A TREATISE , CPON THE DISEASES AND HYGIENE OF THE ORGANS OF THE VOICE. B Y CHEVALIER OF THE ROYAL ORDER OF THE LKO/fjN OF HONOR. DOCTOR OF MEDICINE, FOUNDER OF THE ORTHOPUONIC IN8TITUTE OF PARIS, FOR THE TREATMENT OF ALL VICES OF SPEECH, DISEASES OF THE VOICE, ETC. TRANSLATED BY J. F. W. LANE, M. D. SECOND EDITION: BOSTON: REDDING & COMPANY, 8 STATE STREET. 1 8 5 7. WVB Entered according to Act of Congress, in the year 1845, by Oris, Broaders and company, in the Clerk's Office of the District Court of Massachusetts. DESCRIPTION OF THE FRONTISPIECE. In this plate a vertical section is supposed to" have been made in the neck, immediately in front of the spinal column, and between it and the organs of the voice. The observer looks from behind forwards. The five first figures refer to bony portions of the skull. 1, the occipital process. 2, 2, portions of the temporal bones. 3, 3, great wings of the sphenoid bone. 4, 4, condyles of the lower jaw. 5, 5, branches of the lower jaw. 6, 6, 6, 6, divided edges of the pharynx drawn outwards. 7, 7, the posterior nasal openings, corresponding to the nasal fossa 1 , or sinuses. 8, the separation of the two fossae covered by mucous membrane. 9, 9, the openings of the Eustachian tube. 10, the soft palate. 11, 11, an elevation marking the site of the levator palate muscle. 12, the uvula. 13, 13, posterior opening of the fauces, or the isthmus. .14, 14, the tonsils. 15, root of the tongue. 16, epiglottis. 17, the opening into the larynx. 18,18, aryteno-epiglottidean folds of mucous membrane. 19, convexity of the larynx. 20, 20, two slight projections corresponding to the ascending horns of the thyroid cartilage. 21, the opening into the oesophagus. 22, the trachea divided transversely. [I3J TABLE OF CONTENTS. Expiration of the air necessary to the voice, 28; different theories of the vocal mechanism, 29; opinions of Aristotle, Galen, Fabricius, Casserius, Dodart, Ferrein, Bichat, Richerand, A» Mechanism of the Voice, 26-51 imals are capable of producing a vocal sound, 14 ; fishes and insects have no voice, 14 ; modification of the voice by circumstances, 15 ; the voice weaker after a meal, 15; this organ cannot be imitated by art, 16; the famous statue of Memnon, 16; singing is a modification of the voice. 17; singing natural to man, 17 ; opinions of Rousseau and Blumenbach, 18; case of a deaf mute, 18 ; influence of the passions upon the voice, 19 ; the difference of the vocal timbre depending upon the moral qualities and inclinations of the individual, 19 ; sympathies of the voice, 20 ; inflexions of the voice with regard to climate and nation, 21; extent and system of the voice in music, 23 ; difference between the articulated and modulated voice, 24. Difference of the voice as regards age, sex, etc., 13 ; what an- The Voice and its Formation, 12-26 Vocal organs, 1; larynx, 2; vocal cords, 7; muscles, 10. Description of the Vocal Instrument, 1-11 Description of Frontispiece, xiii Translator's Preface, ix VI TABLE OF CONTENTS. Cuvier, Dutrochet, Magendie, Biot, Savard, Despinay, 29; former opinion of the author, 35; criticism upon all ancient and modern opinions, 37 ; case of a vocal anomaly in a singer of the Italian theatre, 42; opinion of the author upon the mechanism of the spoken voice, and of singing in the grave notes, 46. The Pharyitgean Voice, oh Faucette, .52-90 The glottis is not the only organ productive of sounds, 52; mechanism of the sounds of the faucette, 53 ; organs which participate in it, 54 ; experiment of M. Deleau, 56; etymology of the word faucette, 58 ; theory of M. Bennati, 60 ; peculiar conformation of the vocal organs in base and soprani singers, 63; particular diseases of each class of singers, 64; why the exercise of singing is more fatiguing than that of speaking, 65; physiological disorders resulting from singing, 66; the most natural object of singing, 68; hygienic advantages to be derived from this exercise, 69; its effects uporr the nervous system and nervous diseases, 70; its protective powers in epidemic diseases, 70; singers and musicians are less exposed to epidemics, 70 ; honors paid to singing among the ancients, particularly the Greeks, 71 j singing pleasant to all men, 71; united with music it constitutes the chief ornament of our large assemblies and our theatres, 71; it elevates the soul of man to God, 71; it inspires great actions and virtue, 71; it excites courage and all the passions, 71; change of the voice at the period of puberty, 72; precautions to be taken at this period, 72; dangers of continuing the exercise of singing when certain conditions are not complied with, 72; what class of persons ought not to sing, 75; vocal illusions, 77 ; ventriloquy, 77; various opinions about ventriloquy, 78; definition of the cry, 83; its mechanism, 85; its variations in every pain, 86; anlaysis of cries, and their intonation in the pain from the application of fire, 86; of a cutting instrument,. 86 ; of an acute affection not caused by an external agent, 87 ; groaning, 87 ; sudden fright, 87; pains of labor, 87; sighs or tears, 88; organs formed by the cries of animals, 88; anecdote related by Cahusac, 88; difficulty of explaining air the vocal inflexions, etc., 89. VII TABLE OF CONTENTS. Aphony and Dysphony, 91-111 Definition and difference of these two vocal alterations, 91; synoptical table of the organic lesions and diseases which may cause aphony and dysphony, 95 ; chronic enlargement of the tonsils, 98; organic prolongation of the uvula, and prolapsus of this organ, 105; its sensibility, 106; its infiltration, 107 ; causes of this affection, 107; it may cause laryngeal phthisis, 109. Chronic Inflammations of the Larynx and Trachea, and of Primitive Laryngeal Phthisis, 112-129 A cold or slight bronchitis, its causes and treatment, 112; of acute and intense bronchitis, its causes and treatment, 114; chronic bronchitis, and its treatment, 117; who are most exposed to catarrhal affections, 118; chronic laryngitis and its medico-chirurgical treatment, 126. Sympathetic Aphony and Dysphony,.* 130-135 What is understood by sympathies and sympathetic aphony, 130; various facts proving the sympathy of the sexual organs with those of the voice, 131; treatment of the vocal alterations of this class, 133. Specific Aphony and Dysphony,.... .136-155 What is understood by specific, 136; what are specific affections, 136; venereal aphony, 137; its symptoms and treatment, 138; scrofulous aphony, 142; difficulty of its diagnosis, 144; its symptoms, 146 ; its treatment, 150 ; exanthematous aphony and dysphony, 151; their symptoms, 152 ; their treatment, 152; chronic scorbutic aphony and dysphony, 153; symptoms, 153 ; treatment, 154. Aphony and Dysphony symptomatic of other particular Affections 156-174 Atonic aphony, 157 ; symptoms, 158 ; treatment, 159; complications, 160; worm-aphony, 162 ; symptoms, 162; treatment, 163; nervous aphony and dysphony, 163; its causes, 163; therapeutical measures, 164; case at the Hotel-Dieu, 165; relative aphony and dysphony, 166. VIII TABLE OF CONTENTS. Hoarseness, or a Cold, 168-170 Particular Modification of the Lartngo-pharywgean mucous Membrane, 171-174 Sore Throat and Inflammations of the Pharynx 175-190 Coryza, or Cold in the Head, 190-194 Gargles, 195-204 Hygiene of the Voice, 205-220 TRANSLATOR'S PREFACE. The voice has ever been the subject of most careful research and diligent examination to physicians and physiologists, and theories innumerable, based only upon the vain imaginings of their promulgators, have been put forth to the world. Important at all times and seasons, as the means of communication from man to his fellows, the medium by which he expresses the most varied passions, the cheering companion of the family circle, and the mighty power by which multitudes are swayed to the will of one, the culture of the voice has within a short, period begun to receive increased and systematic attention. From ignorance of its laws, many a talented speaker has been compelled, after a short period, to relinquish translator's preface. X the eminence he had already attained, and in some new, perhaps less favored path, attempt to exercise the same degree of influence. Many professions require the most constant and fatiguing exercise of the vocal organs, for which a regular course of training should be gone through. Yet these very professions are entered upon by our young men, without once pausing to reflect, whether they can subject the voice to the arduous duties it may be called upon to perform, or whether the seeds of more fatal disease will not rather be sown, and they themselves numbered with the victims of consumption. Only by gradual efforts does the blacksmith at length gain strength to wield day by day so powerfully the heavy hammer, which our unaccustomed arms will scarce avail to raise from its situation even once. The same is true of all our organs ; they must by gradual practice be brought to their full powers. How preposterous, then, it is to dream, that the retirement of the closet, or the severest study can qualify a man in the use of his translator's preface. XI voice for the pulpit, the bar, or the stage, immediately upon entering his professional career. The present translation was undertaken at the request of an eminent Professor of Elocution, with the hope, that it might prove useful to the general reader, by pointing out to him the physiology and diseases of the organs of the voice, the medical treatment of the more common of these affections, and the conditions necessary to preserve them in health. Such points, as related strictly to the surgical details, have been intentionally omitted, in order to render the work as compact as possible, and also because the surgeon, whom these points alone concerns, will find them given at length in the surgical works of the day. In the course of the translation it has even seemed that there were some hints and suggestions, which might not be found altogether useless by the medical profession. Of the merits of the original work it will be sufficient to say, that to the author, Mons. Colombat de l'Isere, was awarded, by the translator's preface. XII Royal Academy of Sciences, the prize of five thousand francs, for his works upon the mechanism of pronunciation, and his success in the treatment of errors of speech, and particularly of stuttering. The favorable and probably unique situation, which he has occupied for many years, as founder and director of the Orthophonic Institution, at Paris, has afforded him such means of observation upon this peculiar class of affections, as have fallen to the lot of no other person. The translator, borrowing the modest language of the author, will only say of his own efforts, — " a subject of this nature requires a more skilful pen than mine, but in undertaking so difficult a task, I have consulted my own powers less than my desire to be useful: • Si desint vires, tamen iaudanda voluntas.' * THE VOICE. CHAPTER I. DESCRIPTION OF THE VOCAL INSTRUMENT. Art can never imitate the mechanism and sounds of the vocal instrument, and man will in vain seek to communicate to mechanical instruments the principles of the animal organization, because he will never have at his disposal the elements of vital action. The organs, which by their union contribute to form and modify the vocal sounds, are the following: 1. The lungs, the reservoirs of the air; 2. The muscles of respiration and the chest, which act like the bellows; 3. The trachea and bronchi, constituting a windpipe bifurcated inferiorly; 4. The larynx proper, which acts as an elastic and movable mouthpiece; 5. The glottis, 1 2 THE VOICE. the vocal cords of which are well represented by the lips of a musician playing upon the horn; 6. Finally, the pharynx or back part of the mouth, the veil of the palate, the uvula, the tonsils, the epiglottis, the palatine arch, the nasal cavities, the maxillary sinuses, the lips, the cheeks, etc., equally contribute to the formation of the voice, and play an important part in the intensity and modulation of the sounds. To render this work complete, a detailed description of all the parts mentioned ought, perhaps, to be given; but as I have nothing new to add with regard to their anatomy, and as such details would enlarge too much a work intended for the general reader, a few words with regard to the form and structure of the larynx are all that seem necessary to me. The larynx, from the Greek Xapwy£, a whistle, the principal organ of the voice, is a kind of cartilaginous box, which, taken as a whole, has the general form of a hollow and reversed cone, with its base turned upwards towards the tongue in the shape of an expanded triangle opening into the pharynx, and its summit, united inferiorly to the trachea, is continuous with that canal by a rounded opening. The superior orifice of the larynx is an oval 3 THE VOCAL INSTRUMENT. Fig. I.i space, bounded in front by the epiglottis, behind ? The right wing of the thyroid cartilage has been cut away in this plate, in order to expose the muscles connected with the edge of the glottis. No. 1. The large horn of the thyroid cartilage. 2. The interior surface of its left wing. 3. The surface of the incision made to remove the right wing. 4. The right arytenoid cartilage. 5. Part of the arytenoid muscle, fi. The thyro-arytenoid muscle. 7. The lateral crico-arytenoid muscle. 8. The posterior crico-arytenoid muscle. 9. The right side of the cricoid cartilage. 10. The first ring of the trachea. 4 THE VOICE. by the arytenoid cartilages, and upon the sides by the folds of the mucous membrane. This superior orifice of the larynx is always open, and passive as regards the formation of the voice and respiration.* The walls of the larynx are chiefly formed by the union of several cartilages, called the thyroid, arytenoid, cricoid, and the epiglottis, which is a Jihro-cartilage. Fig. 2. The thyroid or scutiform cartilage, from the Greek &vQeog, a buckler, and stdos, form, is the largest of all the cartilages of the larynx. It ? Those who have never seen, or who have badly studied the larynx, always confound the superior opening of this organ with the glottis, which is below. The name of epiglottis contributes to perpetuate this error, because the inference is that the epiglottis immediately covers the glottis. 5 THE VOCAL INSTRUMENT. forms the anterior wall of this organ, and the projection in the neck, which is called Adam's apple, marked 1 in the figure ; 2 indicates the square sides of this cartilage ; 3 its upper, and 4 the smaller, horns. Fig. 3. The two arytenoid cartilages (2,) from the Greek aqviuivu, a, ladle, and ei8o;,form, united by their anterior edges to the posterior borders of the preceding are situated at the posterior and superior part of the organ. The cricoid cartilage, (1, Fig. 3,) from the Greek xgixos, a ring, and etdog, form, circular, as its name indicates, is situated at the inferior part of the larynx, and united by its superior borders, through the intervention of a membrane, to the inferior borders of the three cartilages just mentioned ; below, it corresponds to the first ring of the trachea of which it is a continuation. 1* 6 THE VOICE. There now remain four cartilages, which are the two corniculaled cartilages, called, also, the tubercles of Santorini, and the cuneiform or cartilages of Meckel; but as these cartilages have been less studied, and as their functions are but little known, the mention of them will be sufficient. Finally, the epiglottis? vigilant sentinel, is placed at the superior -paTt of the larynx, and fixed to the upper border of the thyroid cartilage, behind the base of the tongue. It is a fibro-cartilage ; its shape has been compared to that of a leaf of parsley; its use is to prevent the introduction of articles of food into the air-passages, and, probably, to modify the sounds as they issue from the glottis. From what has been said, it will be seen that the arytenoid cartilages are by their situation, at the posterior and superior part of the larynx, opposed to the thyroid, which forms the anterior and superior part of this organ. The connections maintained by these three cartilages with regard to each other, are of the highest importance in the formation of the vocal sound. In fact, two ligaments, formed of elastic and parallel fibres, enclosed in a fold of the mucous membrane, * Vide Frontispiece. 7 THE VOCAL INSTRUMENT. Fig. 4.* slender and about two lines in width, are inserted behind into an anterior projection at the base of the arytenoid cartilages, and passed forwards to be fixed in front to the middle of the angle on the interior of the thyroid. These two ligaments, which I call the lips of the larynx, were named by Ferrein the vocal cords, and are called by * In this plate is represented a view of the larynx from above, G E II the thyroid cartilage, enclosing the ring of the cricoid, r u x w, and -turning upon the axis x z, passing through the lower horns, 4, Fig 2; N F, N F, the arytenoid cartilages connected by the transverse arytenoid muscle ; T V, T V, the vocal ligaments ; N X, the right lateral crico arytenoid ; v k f, the left thyro-arytenoid ; N1, N1, the posterior crico-arytenoids ; B B, the crico-arytenoid ligaments. 8 THE VOICE. anatomists of the present day the inferior ligaments of the glottis, or the thyro-arytenoidean. The interval between them forms the glottis, an oblong fissure, from ten to eleven lines in length in the adult male, and from two to three broad in its widest part, varying-, however, and more considerable behind than before, where the two vocal cords approximate each other, so as to touch at the point of their insertion into the thyroid cartilage. These ligaments, covered by the fleshy fibres of the thyro-arytenoid muscles, to which they adhere, and which they separate from the lateral crico-arytenoid muscles, are enveloped by the mucous membrane of the larynx through the remainder of their extent. Their superior face, directed outwardly, constitutes the lower wall of a depression named the ventricle of the larynx, the upper wall of which is formed by the superior ligaments of the vocal instrument, which are situated more externally, about the middle of the anterior face of the arytenoid cartilage. These ligaments, which are merely a fold of the mucous membrane of the larynx, are not fibrous, are less elastic than the inferior, and represent superiorly another kind of glottis, which is separated from the true glottis by the ventricular cavities just mentioned. 9 THE VOCAL INSTRUMENT. The larynx, as well as the trachea, is lined by a mucous membrane, but it is more sensitive than that of the trachea, and the contact of the smallest foreign body causes in it an excessive irritation, the severity of which strikingly contrasts with the small extent and apparently slight importance of the organ. It is in consequence of these irritations, increased, too, by painful and prolonged movements in the exercise of certain professions, that we often meet with alterations, which, although but slightly visible in the autopsy, have occasioned such mournful results as even to have hastened the hour of death. The larynx is much more developed and prominent in man than in woman, in whom this organ has but two thirds and even the half of the volume of that of man. In the latter, the retreating angle of the thyroid cartilage is acute, while it is rounded in woman, in whom the central slope of the superior border of the same cartilage is less deep, and the epiglottis less large, less thick, and less prominent than in man. Less striking differences are to be observed in the foetus and the infant; only the larynx is not so much developed as it will be at a later period, proportionally in either sex, but especially in ours. It is very remarkable, that this increase is 10 THE VOICE. not progressive, like that of the other organs, but, on the contrary, develops itself almost at once at the period of puberty, and the energy of its functions makes itself apparent at the same time with that of the generative organs. It is this rapid increase, corresponding with the change in the voice, which furnishes us with the most certain signs of puberty. After this period, the larynx experiences no remarkable change, its edges simply become more decidedly developed, its cartilages become hardened and in part ossified in old men, with the exception of the glottis, in which I am not aware that any rudiment of ossification has ever been discovered. In eunuchs this organ is as small as in woman; and the removal of the testicles at an early period, by arresting the development of the larynx, perpetuates in males the clear and feminine voice of adolescence, and even destroys the timbre of that already formed, when the operation has been resorted to soon after the period of puberty. Finally, to terminate all these dry and lengthy anatomical details, I will add, that several muscles are inserted into the larynx. Some of these muscles are external, and intended to move the entire organ, as to lower or elevate it, to carry it backwards or forwards, or, finally, to hold it steady. The other muscles are internal, and 11 THE VOCAL INSTRUMENT. have for their object to change the relation of its parts, as to enlarge or contract the glottis, to stretch and relax the vocal cords. The external muscles, which attach the larynx to the neighboring parts, are, the sIerno-thyroids, the constrictors of the pharynx, and all the muscles of the hyoid region, etc. The internal muscles, which impart all their motions to the cartilaginous pieces composing the organ, are, the crico-thyroids, the posterior crico-arytenoids, the lateral crico-arytenoids, the thyro-arytenoids, and the arytenoid, properly so called. I will add, also, that the larynx has several glands, the uses of which are but little known; these glands are, the epiglottic, the arytenoid, and the thyroid. The functions of the latter, especially, are entirely unknown; those of the others seem to be to secrete a mucus, which lubricates the larynx and the epiglottis, keeps them supple and movable, and prevents them from being irritated by the continual passage of air during respiration, singing, and speaking. Lastly, the nerves of the larynx, which are two on each side, have been named laryngeal for the superior, and recurrent for the inferior. I shall close by saying that the division of these nerves causes aphony, or loss of the voice, with which we shall be occupied in a future chapter. CHAPTER II. THE VOICE AND ITS FORMATION. The voice, Mvr\, the voice — is an alteration of the voice, which renders its emission more or less difficult, and often even painful. These affections must not be confounded with mussitation and dumbness; in the latter, the emission of the simple voice is uninjured, but not being modified by the motion of the tongue, lips, and other parts clrarged with the articulation of the sounds, they cannot, for this reason, be formed. In mussitation, .on the contrary, the motions of the speaking organs take place, but they are not preceded or followed by any kind of vocal sound, even the most feeble. In complete 92 THE VOICE. aphony the sonorous voice is entirely destroyed, but the individual can, as is improperly said, speak in a low voice, and express his thoughts by the aphonic voice at short distances, which is not the case in mussitation. If, as those pretend who compare the larynx to a mechanical instrument, the voice were merely the result of the vibrations, which the air issuing from the lungs experiences when traversing the glottis, it would be very difficult to understand why this admirable organ is altered, or even entirely lost in many diseases, although the larynx often at the time undergoes no lesion or alteration, either in its muscles, membranes, or cartilages. These modifications must, however, depend upon a cause which requires to be sought for ; this cause, in our opinion, can only be a new mode of vitality impressed upon the vocal organ by the sympathetic reaction of some other affection more or less remote. It may then be said, that the voice is not a simple vibration, but that it is living, and is animated like the organs which produce it. The voice being the sonorous expression of our sentiments, it must necessarily change with those which it expresses; it must then be modified by the diseases which influence the vitality of the 93 APHONY AND DYSPHONY. whole system, or which react, sympathetically, upon the vocal organs. Dysphony, or difficulty in the emission of sounds, and aphony, or complete extinction of the voice, are usually symptomatic, and cannot, for this reason, be studied by themselves in a practical aspect; but by considering these alterations of the voice as being the ordinary symptoms of some other affection, it becomes of the highest importance to give them the most serious attention. The aphony which is observed in continued ataxic fevers, almost always renders the prognosis fatal; it is the same in adynamic fevers and inflammations complicated with adynamia, in which the alterations of the voice, joined to some other unfavorable signs, are almost always followed by death. The author of the book of the Coacians regards as a very bad sign, aphony accompanied with great weakness and a high and painful respiration. He considered the loss of the voice to be even more unfortunate in its influence upon the prognosis in acute diseases, especially in those which manifested themselves with much pain ; it was the same in fevers with convulsions and deaf delirium, or rather with delirium and dulness. Hippocrates also relates in his book of 94 THE VOICE. epidemics, several observations, which fully confirm the truth of his opinions, and the justice of his prognosis. When the aphony is sympathetic, in that it is derived from a lesion at a distance from the larynx and throat, the treatment must therefore be studied by seeking to combat the morbid state which has produced it, and to discover the sympathies of the distant organs, which react upon the vocal apparatus. If, on the contrary, the alterations of the voice depend upon a pathological state of the speaking organs, properly so called, it is evident that the treatment must be subjected to the nature of the affection, and that resort must often be had either to medicine, or surgery, according to the circumstances which will be pointed out. In mentioning the diagnosis peculiar to each sort of affection, I shall establish the means of cure proper to be employed, and the therapeutical agents which have most frequently succeeded in my own hands; taking care, also, to make known my failures, and to point out the danger of several empirical methods even now employed. To render the study of the affections of the voice more easy, I have made a classification of them, in which I divide them into four kinds, ac- 95 APHONY AND DYSPHONY. cording as they constitute aphony, or produce only dysphony, which consists in a greater or less difficulty of emitting the vocal sounds. Synoptical Table of the Diseases and Organic Lesions, which may cause Aphony and Dysphony. First Species. — Idiopathic cases of aphony and dys- phony, arising from a physiological, anatomical, or traumatic lesion of the vocal organs. These may be caused by the inflammations of the larynx, by those of the trachea, bronchi, isthmus of the fauces, tonsils, uvula, veil of the palate ; by laryngeal phthisis, oedema of the glottis, thickening of the pharyngo-laryngean mucous membrane, atony and paralysis of the muscles of the pharynx and larynx, spasm of these organs; by falling down of the uvula, by its division with that of the veil of the palate and of the palatine bones ; finally, by wounds or contusions of the larynx and trachea, or an opening situated below the glottis ; finally, by the section or lesion of the laryngeal and pneumo-gastric nerves, etc., etc. Second Species.—Aphony and dysphony symptomatic of certain diseases which affect the whole economy. These may be caused by adynamic fevers and 96 THE VOICE. ataxic; by some worm affections ; by pulmonary phthisis; by aneurism of the aorta which then compresses the left recurrent nerve; by lesions of the spinal marrow, excessive swelling of the stomach; by apoplexy, hemiplegia, anemia, general weakness, convulsions, epilepsy, hysteria, catalepsy, chorea, insanity, cholera, frenzy; acute moral affections, such as fear, anger, joy, etc.; finally, by the abuse of ardent spirits, and the introduction into the economy of some poisonous or narcotic substances, etc. Third Species.— Sympathetic aphony and dysphony, de- pending upon the reaction which results from a, pathological condition of certain organs more or less remote, and having no immediate relation with the vocal apparatus. These may be caused by a falling down or an enlargement of the womb; by the presence of a polypus in the cavity of this organ; by ulcerations situated about its neck ; by the state of pregnancy ; by amenorrhea ; by dysmenorrhea; the sudden suppression or the commencement of the menses ; by the swelling or inflammation of both testicles ; by chronic hepatitis ; a derangement of the system of the vena porta, or atony of the primae via?; finally, by the suppression or diminution of a natural or artificial discharge, by perspi- 97 APHONY AND DYSPHONY. ration too long continued or suddenly stopped, especially about the feet and cutaneous surface. Fourth Species. — Specific aphony and dysphony, result- ing from a primitive or consecutive remote affection, which has been conveyed to the vocal organs. These may be caused by the venereal, scrofula, scurvy, arthritis, rheumatism, gout, psoriasis, herpes; by nearly all the exanthematous affections ; finally, by the ill-managed employment of the preparations of iodine and of mercury, which sometimes give rise to swellings and ulcerations of a peculiar nature. As it does not enter into the plan of this work to treat of all the general or local affections mentioned in this synoptical table, I warn my readers that I shall content myself with simply examining the alterations and lesions of the organs producing the voice, taken collectively and separately. I shall therefore pass in silence over all the acute diseases, as well as all those general affections of the second class which affect the whole economy, and give birth to symptomatic aphony or dysphony. 9 CHAPTER VI. CHRONIC SWELLING OF THE TONSILS. Among the diseases of the organs which form a part of the isthmus of the throat, none is more frequent than'hypertrophy of the tonsils. The chronic swelling of these glands arises from acute inflammations and irritations often renewed, which at length produce a permanent dilatation of their blood-vessels, and consequently a greater quantity of nutritive materials to these organs. This swelling increases in proportion to the number of the inflammations of the isthmus of the throat. At first, it produces but a slight uneasiness in swallowing, and an immaterial alteration in the voice, especially in the acute sounds of the second scale; but it often happens that considerable swelling remains, and then constitutes hypertrophy of the tonsils, which may be carried to such a degree, that these glands touch the uvula, and so contract the isthmus of the throat, that the emission of sounds is almost im- 99 SWELLING OF THE TONSILS. possible, and respiration becomes extremely difficult. The voice is rendered very hoarse and nasal, the pronunciation of words is changed and thickened, and persons laboring under this affection always speak as if their mouth was filled with food. Another inconvenience of no less magnitude is joined to those already pointed out. It is, that during deglutition, the food, especially liquids, are rejected through the nasal cavities, because the veil of the palate, disturbed in its functions by the tonsils, the volume of which is considerably augmented, cannot raise itself and completely close the posterior openings of the nasal sinuses. When the disease has reached this point it becomes necessary to adopt some remedy. We will now mention those which we have found to succeed in similar cases. If the swelling was not of very long standing nor very considerable, as often takes place after a prolonged cold, the treatment might be conducted as in acute inflammations of the tonsils, and antiphlogistics should be employed, with revulsions and sudorifics taken hot, to which might be added, with advantage, some astringent gargles. If these measures do not completely succeed, there is another which rarely fails in its effect, and which promptly reduces the tonsils to 100 THE VOICE. their normal state; it is cauterisation with the nitrate of silver passed over the whole surface of these glands. This process, which I have very often employed with success, has also succeeded in the hands of my friend, Dr. Carron Duvillards, a young physician distinguished in medical practice and literature, and to whom science owes several important discoveries, especially in regard to the therapeutics of diseases of the eyes. If a liquid caustic be employed for the cauterisation, or a solution of the nitrate of silver conveyed to the organs by means of a hair-pencil or lint, care should be taken not to take up too much liquid, for fear that some drops might fall upon the healthy parts of the mouth or throat; when the operation is ended, the patient should be made to gargle his mouth with barley-water sweetened with honey, in order to remove those parts of the caustic which may not have acted upon the diseased surfaces. If the swelling of the tonsils depended upon a scrofulous diathesis, as I have seen it in several instances, then the antiphlogistic treatment would be more injurious than useful; and previous to cauterisation the preparations of iodine might be successfully employed, such as frictions with the ointment of the hydriodate of potash upon the 101 SWELLING OF THE TONSILS. superior and external part of the neck, corresponding to the external face of the tonsils; to these measures might be added, gargles made with one pint of distilled water holding in solution four grains of iodine ; and it will also be of advantage to make use of baths of salt and water, or of soap-suds, or, better yet, of sea water. At the same time may be employed dry frictions upon the skin, with wool dipped into some alcoholic substance; to these measures may be added the iron mineral waters and bitter drinks of hops and gentian ; finally, the treatment will be completed by the cauterisation with the nitrate of silver. When the swelling is very considerable, and possesses the inconveniences which I have pointed out above, or when cauterisation and the other measures have been employed without effect, as in cases of less severity, the tonsils must be removed. Finally, one thing must not be lost sight of in the treatment of chronic enlargement of the tonsils,—that to this affection are often joined a clammy state of the mouth and frequent disposition to vomit. Physicians, even the well-instructed, who have not observed these diseases, regard these phenomena as symptoms of an irritation of the stomach, which they think them- 9* 102 THE VOICE. selves frequently called upon to combat, while the phenomena observed by them are purely local. The clammy and foetid state of the mouth depend upon an alteration in the mucosities of this organ, in consequence of a morbid secretion of the mucous membrane covering the tonsils, or from the irritation, which is propagated by continuity of tissue over the whole bucco-pharyngean mucous membrane. The disposition to vomit arises from the consecutive inflammation of the uvula, in consequence of the friction of this organ against the base of the tongue. This last phenomenon will disappear as soon as the tonsils have resumed their natural state, or been excised. The tonsils are also subject to several affections which always more or less alter the voice. Thus there are sometimes formed in them kinds of calculi, the result of a thickening of the mucous matter and of the crystallization of the salts which enter into the chemical composition of the mucus; hence result concretions, which are sometimes tender and viscous, sometimes hard and crystalline, and of a yellowish color. The former are capable of being altered and of putrifying in the very body of the tonsil, which causes a most foetid odor to exhale from the mouth, quite as SWELLING OF THE TONSILS. 103 insupportable to the patient as to those about him. The concretions of the second kind, exclusively composed of the phosphate of lime, are nonputrescent like all the saline concretions. They sometimes distend the tonsils in an extraordinary manner, and dilate the depressions of these glands, so that their openings expand, and even permit them to be seen and touched with a pen, when the mouth is widely opened. One of the symptoms, which indicates most certainly that the swelling of the tonsils is due to the presence of these calculi, is, that the individuals who are subject to them often spit out some fragments of these concretions, which are detached and fall into the throat. If deglutition is rendered irksome, and the voice is altered in singing and speaking, the only way to remedy these inconveniences would be to practise excision of the tonsils, as I have once done with success, and as was performed by M. Blandin, a short time since. There are also developed in the tonsils, very rarely indeed, true acephalocysts, or vesicular worms, which occasion these glands to take on a considerable increase, and which is almost always confounded with their hypertrophy, properly so called. But in this instance the error of diagno- 104 THE VOICE. sis has no inconvenience, especially if excision is performed ; for this operation is the only measure which can succeed, as I have seen it performed by M. Dupuylren. I will relate the case. A young man presented himself for the opinion of this celebrated and skilful surgeon for an excessive enlargement of the tonsils, which altered his voice considerably, and greatly impeded deglutition. M. Dupuytren judged excision of the gland to be the best remedy, and the patient, possessing the utmost confidence in the skill of the operator, immediately requested him to perform it. During the incision, a quantity of moisture flowed out, and upon the part removed might have been perceived the half of a cyst, whose slight adhesion, elasticity and opaque color, left no doubt as to its nature. The remainder of this vesicular sac was extracted with the greatest facility, and the operation was followed by a complete cure. The tonsils are also subject to some other diseases, such as cancer, which is incurable and happily very rare; certain abscesses which are opened without resorting to art; finally, ulcerations of various kinds, which require appropriate treatment, of which the size of this work does not permit us to speak, but which will be spoken of in treating of specific aphony. CHAPTER VII. ORGANIC PROLONGATION OF THE UVULA, AND PRO- LAPSUS OF THIS ORGAN. The uvula is a cone-shaped appendix, free and floating in the throat. Its apex is turned downwards towards the dorsal face of the tongue, and its base is united to the veil of the palate, of which it is a prolongation. The length and width of the uvula vary with the individual, and its two opposite faces present a line which is often quite deep. The structure of this appendage, which is slightly complicated, encloses a great number of mucous follicles; it is formed by the approximation of the two muscles, azygos uvula, which are sometimes distinct, sometimes confounded as one muscle. The uvula is covered on all sides by the ouccopharyngean mucous membrane, and is formed of two lateral parts very distinct in young subjects, but united at a later period at the line. In some individuals, the two portions of the uvula remain 106 THE VOICE. separated during life, in consequence of an accident in their formation, and this division is very often continued through the whole extent of the veil of the *>alate. The uvula also may not exist. Frequently no inconvenience results from it, but more generally speaking, singing in the acute notes and deglutition are executed with more or less difficulty. There are few parts whose sensibility is more marked than that of the uvula; when the summit of this organ is irritated by the contact of the tongue, or when it is excited by any lively irritation, the stomach is sympathetically excited, and nausea or even vomiting will result. For this reason, when it is desired to increase the action of an emetic, the finger is almost instinctively conveyed to this organ, which is likewise sometimes tickled for the same purpose with the feathers of a quill. In consequence of its excessive sensibility, the uvula is subject to several diseases, and to frequent inflammations, which impart to it a degree of development, and often, also, a condition of prolapse which sometimes passes into the chronic stage, and which then constitutes a true hypertrophy of the glandular layer of this organ. At other times, this prolongation and morbid develop- 107 PROLONGATION OF THE UVULA. ment of the uvula depend upon a submucous oedema, which always yields to the action of the nitrate of silver. The serous infiltration of the uvula is most frequent in the northern countries with a cold and moist climate, and it is usually observed in individuals of a lymphatic constitution, and those liable to catarrhal affections. It manifests itself sometimes suddenly, in consequence of cold drinks when the skin is covered with perspiration, or after a sudden chill of the entire body, or of the feet merely. A young lady of my acquaintance was attacked with an infiltration of the uvula after partaking of an ice at a ball, being very hot from dancing. Her uvula had in a short time acquired a considerable volume, so that it had lost its primitive form, and become rumpled, pale and semi-transparent. Cauterisations and astringent gargles soon reduced this organ to its normal condition, which, however, gave her no pain previous to the treatment, but merely incommoded her much in speaking, and excited a frequent disposition to cough and to vomit. In chronic inflammations of the uvula, the organ acquires a much smaller size, its color is much deeper than in the natural state, and it becomes the seat of a sensation of heat and of 108 THE VOICE. smarting, which is propagated from the veil of the palate to the neighboring parts, and which may, in a great number of cases, cause a complete aphony, or, at least, a noticeable dyphony. In this case, antiphlogistics must first be employed ; general bleeding, leeches in great numbers placed upon the verge of the anus, emollient injections, hot acidulated drinks, principally tamarind water ; astringent gargles, especially those made with the sulphate of alum or of zinc ; the application of a large blister to the nape ; general baths, foot-baths with the addition of hydrochloric acid ; issues on the posterior part of the neck. When this inflammatory state of the uvula appears to coincide with a suppression of the menses or of an ha;morrhoidal flux, emenagogues may be employed with advantage, especially those containing the subcarbonate of iron. Aloetic purgatives, frictions upon the lower limbs may be resorted to; finally, every measure should be tried to combat the disease, whether by acting at once upon the diseased organs, or upon those of which the natural or artificial discharges have been suddenly suppressed. Venereal ulcerations sometimes affect the uvula even to its destruction; in those cases where the presence of the venereal taint is well 109 PROLONGATION OF THE UVULA. established, to the general and local antisyphilitic treatment must be added cauterisations with the nitric acid upon the ulcerated surfaces, and the treatment may be terminated by the mineral astringent gamles. In consequence of too long continued exertion of the vocal organs — as sometimes happens in certain professions, for example, among singers, orators, players upon wind instruments, public criers, etc. —the veil of the palate, and especially the uvula, fall into a state of atony, which occasions, in the latter, a relaxation and prolapsus, which may be followed by serious inconveniences; for, as M. Lisfranc observes, there may sometimes result a fatal laryngeal phthisis, or gastric and bronchial irritations, produced and kept up by the tickling of the throat by the free and floating extremity of the relaxed organ. The fall of the uvula, merely from the disagreeable sensation which it produces by provoking, as we have already said, a constant desire to swallow and to vomit, would always be a great inconvenience ; but, in addition, it seriously impedes, and even completely prevents the modulation and articulation of sounds in singing, and especially in speaking, as is observed by M. Bennati, when these acts are successive, as in 10 110 THE VOICE. prolonged reading, parliamentary speaking, and in singing, which is thus rendered impossible. There may often result from it a complete and permanent aphony from the dry state of the throat, and the frequently repeated efforts made in speaking. In this case, as in those already cited, recourse must promptly be had to cauterisation of the organ, and to astringent gargles. If, by this measure, a speedy change is not soon obtained for the better, and the contractile faculty of the muscle of the uvula is not sensibly augmented; and if, above all, the individual is not a singer by profession, prompt recourse may be had to excision of the uvula, which is a speedy operation, attended with but little pain. The only inconvenience which can result from this operation, and that by no means constant, is that of permitting the nasal secretions to fall more easily into the throat, and of preventing, sometimes, as in excision- of the tonsils, the formation of some acute notes of the faucette, or of the second scale. In individuals having a base voice, or simply a laryngeal voice of the middle scale, this latter inconvenience is less to be feared; at any rate, it cannot be compared with those result* ing from a prolapsus of the uvula. PROLONGATION OF THE UVTJLA. Ill In those who have a division of the veil of the palate, the uvula is always divided; it even sometimes happens that one of the halves of this organ is more developed than the other, and then the separation does not appear to be in the middle. When the division is limited to the uvula, and the individual experiences but slight inconvenience in the articulation and modulation of sounds, an operation should not be attempted. If the separation should, however, extend into the veil of the palate, as is sometimes the case, the inconveniences resulting from it are of so serious a nature as to require immediate surgical assistance by an operation named staphyloraphy. CHAPTER VIII. CHRONIC INFLAB1MATIONS OF THE LARYNX AND TRACHEA, AND PRIMITIVE LARYNGEAL PHTHISIS. The larynx and bronchi, continually irritated by the contact of the air, and the injurious influences of heat, moisture, and cold, are, for this reason, more exposed than the other organs to acute and chronic inflammations. But from the nature of this work, we shall treat only of those chronic affections which alter the voice, and not of the acute, which are often soon fatal, such as certain inflammations of the larynx, croup, oedema of the glottis, which demand immediate relief, and which are rather diseases of the respiration than of the voice. We think it our duty to abstain from speaking of this latter class of diseases, on the one hand, that we may not wander from our subject, and, on the other, that we may extend our remarks upon chronic inflammations of the larynx, and upon primitive laryngeal phthisis, not coincident with any pulmonary 113 INFLAMMATIONS, ETC. trouble. We shall, however, make a few rapid remarks upon the acute but slight inflammations of the bronchi and larynx, which merely produce hoarseness and a little cough. These affections, united or separate, are neither more nor less than what is commonly called a cold, constituting a simple indisposition, which scarcely merits the name of sickness; which, therefore, does not in general attract the attention of physicians, or those affected by them. The symptoms of a cold are a cough more or less severe, hardly painful, and the expectoration of some grayish spits, with some passing chills, which, with the other phenomena, occasion no trouble in the functions of the organs, and almost always permit those laboring under them to engage in their usual avocations. If this slight affection is never disquieting, it nevertheless presents great inconveniences, especially to those whose condition obliges them either to speak or to sing in public, for it always produces hoarseness, and sometimes even complete aphony. It will therefore be useful to say some words upon the means of preventing it, and of curing it as soon as possible, the more so, inasmuch as it may easily increase in intensity, and occasion a chronic or acute laryngitis, unfortu- 10* 114 THE VOICE. nately too often beyond the resources of medicine. But as the causes of a cold, and the means of preventing it, are nearly the same with those of bronchitis and laryngitis, we shall reserve our remarks till after we have spoken of this latter class of affections, contenting ourselves, for the present, with pointing out the course to be followed in combatting a cold and hoarseness. These slight shades of bronchitis and laryngitis are very frequently cured with the aid of simple hygienic precautions, the principal of which are the repose of the vocal organs, and the care to be taken in avoiding cold and moisture. To these measures, which alone are not always sufficient, may be added the use of cough mixtures, mucilaginous preparations, such as warm infusions of violets, of borage, or decoctions of dates, jujubes, figs, grapes, etc., sweetened with honey or sugar, or with syrups of gums, marsh-mallows, etc., or cut up in milk. But a measure which almost always dissipates a cold, and which causes the hoarseness to disappear as if by magic, is to endeavor to excite a strong perspiration by the administration of diaphoretic drinks containing much gum, such as an infusion of borage-flowers, of elder, and of honeysuckle in equal parts, a handful of each to the 115 INFLAMMATIONS, ETC. pint, with an ounce of gum Arabic, sweetened with honey or syrup. These drinks should be taken in the evening, some time after eating, and as hot as possible, so as to excite the perspiration as soon as possible, which will be still more favored by retiring to a bed well warmed, and abundantly furnished with coverings. I have obtained a great number of rapid cures by these diaphoretic infusions, the free use of which need not be feared. The effect of these hot drinks might be further augmented by the addition of one or two table spoonfuls of rum or brandy ; but this addition is only adapted to those who are in the habit of using these liquors, and would prove injurious to persons with irritable stomachs. In any case, these measures should only be employed at the commencement of slight colds, especially when it is desirable to put a speedy end to the hoarseness or aphony, and when the individual is from some circumstances obliged to speak or sing in public, and it cannot be postponed, as frequently happens to singers, comedians, lawyers, etc. A milder, more uniform temperature, an absolute silence, a rigid diet, should be the first conditions to be fulfilled when the bronchitis invades in a more acute and intense manner; that is, when it manifests itself by a strong fever, an 116 THE VOICE. intense headache, full and frequent pulsations of the arteries, a violent and painful cough, a sensation of burning heat in the chest, chills on the surface of the body, a considerable oppression and dyspnoea, no expectoration, or the expulsion of some bloody spits. The conduct differs in this case from that for a slight bronchitis, and begins by the employment of blood-letting, cupping, the pectoral drinks we have already mentioned ; to which may be added the loocho, doses of oil, very hot emollient poultices, often renewed, and applied upon the chest. If the cough were very painful and convulsive, the narcotics might be employed with advantage, which should be suspended as soon as expectoration became easier, and the spits were rendered more abundant. If, after all, the bronchitis were prolonged, and threatened to pass into the chronic state, a large blister might be applied with advantage upon the chest, or, what has seemed to me preferable, friction might be made over the sternal region with the ointment of the tartrate of antimony, until large varioloid pustules were developed, which might be still further irritated by putting a piece of flannel upon them. Emollient vapors and emetics, recommended by several physi- 117 INFLAMMATIONS, ETC. cians, have always appeared to us inefficacious, and even sometimes injurious. When the acute bronchitis is prolonged beyond twenty or thirty days, without having been renewed by any anterior causes, and when the heat in the chest under the breast-bone and the resistance of the pulse have disappeared, good results are often obtained by the employment of aromatic and diaphoretic drinks; also, about the same period, local rubefacients and vesicants are applied upon the chest with the most advantage. Chronic bronchitis ordinarily arises after repeated colds, or one or more attacks of acute and intense bronchitis; the treatment of this affection is based in part upon the same foundations as that of acute bronchitis. Bleedings, however, are rarely useful; for this reason, practitioners seldom resort to them when the affection is ancient. In this case, too gummy and mucilaginous drinks, with a feculent and milky diet, give place to decoctions of Iceland moss and ground ivy, the internal use of sulphur, of mercury in small doses and in pills, and balsams, with sulphuretted mineral waters. To these measures are added, especially among lymphatic persons, the moderate use of good old Bordeaux wine, and a diet principally composed of roast meats ; 118 THE VOICE. recourse may also be had to dry frictions and revulsives; it is advisable to wear flannel waistcoats, woollen socks, and to reside in the country, if possible in a chamber exposed to the south. The symptoms of chronic bronchitis are reduced, in general, to the cough, expectoration, and an alteration in the voice, which varies as the inflammation of the mucous membrane is more or less prolonged in the direction of the larynx. Sometimes chronic bronchitis terminates in tracheal phthisis. This affection, although often beyond the resources of medicine, may continue for a long time, like laryngeal phthisis, without presenting any general appreciable symptoms; frequently, too, the general condition of the patients, by tranquillizing them as to their actual state, induces them to neglect their treatment, until they fall as it were of a sudden into a desperate condition. If we were not to speak of laryngitis, we would add several modes of treatment adopted for chronic bronchitis, but as the measures will be pointed out in the treatment of laryngitis, it will be useless to speak of them ; we shall, therefore, content ourselves with a few words upon the causes of bronchitis in general. Lymphatic, feeble, exsanguine individuals, who 119 INFLAMMATIONS, ETC. have little vital heat, or who are constitutionally lymphatic, are more subject to attacks of bronchitis, and to taking cold, as it is commonly called, upon any exposure to the slightest, and often the most inappreciable causes. It is the same with individuals whom exaggerated precautions, resulting from an effeminate and bad education, have rendered too impressible to the action of external agents. The convalescent, those who are weakened by considerable haemorrhage or a chronic disease still existing ; lastly, those who have been frequently attacked by catarrhal inflammation, are more liable to contract all the species of bronchitis. The most frequent causes of these affections of the bronchi are the impression of cold upon the whole body, or only upon certain parts, especially on the chest, shoulders, arms, feet, etc. The impression of cold is the more lively, and its action the more prompt, as the body is the more heated; for this reason, the inflammations of the bronchi are more frequent during spring and autumn, when they often reign epidemically, than during summer or winter, when the variations in the temperature of the atmosphere are less frequent and sudden. These affections often also arise from the in- 120 THE VOICE. fluence of the immediate contact of the cold air upon the bronchial mucous membrane, as well as the influence of that which has an elevated temperature, or which is charged with vapors or irritating gases, such as chlorine, ammonia, acetic acid, nitrous gas, etc. The inspiration of air holding in suspension particles of foreign bodies, such as dust, charcoal, plaster, lime, meal, etc., may also give rise to inflammations of the air-passages. But as Laennec has observed, the inflammations which are caused by physical, chemical, or mechanical agents, are in general less severe and less rebellious than these same inflammations arising from the other causes mentioned. I have been called upon to treat many cases of chronic bronchitis, and cases of this kind are more frequent than is commonly supposed. The causes of these attacks of bronchitis were various ; some arose from the too prolonged exercise of the vocal organs, as in singing, declamation, the forced cries of certain professions, etc.; others from various cutaneous eruptions, as small-pox, measles, scarlatina, the rash ; to these may be added the hooping-cough. They are always preceded or followed by a more or less severe bronchitis, the invasion of which, as also that of the acute exanthematoifs diseases, is ordi- 121 INFLAMMATIONS, ETC. narily preceded by uneasiness, chills, sneezing, loryza, soreness of the throat, etc. Our intention in this work being only to treat of the affections of the vocal organs properly so called, especially of those of the throat, which alter the voice or entirely prevent the formation of the sounds, we shall here terminate what we have to say upon bronchitis, the causes, symptoms and treatment of which we have rapidly exposed with the view of rendering it more complete, because, as has already been said, chronic inflammations of the bronchi often produce aphony or dysphony, while there is no affection of the larynx, pharynx, or isthmus of the throat. If the voice were a simple vibration of the glottis, it would not be altered in bronchitis, although in this disease the larynx often experiences no alteration. The aphony which arises in this latter case can then only be assigned to a new mode of vitality, which exerts its influence upon the glottis and the larynx. If inflammations of the bronchi often produce a change in the voice, there are some cases in which this admirable organ always remains more or less unaffected; while the slightest inflammations of the larynx, especially those of the lips of the glottis, always produce more or less dysphony. it 122 THE VOICE. As it is with regard to their phonic relation rather than their respiratory, that it is our intention to examine the diseases of the larynx, it will be best for us to pass over in silence all the acute alterations, which, in this respect, form more properly a part of the affections of the organs of respiration, than of those of the voice. We shall therefore say nothing about intense acute laryngitis, or about croupal and pseudomembranous laryngitis, which present such great dangers and are so often suddenly mortal, not from the nature of the disease, but from its situation. In fact, the larynx serving as a tube for the passage of the air, and this tube being considerably contracted by the approximation of the lips of the glottis, it would result that the slightest thickening of the mucous membrane, the merest layer of mucosity, or pseudomembranous concretions, might, by rendering the entrance of the air very difficult, bring on all the symptoms of asphyxia. I will content myself with saying that these species of acute laryngitis demand the most prompt and energetic measures; for the least delay in their administration is often the sole cause of their inefficacy. Large, general, and local bleedings should be immediately resorted to, derivatives of every kind should be employed, 123 INFLAMMATIONS, ETC. emetics, also, and tracheotomy should be resorted to at an early rather than a late period, if the symptoms seem to grow worse rapidly. This latter operation has often failed because of too long delay before resorting to it. Chronic laryngitis may be consecutive to an acute laryngitis, but it more often begins in the chronic form after extreme fatigue and long-continued use of the organ of the voice, and is kept up by the repeated exercise of this organ required by certain professions. In some cases it is primitive, and entirely independent of pulmonary phthisis; it then takes the name of primitive laryngeal phthisis, to distinguish it from laryngeal phthisis consecutive to a pulmonary affection, of which it is a symptom, and therefore called symptomatic laryngeal phthisis. Laryngeal phthisis may then exist alone, without coinciding with pulmonary phthisis; it may therefore be primitive. No doubt can remain with regard to this, when it is considered that a certain number have been cured, some cases of which I have seen. Moreover, in the autopsies of a few individuals, who have succumbed to a laryngeal phthisis, I have found pulmonary tubercles in their native or crude state, which could not certainly have exerted any influence 124 THE VOICE. upon the course of the disease. I might here add another argument in favor of this opinion, that certain forms of phthisis called specific, such as laryngeal venereal phthisis, etc., are developed and run their courses independently of any pulmonary affection. There is, then, no doubt but that laryngeal phthisis or ulcerating laryngitis may be developed suddenly, or be consecutive to a chronic laryngitis, very frequently coinciding with the general symptoms of a pulmonary phthisis, the principal of which are, hectic fever, night sweats, swelling of the legs, diarrhoea, etc., etc.; the local symptoms of primitive laryngeal phthisis, etc., are, the alteration of the voice or complete aphony, a dry painful cough, often convulsive and accompanied by the vomiting of purulent or at least puriform matters. The cough increases by night, and the patient is often awakened by the suffocation he experiences. There is joined to a foetid breath a great difficulty and a quick pain in swallowing the food, both liquid and solid; deglutition is followed by violent attacks of coughing, and the unfortunate patients sometimes require to be nourished by means of an resophagean tube. Such are the local and general symptoms of primitive laryngeal phthisis, and of 125 INFLAMMATIONS, ETC. laryngeal phthisis consecutive to a pulmonary affection; as the latter always terminates in death, and as we are only concerned with the primitive and curable laryngeal phthisis, and with simple chronic laryngitis, which is also curable, we will content ourselves with speaking only of these two diseases which present a chance of cure. As we have already pointed out the symptoms of curable and incurable chronic laryngitis, we will now expose those by which this simple and primitive disease manifests itself. At first the voice is very much altered, and its emission is always more or less painful and often impossible. The patients experience in the region of the larynx a sensation of uneasiness, accompanied with a dry cough, or followed by the expectoration of guttural mucosities which often bring with them the small tonsillary concretions we have mentioned. This condition may last a long time without presenting any general symptoms, and frequently the patients, deceived by an apparent condition of general health, neglect all the therapeutical measures prescribed them, and allow the disease to go on until it is beyond the reach of medicine. Most of those attacked with this disease, fall 11* 126 THE VOICE. victims to it at the moment when they least expect it, because their death is still further accelerated by the oedema of the glottis or oedematous laryngitis, which is simply an acute inflammation of the submucous cellular tissue of the vocal cords. If such a fatal termination is the almost constant result of chronic laryngitis when it has reached an advanced stage, it is not so with this affection taken in season, and in a great many cases therapeutical agents may be opposed to it, the more efficacious if the disease is attacked at its very outset. The diagnosis of primitive laryngeal phthisis is of the highest importance ; the physician should especially examine with the utmost care by means of the stethoscope the condition of the lungs, and explore directly, by means of the sight and touch, all the parts constituting the isthmus of the throat; as, the uvula, veil of the palate, tonsils, columns, epiglottis, and even the superior opening of the larynx. As these affections are often the sad result of too long exercise of the vocal organs, and as they have nearly the same causes which we have assigned to bronchitis, I shall, in order not to render myself tiresome by repetition, pass them over in silence, that I may the more readily arrive at the 127 INFLAMMATIONS, ETC. most, important part, which is the therapeutical. Although the treatment of chronic laryngitis and laryngeal phthisis has never been fixed upon in a positive manner, I will point out the principal measures which seem to me best adapted to combat these two affections. An absolute silence should first be directed, and, in order to leave the affected organs as much as possible in repose, the patients should be requested to resist the disposition to cough as much as they can. It would be happy for them if they could in these cases suppress the cough as they can the speech, which can be supplied to a certain point by signs and writing. Recourse may be had to flying blisters, moxas, small cauteries, and what has appeared to me preferable and from which I have obtained very good results, to frictions upon the sides of the larynx, with the ointment of the tartrate of antimony, till the pustules are formed. Small bleedings from the arm, to the amount of a quarter or half a porringer, the applications of leeches to the sides of the larynx, scarifying cups upon the nape or to the lateral parts of the neck, will act, at the same time, as derivative and antiphlogistic measures. Finally, the inspiration of the vapor of tar water, and especially of that of a 128 THE VOICE. solution of creosote water, made with one.scruple of creosote to four ounces of water, may be employed with advantage. This latter measure which I have employed with advantage, and which modifies and very quickly in some cases cicatrises over chronic ulcers of a bad character, requires to be employed a great number of times, and to be studied with the greatest attention, that positive conclusions may be drawn with regard to its efficacy in the treatment of ulcerating laryngitis. Such observations perhaps I shall have the advantage over every other person in making, from the care which I have taken to mark the effect of this new therapeutical agent in chronic diseases of the larynx. During the treatment of these guttural affections, the patients should be restricted to a soothing regimen composed of porridge, gelatinous broths, feculent or other articles of diet which should have as nearly as possible the consistence of pap, in order to render the deglutition easier and less painful. finally, the same measures may be pursued towards the patients as were pointed out in the treatment of chronic bronchitis. When primitive ulcerating laryngitis resists the measures we have recorded, there yet remains another which we have never employed, but 129 INFLAMMATIONS, ETC. which appears to have met with the greatest success in the hands of the Irish surgeon Carmichael. This measure which we should hesitate to adopt, regarding it as the only means of safety from a certain death, is tracheotomy performed in the manner recommended by this celebrated surgeon. As this operation is very important in its results, we deem it a duty to refer the reader to the original article in The Dublin Medical and Surgical Journal, for 1833. CHAPTER IX. SYMPATHETIC APHONY AND DYSPHONY. The secret of the sympathies is evidently the same with that of the nervous action. Before speaking of the sympathetic vocal alterations, we will say a few words rapidly with regard to what is understood in medicine by sympathy, a word derived from the Greek