to be continued into the ears in this way; and that is the reason why so many diseases of the ear follow the sore throat of scarlet-fever, chronic sore throat, chronic catarrh of the nasal passages, and so on. Some of the muscles of the palate cover a portion of the walls of the orifice of this tube, and this accounts for pain in the ears felt in many diseases of the throat, especially during the act of swallowing, which draws on the orifice of the tube to open it and let air penetrate into the drum of the ear.

If the tongue is pulled forcibly forward, a little curved projection is sometimes seen behind it, at its deepest portion. This, the epiglottis, is a valve of gristle, by which the air-passage is covered over, during the movement of swallowing, to prevent the food or drink from going the wrong way, i. e. into the larynx instead of the gullet. [See Larynx and Epiglottis y article Voice .] It participates with the movements of the tongue, to the root of which it is attached by a strong ligament. It is also attached by ligaments to the sides of the throat ; and when these ligaments are very tense, their edges present to the fingei the sensation of a thin and firm foreign body, such as a pin or fish-bone, and are even liable to be mistaken for the intruder in cases in which such foreign bodies have been swallowed, and be thus ruthlessly pulled upon by those who are not aware of this circumstance.

The larynx, which is guarded by this trap-door-like epiglottis, and which will be described in the article on Voice, to which it more appropriately belongs in this volume, is the vestibule or entrance into the windpipe {trachea). The windpipe is a hemispherical or tunnel-shaped tube running down the front part of the neck, dipping behind the breastbone into the chest, where it divides and subdivides into the bronchial tubes. As respiration must be continuous, it is essential that this tube should always be open ; and it is therefore strengthened by a series of hoops of cartilage in its front or hemispherical portion, while its posterior or flat portion is membranous and flexible, so as to yield to the pressure of articles of food or

GENERAL CONSTRUCTION OF THE THROAT. \J i. Cartilage of the windpipe. 2. Membranous posterior wall of the windpipe. 3. Free space or cavity of the windpipe.

drink which pass down the gullet or food-pipe, which is just behind it. Most popular accounts of this tube convey an impression Fig. II.— Diagram of a Transthat it is circular rather verse Section through the Main than more or less he mi- Windpipe, or Trachea, of a Male spherical, as here de- Subject, scribed and figured.

The membranous portion is smaller in the female than in the male.

All the structures of the throat are lined, or covered, rather, with mucous membrane containing numerous little glands which secrete a bland 3 lubricating fluid which keeps the parts moist, pliable, and comfortable. When this fluid is deficient, the parts become dry and uncomfortable ; and when it is in excess, it becomes mingled with little cast-off scales, similar to those cast off by the skin, as observed id the water after a bath, forming thick, tenacious masses of mucus, which irritate the parts and give rise to cough to get rid of them. The mucous membrane of the nasal passages and of the windpipe is provided with minute brush or hair-like processes, visible only under the microscope, which are continually waving towards the exterior of the body, and thus assist in brushing out any excess of mucus or particles of dust 2* B which have been inhaled into the nose or windpipe. In certain affections, these little hair-like appendages {cilia) are destroyed, without being reproduced, as they are in the healthy state ; and then there is some difficulty in getting rid naturally of the products alluded to in the last sentence, giving rise to more or less painful voluntary efforts of hawking, hemming, and coughing to eject them. Besides this, the delicate mucous membrane is exposed to the irritation of the air, and thus becomes further and further diseased, sometimes leading to the formation of real sores or ulcers. It is quite likely that many severe sore throats would be prevented, if the little annoyances which the loss of the cilia occasion were promptly remedied by application to the physician instead of the more frequent resort to the various cough mixtures, expectorants, and lozenges exposed for sale. Many of these preparations are absolutely injurious, while there is only one chance out of very many that the article resorted to will happen to suit the individual case to which it is applied, even when the remedy is a good one.

Chapter II. Care Of The Throat

THERE are few individuals who pass their lives without having been at some time affected with more or less sore throat. In variable climates sore throat is much more frequent than in equable climates. It is much more frequent, also, in localities where individuals are exposed to the irritating influences of particles of dust and other materials in the atmosphere, and which are inhaled in respiration. Consequently, people working in factories, chemical laboratories, and the like, are quite subject to sore throat independently of any special proclivity thereto; while they are still more likely to suffer if constitutionally subject to sore throat. Such individuals are recommended to wear little respirators in front of the nose and the mouth during exposure, in order to filter the respired air, as it were, and catch these little particles in their passage towards the throat. There is a variety of respirators for use, under these circumstances, some of which are so arranged as to contain masses of raw cotton or wool, which collect the dust

THE THROAT AND THE VOICE.

and dirt, and which can be removed from time to time as they become foul. One of these, represented in

Fig. III., is composed of meshes of delicate silvered wire, covered in front with a piece of silk. Pliny mentions that workers in mines were accustomed to fasten bladders before their mouths; and that the Roman bakers placed cloths in front of their faces when working in atmospheres

loaded with dust.

Fig. III. — Oro-nasal Respirator. T , . r . r i

It is often found, too,

that individuals suffering from consumption, chronic bronchitis, or even only with undue delicacy of the mucous membrane of the throat, are unable to face the air in windy and inclement weather. Sometimes they are unable to withstand the changes of temperature even on days which promise to be pleasant. Under such circumstances, they are compelled to keep in the house, or to muffle the mouth and nose with a handkerchief, veil, or something of that kind when they go out into the open air. The temperature of the inspired air is modified by the warmth imparted to the comforter

CARE OF THE THROAT.

by the hotter air of respiration, while, at the same time, its pungency is moderated, if too rich in oxygen for the sensitive throat or air-passages. Unmitigated sunlight is known to be often irritating to sore eyes ; and in like manner unmitigated atmospheric air is sometimes too irritant to sore throats, sore air-passages, and sore lungs. In Great Britain, a respirator of a series of fine metallic meshes, covered with silk, is much used, and, if duly appreciated, would be much used in this country also. Some respirators are made merely to cover the mouth, so as to encourage nasal or normal respiration; and others (Fig. III., pi 20) to cover both mouth and nose. These appliances are rather unsightly, to be sure, but their use often enables invalids to take regular out-door exercise, in carriage or on foot, instead of undergoing compulsory confinement to the house for fear of catching cold. Ladies may make use of a respiratory veil (Fig. IV.), devised by Mr. Lenox Browne, of London. It consists of a piece of plain, unspotted blonde, with a double

Fig. IV.

The Respiratory Veil.

thickness of silk gossamer on the lower four inches. The part that covers the mouth and nostrils is stiffened by a layer of thin wire gauze, so that the veil may stand a little away from the mouth and be more comfortable. Such a veil is easily made at home.

There is a special proclivity to sore throat in many persons. This is often hereditary. People so disposed require more precaution than others in exposing themselves to the changes of the atmosphere, and to other causes which are likely to excite sore throat.

The most frequent exciting cause of diseases of the throat appears to be the direct action of cold upon the heated body, especially during active perspiration. Sudden exposure to .heat when the body has been chilled, is likewise a frequent cause of sore throat. It is therefore necessary to avoid these sudden exposures. In cold weather, for instance, when the temperature in-doors is much higher than it is out of doors, one should not go into the open air directly from a warm room, or go at once into a very warm room, and still less, close to a fire, on coming into the house from the street. A few minutes should be passed in the entry, in either instance, so as to render the change more gradual. In similar manner, a cool bath should not be taken while the body is in active perspiration, lest it check the natural transudation of fluids and throw them in, as it is termed, upon the

CARE OF THE THROAT.

internal organs, to their detriment. Taking a child from a warm bed to the window to see a parade, etc., is a not infrequent cause of the severest kind of sore throat.

Another frequent source of sore throat, to which males are subjected much more than females, is breathing in an atmosphere laden with tobacco smoke, as in the sitting-rooms of public houses, certain concert-saloons, and the like. This is a much more frequent source of danger than smoking tobacco in a private apartment, although that, too, is sometimes a cause of sore throat. If a smoker is subject to attacks of sore throat, and is too wedded to his weed to divorce himself from it, he should smoke a long-stemmed pipe in preference to any other contrivance, because it renders the smoke cooler by the time it reaches the throat. The next safest thing to smoke is a long cigar, not much more than half of which should be used, because the remainder becomes warmer and more loaded with the poisonous products of the combustion. A short pipe is not as safe as a cigar, and a cigarette is the most injurious of all. The habits of inhaling the tobacco smoke, of swallowing it, or of passing it out by the nose, are all likely to lead to disease of the parts over which the smoke is forced. Indeed, there is a peculiar condition of the throat produced by tobacco smoking, which almost any slave to the practice can observe in himself. It consists in a series of opalescent or milky-looking patches at the inside of the corners of the mouth and lips, and some other localities, due to a sort of raising of the outermost layer of the mucous membrane. These spots are known as the milky patches of smokers, and are sometimes mistaken for evidence of a very unfortunate constitutional form of sore throat. They subside, usually, on abandoning the practice.

Another source of sore throat, very common in the United States, is the use of ice-water at meals. Many persons take their coffee, tea, soups, meats, and vegetables very hot, and cool the parts — mouth and throat — by draughts of ice-water immediately afterward. This frequent alternation of extreme heat and cold eventually injures the delicate structures subjected to it. Even when ice-water is used at proper times, it is best to take it by sips, which should be allowed to remain a few moments in the mouth until the extreme chill has passed off, than to pour it down the throat in a series of continuous swallows.

Another source of sore throat exists in overstraining the muscles in loud talking, protracted reading aloud and singing, screaming, calling to the deaf, and so on. In public speakers and singers, sore throat is often due to improper methods of breathing and of using the voice, and is only to be corrected by judicious elocutionary exercise, or a system of vocal gymnas-

CARE OF THE THROAT.

tics. Theatrical performers, on the other hand, who pay much greater attention to a proper use of their vocal organs, rarely suffer from this cause, although they are subject to sore throat from ill-ventilated dressing-rooms, exposed and illy heated stage-flies, and the like.

Finally, the inordinate use of alcoholic liquors is another source of sore throat.

Individuals predisposed to contract sore throat, or specially liable to exposure to the causes that produce it, should get into the habit of bathing the surface of the body every morning on leaving the bed. Those who prefer the regular bath by immersion may resort to that. Some prefer the shower-bath. When the full bath is inconvenient, the body should be mopped with a wet sponge or towel, the temperature of the water being as cool as is consistent with a feeling of comfort. If the practice is begun during warm weather, with the ordinary water in the washbasin, it can be continued on into the winter, and throughout the winter, too, for that matter, by most persons, without any necessity for heating the water as the weather becomes colder. If the practice is commenced during the cold weather, the water may be used warm at first, and gradually be used less and less warm as the individual becomes accustomed to it. If the cold bath or cold bathing chills the surface at any period of the year, summer or winter, or does not 3 produce an agreeable glowing sensation after it, the water used may be impregnated with a little table salt, pickling salt, or sea salt, in the proportion of a handful to a bucket of water. A bag of salt may be immersed in the water a short time before it is used. Where even this plan fails in its purpose, a cloth or sponge dipped in warm water, warm salt water, or warm acidulated water, (say a teaspoonful of aromatic sulphuric acid or a teaspoonful or two of vinegar to the ordinary basinful,) may be applied to small portions of the body exposed in succession, until the system becomes educated, as it were, to endure simple water at ordinary temperatures. There is no necessity for the use of a flesh- brush or rough towel after these ablutions, though there is no objection to be made to their use when their effects are agreeable. These baths are excellent tonics to the skin, and, through the influence of the nerves ramifying in it, to the system at large. They induce increased tolerance to ordinary atmospheric changes, and often inure the constitution toresist injurious influences which might otherwise be sustained by forced or unexpected exposure to extraordinary changes.

A person subject to diseases of the throat should be exceedingly careful as regards the use of underclothing. The undershirt and drawers should be of flannel, or of some mixed fabric containing wool, such as the ordinary merino garments of the shops. Those

CARE OF THE THROAT.

who can afford it may use silk. Silk and wool, being animal fabrics, are much more suitable for covering the human animal than vegetable fabrics, such as cotton and linen. Buckskin and chamois, though animal fabrics, are not suitable for underclothing, no matter how well "perforated " they may be to provide better ventilation. They are very soon rendered very filthy garments, even on the cleanliest bodies, because they retain accumulated products of cutaneous secretion, which undergo decomposition, and are often productive of great injury. An undergarment should be of ioose texture, and capable of being easily washed or made clean.

To suit the varying seasons of a climate such as ours, three varieties of weight of underclothing should be used, — one, the lightest texture made, for the extreme heat of summer; one of medium texture, for late spring and the autumn, and one much heavier, for winter and early spring. Changes from heavy fabrics to lighter ones should not be made until there is positive evidence of confirmed change of season. Some individuals wear underclothing of very light texture altogether, and use one, two, or more of them, as may be required, in preference to having garments of varying texture. The plan is a good one, especially for those who are apt to make too premature changes. It is very serviceable, too, when a change is made from heavy outer garments to light ones, as in dressing for an evening entertainment, when the lessened weight in the dress-clothing may be supplemented by an additional light undershirt and a pair of drawers. The underclothing worn in the daytime should be removed on going to bed, and be turned inside out to air and become well dried and ventilated by morning. It is very imprudent to sleep in the same underclothing which has been worn all day, or to wear during the day the underclothing used at night. It is rarely necessary to keep underclothing on in bed, as there is little or no exposure to direct atmospheric change ; but where the protection of a cotton night-gown is insufficient, a flannel night-gown may be used, or a special set of underclothing.

In the matter of stockings, there is not so much necessity for the use of wool in preference to cotton, even in winter.

Boots and shoes are very important articles of clothing with regard to the health of individuals subject to sore throat. Two pairs should always be in use at the same period, to be worn on alternate days respectively, inasmuch as a single night's exposure to the air is usually insufficient to free them from moisture ; and the practice of having two pairs in wear at a time will be found productive of an economy of about thirty-three per cent., a matter of some moment to many people in hard times. An additional pair,

CARE OF THE THROAT.

2 9 exceptionally well-soled, should be kept for use in inclement weather. What are called double-sc^ed shoes or boots should be worn in winter, and in wet weather at any season ; and quite light soles are perfectly safe in hot and dry weather.

Water-proof shoes, rubbers, furs, and mufflers of all sorts, are not to be recommended for customary use. Rubbers and light water-proof cloaks are advisable on occasions of special exposure, but should be removed as soon as the special occasion has passed. Water-proof garments should have slits under the armpits, and af other protected points, to favor ventilation.