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, Consulting Aurist to the Pennsylvania Institution for the Deaf and Dumb, Aurist to the Presbyterian Hospital, etc. II. Long Life, and How to Reach It, By J. G. RICHARDSON, M.D., of Philadelphia, Professor of Hygiene in the University of Pennsylvania, etc. If IV The Summer and its Diseases, By JAMES C. WILSON, M.D.,of Philadelphia, Lecturer on Physical Diagnosis in Jefferson Medical College, etc. Eyesight, and How to Care for It, By GEORGE C. HARLAN, M.D., of Philadelphia, Surgeon to the Wills {Eye) Hospital. V. The Throat and the Voice, By J. SOLIS COHEN, M.D., of Philadelphia, Lecturer on Diseases of t fie Throat in Jefferson Medical College. VI. The Winter and its Dangers, By HAMILTON OSGOOD, M.D., of Boston, Editorial Staff Boston Medical and Surgical Journal. VII. The Mouth and the Teeth, By J. W. WHITE, M.D., D.D.S., of Philadelphia, Editor of the Dental Cosmos. VIII. Our Homes, By HENRY HARTSHORNE, M.D., of Philadelphia, Formerly Professor of Hygiene in the University of Pennsylvania. IX. The Skin in Health and Disease, By L. D. BULKLEY, M.D., of New York, Physician to the Skin Department of the Demilt Dispensary and of the -\ ezu } "ork Hospital. X. Brain Work and Overwork, By H. C. WOOD, Jr., M.D., of Philadelphia, Clinical Professor of Nervous Diseases in the University of Pennsylvania, etc. XI. Sea-Air and Sea-Bathing, By JOHN H. PACKARD, M.D., of Philadelphia, Surgeon to the Episcopal Hospital. Other volumes are in preparation, including the following subjects : M Preventable Jiseases," "Accidents and Emergencies," "Towns we Live In," "Diet in health and Disease," "The Art of Nursing," "School and Industrial Hygiene," lk et °' * ne >' uil1 be l6mo in size, neatly printed on tinted paper, and bound in ^loth, 50 cents. Mailed free upon receipt of price. LINDSAY & BLAKISTON, Publishers, Phila. AMERICAN HEALTH PRIMERS. EDITED BY W. W. KEEN, M.D., Fellow of the College of Physicians of Philadelphia, and Surgeon to St. Mary's Hospital. ■H2- -©* AMERICAN HEALTH PRIMERS. THE Throat and the Voice. BY J. SOUS COHEN, M.D., Lecturer on Diseases of the Throat and Chest in Jefferson Medical College, and on Physiology and Hygiene of Voice in the National School of Elocution and Oratory. $ — - 1879. &J - PHILADELPHIA: LINDSAY & BLAKISTON. 1879. ■f* Copyright. LINDSAY & BLAKISTON. 1879. CONTENTS. 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 Wind- pipe 72 XI. Morbid Growths in the Throat and Wind- pipe . . . \ . . . .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 89 113 116 129 134 143 147 154 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 dis- played in the " Primer," ample material is ac- cessible in various treatises on Anatomy, Phys- iology, Physics, and Vocal Culture. Study from these sources will be the more profitable, the more it is supplemented by personal investiga- tion. Fig. I, — Diagrammatic Anatomical Sketch of the Throat and Adjoining Structures, in Vertical Section ; to Indi- cate 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 en- close the most important, or most vital, part of the spinal cord. Thus the throat and neck, together, are very im- portant regions of the body. The neck is directly 9 10 THE THROAT AND THE VOICE. exposed to atmospheric changes of wind and moist- ure, 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 del- eterious substances may happen to be floating in the atmosphere. Fig. I. (see Frontispiece) is a diagramatic, anatom- ical sketch, showing the double route taken by the air through the nose and the mouth to the air-tube, as des- ignated 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 indi- vidual whose tongue is kept flat down on the floor of the mouth by a paper-cutter, spoon-handle, or some- thing of that kind. This will expose to view the in- terior of that portion of the throat (the middle por- tion 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 mo- ments 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 wind- pipe {primitive, diminutive, and terminative or ulti- mate 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, pro- gressively, smaller and smaller, the terminal ones be- ing 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 fol- lows down directly into the gullet (food-pipe, oesoph- agus), 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 gul- let, however, is a flaccid tube, its anterior and poste- rior 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 habit- ually through the mouth, that method of breathing is indicative of some obstruction in the nasal passages 12 THE THROAT AND THE VOICE. 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 por- tion 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 phar- ynx ; 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 mem- brane (mucous membrane) of the mouth and throat. Its lower border is crescentic on each side, the cen- tral 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 " hem- ming" or to a slight cough to relieve the disagree- able 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 inflamma- tion 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 opin- ion 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. 14 THE THROAT AND THE VOICE. 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 dis- eases of the bones of the spinal column in this loca- tion, 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 swallow- ing. As this disease occurs most frequently in chil- dren, 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 fore- finger, 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 exist- ence 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 con- tinued into the ears in this way; and that is the rea- son 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, dur- 1 6 THE THROAT AND THE VOICE. ing 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 Epi- glottis y article Voice .] It participates with the move- ments of the tongue, to the root of which it is at- tached 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 for- eign bodies have been swallowed, and be thus ruth- lessly 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 wind- pipe {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 bron- chial 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 car- tilage 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. Mem- branous posterior wall of the wind- pipe. 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 Trans- that 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 por- tion 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 lubrica- ting 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 1 8 THE THROAT AND THE VOICE. 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, expec- torants, 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 atmos- phere, and which are inhaled in respiration. Conse- quently, people working in factories, chemical labora- tories, 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 rec- ommended 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 circum- stances, some of which are so arranged as to contain masses of raw cotton or wool, which collect the dust 19 20 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 men- tions that workers in mines were accustomed to fasten bladders be- fore 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 mu- cous 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. 21 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 respira- tion; and others (Fig. III., pi 20) to cover both mouth and nose. These appliances are rather unsightly, to be sure, but their use often en- ables invalids to take regular out-door exercise, in car- riage or on foot, instead of undergoing compulsory con- finement to the house for fear of catching cold. Ladies may make use of a respira- tory 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. 22 THE THROAT AND THE VOICE. thickness of silk gossamer on the lower four inches. The part that covers the mouth and nostrils is stiff- ened 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 them- selves 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 expo- sures. In cold weather, for instance, when the tem- perature 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 per- spiration, lest it check the natural transudation of fluids and throw them in, as it is termed, upon the CARE OF THE THROAT. 23 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, cer- tain 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 some- times 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 con- trivance, 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 swal- lowing 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 condi- tion of the throat produced by tobacco smoking, which almost any slave to the practice can observe in 24 THE THROAT AND THE VOICE. 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 after- ward. 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. 25 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 pro- duce it, should get into the habit of bathing the sur- face 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 wash- basin, 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 com- menced 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 26 THE THROAT AND THE VOICE. 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 hand- ful to a bucket of water. A bag of salt may be im- mersed 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 sul- phuric 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 be- comes 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 atmos- pheric changes, and often inure the constitution to- resist injurious influences which might otherwise be sustained by forced or unexpected exposure to ex- traordinary changes. A person subject to diseases of the throat should be exceedingly careful as regards the use of under- clothing. 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. 27 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 cot- ton 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 produc- tive 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 ex- treme 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 28 THE THROAT AND THE VOICE. light ones, as in dressing for an evening entertain- ment, when the lessened weight in the dress-clothing may be supplemented by an additional light under- shirt 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 under- clothing on in bed, as there is little or no exposure to direct atmospheric change ; but where the protec- tion of a cotton night-gown is insufficient, a flannel night-gown may be used, or a special set of under- clothing. 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 sub- ject 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 moist- ure ; 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 per- fectly 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 advis- able 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 arm- pits, and af other protected points, to favor ventila- tion. Confirmed invalids who cough on exposure to the outer air, should be careful not to talk during open- air exercise, and should wear a folded veil or a respi- rator in front of both nose and mouth when exposed to the wind, in order to modify the irritating influence of cold air upon the delicate mucous membrane of the throat. It is the confirmed opinion of the author, that if invalids suffering from diseases of the respira- tory organs would make systematic use of respirators, they would be spared a great deal of suffering, and would actually prolong their lives by the practice. 3* CHAPTER III. ACUTE SOKE THROATS. THE term acute sore throat is used to designate an inflammatory condition, of comparatively short duration, affecting any portion or portions of the structures of the threat. Physicians apply separate names to inflammations confined to certain regions, but it is not requisite in this volume to allude to them individually. The chief general causes of acute sore throat are those already enumerated (pp. 22 and 23). There is another cause which must be borne in mind, which occurs chiefly in the dwellings of the poor, who are compelled to allow their children to play about the kitchen, and are unable to watch them carefully. The little ones try to get a drink of water for them- selves from the spout of the kettle of hot water, and thus inflict severe and often irreparable injury upon their throats and their upper air-passages. In many instances, death is inevitable after an accident of this kind. Care must be taken, therefore, that the kettle of hot water, coffee, or whatever it may be, shall be kept out of the reach of children. A similar acci- 30 ACUTE SORE THROATS. 3* dent sometimes occurs with grown folks who are not careful about looking at their medicine bottles, and thus swallow a caustic liniment instead of a medicinal mixture, or administer the same to others. It is a good plan to insist upon it, that the apothecary should put all poisons, liniments, and the like in roughened bottles, — a special kind of which is made for the pur- pose, — so that the sensation imparted to the hand, even in the dark, will indicate caution, and thus pre- vent the liability of making such a dreadful mistake. Scalds of the kind alluded to are apt to be very severe. The cough and spasm produced by the act of swallowing these hot and acrid drinks involuntarily spatters them about the top of the larynx, the upper part of the throat, and even into the nasal passages. Much of the mucous membrane of these parts is killed at once, and there is violent inflammation, with great swelling, sometimes to such an extent as to choke the patient to death, unless the windpipe is opened sur- gically to allow access of air to the lungs from an arti- ficial aperture. Whenever such an accident occurs, whether in daytime or at night, the nearest reliable physician shouW be sent for at once, and the mind be prepared to learn that recovery is doubtful ; and that, even if it take place, a great deal of deformity may result, interfering, perhaps permanently, with freedom of swallowing and freedom of breathing. Ordinary sore throats, such as follow exposure to 32 THE THROAT AND THE VOICE. cold, usually implicate the soft palate, uvula, and ton- sils, and even the base of the tongue. Sometimes the back part of the throat (the pharynx) is involved, but not often. In some instances the upper portions of the air-passages (larynx and trachea or windpipe) are also affected, and in others the nasal passages likewise. The same sort of sore throats is likewise due, in some instances, to the peculiar influence of certain medicines which are being used in the treat- ment of other diseases. These medicines are chiefly preparations of mercury, iodine, antimony, zinc, bella- donna, and stramonium. Whenever, therefore, a sore throat occurs, during treatment for another disease, and there is no ostensible reason to account for it, it is well to have the inquiry made as to whether it might not be the result of the action or overaction, or poisonous action of remedies in use at the time. Sometimes, too, these sore throats are occasioned by what is known in medical parlance as " reflex ac- tion ; ' ' that is to say, that an irritation of the nerves from a disease in the heart, liver, intestines, or some other organ, may be propagated along the spinal cord, which consists of the combined bundles of the nerve filaments that extend from it to all parts of the body, and then proceed from the spinal cord along the nerve fibres that leave it at another point to extend to the lining or mucous membrane of the throat. Sore throat, again, occurs from an extension of ACUTE SORE THROATS. 33 various diseases in the mouth, tongue, nose, and windpipe. It also occurs as a part of the ordinary manifestations of scarlet-fever, and likewise, but to a less extent, of small-pox and of measles. It also occurs in connection with a number of acute mala- dies, such as erysipelas, typhoid fever, rheumatism, influenza, and certain diseases of the skin. It like- wise occurs in a number of chronic diseases. The reason why the throat is affected in many of these affections has not yet been satisfactorily determined. Common Sore Throat. — This is a slight superficial inflammation of the covering or mucous membrane of both surfaces of the palate and uvula, and usually of the mucous or covering membrane of the tonsils also, extending, in some cases, to the same covering of the back part of the throat (the pharynx) ; but the mucous membrane of the mouth remains free. It is most frequent in children and quite young adults. The parts affected are red in color, more or less swollen, and secrete an excess of mucus. They are often quite painful on swallowing. Speech is often indistinct, but there is no hoarseness. There is no cough unless the uvula is elongated and tickles the back part of the tongue or the valve (epiglottis) on top of the air-passage. Sometimes a sore throat of this kind following exposure to wet, is very severe for a day or two, and subsides suddenly to give way to an attack of acute C 34 THE THROAT AND THE VOICE. rheumatism. This form is known as rheumatic sore throat, and probably involves the muscles, or the sheaths of tissue in which the fibres of the muscles are enclosed, rather than being confined to the mu- cous membrane. In severe cases there is considerable fever, and this is severer in children than in adults. In severe cases, too, the glands at the angles of the jaw become swollen. It often happens that the sore throat is limited to one side of the body, and then the other side is apt to become affected, as the diseased action subsides in the first locality ; and if the individual be impru- dently exposed, the second attack is apt to be more intense than the first one. Unless there is some grave constitutional disorder, this form of sore throat gets well spontaneously in from five to ten days, according to its severity. Very often, cases of slight sore throat require no special medical treatment whatever. It is prudent, however, to keep in the house, lying upon a couch or bed, with a thin coverlid over the body to equalize the heat of the surface. This precaution will shorten the duration of the attack considerably, and render it less likely to subside into a chronic sore throat, as many neglected cases do. The bowels should be kept relaxed by resort to some mild medicine, as castor-oil, salts, magnesia, or rhubarb. The free use of muci- ACUTE SORE THROATS. 35 laginotis drinks, such as barley-water, gum-arabic water, slippery-elm water, and the like, and of small fragments of ice retained in the mouth until melted, if agreeable, as they almost always are, will soothe the pain in the throat. Intense heat of the skin may be allayed by sponging the body with acidulated tepid water, bay-rum and water, or alcohol and water. This, with restriction to a very light and easily di- gested diet for a day or two, will be all that will be required in moderate and ordinary cases. Severe cases require the advice of the physician. Quinsy. — This is a severer form of sore throat, in which the inflammatory action is not confined to the mucous membrane, but involves the tissues beneath it. It is quite liable to go on to what is called sup- puration, or the formation of pus. The organ most prominently involved is the tonsil ; but the palate and uvula, the base of the tongue, the valve of the air-passage, the back of the throat, and the tissues that connect these various structures are all liable to be involved to a greater or less extent. It occurs more frequently in individuals with diseased tonsils than in other persons, and is most frequent in chil- dren and young adults. It is more dangerous in chil- dren than in adults, and in individuals with enlarged and diseased tonsils. Quinsy usually begins with a chill, and this is fol- lowed by fever within twenty-four hours. Pain in 36 THE THROAT AND THE VOICE. the throat is an early symptom. All the visible struct- ures of the throat are inflamed and swollen, the ton- sils in particular — sometimes only one of them, some- times both of them, but usually one much more than its fellow. The swollen tonsil may project beyond the middle line of the throat, or the two tonsils may touch. They are usually covered with whitish or yel- lowish creamy secretions. The pain in the tonsil sometimes runs up along the fold behind it into the ear, with the vent-hole of which it is continuous (see page 15). There is indistinctness of speech, difficulty and pain in swallowing, and difficulty of breathing if the swelling is very great. The parts become dry, taste is impaired, and the breath offen- sive. Sometimes the saliva dribbles from the mouth because it cannot be swallowed. Sleep becomes diffi- cult or impossible when the mechanical impediment to breathing is great, or when the nervous system is excited by fever and suffering. Children are liable to delirium and convulsions. The disease lasts longer than common sore throat ; and though the tendency of the attack is to recovery in most instances, there are not a few in which it is fatal from the formation of burrowing abscesses, which inflict irreparable injury. In many instances an abscess forms in the tonsil, and when this bursts spontaneously, or is discharged by the surgeon's knife, relief to pain is usually immediate, and the inflam- ACUTE SORE THROATS. 37 matory process soon subsides, provided there are no more abscesses. An abscess that bursts spontaneously may suffocate the patient by flooding the air-passages \ but this is infrequent. It is best and safest, however, to submit to an operation, if suggested by the medi- cal attendant. A child, tormented for days by sleep- lessness from pain, will sometimes go to sleep on the lap of its mother or nurse, after the discharge of such an abscess, even before the surgeon has wiped his knife. Nothing is said about treatment of these cases, as they are too important to be intrusted to untrained hands. It is quite likely, however, that the use of gargles will be suggested in the treatment of this dis- ease. They are rarely of any service, chiefly because their use entails a great deal of pain. They may be entirely superseded, in the treatment of this and other forms of sore throat, by the use of sprays or douches propelled from the so-called atomizer, so frequently in use for diffusing sprays of cologne water and the like. The use of these sprays entails no pain, is really grateful and soothing, and the fluids reach the remoter parts of the throat which are never reached by the gargle. A gargle as ordinarily used only reaches the palate and base of the tongue, as a rule, as may be seen by experimenting with colored water — indigo water, for example. To reach the back part of the throat, it must be half swallowed ; a dif- 4 38 THE THROAT AND THE VOICE, ficult practice, and too painful for the subject of a sore throat. It is better to try and bring the fluid of the gargle in contact with the sore parts by hold- ing it in the mouth, and then gently turning the head to one side and to the other, backward and forward, so as to let the fluid bathe the parts in succession, without making any gurgling noise by forcing the air through it as in the usual method. Another good plan is to carry the fluid back to the root of the tongue in a teaspoon, and then pour it over the parts as the head is thrown back, which will bring it in contact with the deeper structures of the throat ; then the sides of the throat are bathed by appropriate motions of the head to either side ; and the process is completed by suddenly bringing the chin down to the breast as the fluid is ejected, so as to bathe the middle portion of the throat, the tonsils, palate, and roof of the mouth. Common Membranous Sore Throat. — It is highly desirable that the public should be aware that there is a comparatively unimportant disease of the throat in which the structures become covered with a membra- nous deposit, and which is often mistaken for diphthe- ria. The tendency in this disease being to sponta- neous recovery, and the disease being mistaken for diphtheria, certain remedies are apt to be vaunted as efficient in diphtheria, because they happened to be used vigorously in a case of common membranous sore ACUTE SORE THROATS. 39 throat which would have gotten well under ordinary management. This affection occurs at all seasons of the year. Some individuals are attacked almost annually. Its most frequent immediate cause is a cold bath, or other exposure to cold, while the body is overheated or in active perspiration. Imperfect drainage and emanations from cesspools and refuse-heaps are often the apparent remote cause. During the prevalence of diphtheria, common membranous sore throat is often contracted by persons susceptible to sore throats from other causes, and may then become a starting- point for the severer disease. It usually begins with a chill, followed by fever, which is sometimes quite severe \ then there are two or three days of ordinary sore throat. At first, the palate, tonsils, or pharynx are covered with groups of little vesicles, which burst, become excoriated, run into each other, and get covered by a grayish -white pellicle or membrane, resembling the similar false membrane of diphtheria, which begins, however, in another way and under other conditions. The vari- ous parts of the throat are swollen, but not nearly as much as in quinsy, and the affection is usually con- fined to one side. A similar form of sore throat sometimes attends advanced stages of consumption in which there has been severe disease of the throat. The disease usually subsides spontaneously in from 40 THE THROAT AND THE VOICE. eight to ten days. Sometimes it is fatal, however, chiefly-in children, from extension of the membrane into the air-passages, death taking place mechanically by suffocation. It is difficult to distinguish this affec- tion from diphtheria, especially when the latter is prevalent; but there is not that profound disturbance of the system due to blood-poisoning, which is the chief characteristic of diphtheria. Common membranous sore throat often occurs again and again in some individuals, which is not the case with diphtheria. The appropriate treatment for this affection is that for ordinary sore throat, with such cleansing and astringent washes, sprays, and lozenges as the attendant physician deems suitable. The Sore Throats of Small-Pox, Measles, and Scarlet-Fever. — The sore throat of small-pox is due to the development of an eruption upon the surface of the throat, mouth, and air-passages similar to that which is developed upon the skin. It is liable to be followed by permanent hoarseness in those who re- cover ; and is quite apt to terminate fatally by ulcer- ation in the air-passages. The sore throat of measles is a catarrhal inflamma- tion of the nasal passages, throat, and air-passages. The mucous membrane of the throat is often affected a day or more in advance of the skin, the palate being covered with small red points. It is liable to be followed by prolonged hoarseness. ACUTE SORE THROATS. 41 The sore throat of scarlet- fever is very severe in some instances, to such an extent, indeed, as to be the main source of danger in that serious malady. Some amount of sore throat attends every case. In some cases it is the only manifestation. Susceptible nurses and physicians are liable to have sore throat nearly every time they are in attendance upon scar- latina. There is a diffuse inflammation of the throat, sometimes with small, pimple-like eruptions, and these manifestations appear a day or two in advance of the manifestations on the skin. The inflammation is of a high grade, not unlike that of quinsy in moderate cases, and proceeding to ulceration and great destruction of tissue in severe cases. The inflammatory process is very apt to ex- tend up into the drum of the ear and produce an abscess, which ruptures through the drum membrane and discharges externally at the outer ear. Many diseases of the ear are due to the sore throat of an attack of scarlet-fever. It is popularly beliered, and sometimes taught by physicians, that children will " outgrow' ' such affections. Nothing can be more erroneous. Every such case demands immediate and skilful treatment, in spite of which, not infre- quently, hearing is often impaired or lost. CHAPTER IV. DIPHTHERIA. DIPHTHERIA is one of those maladies known as blood diseases ; that is to say, it is due to some deleterious matter that gets access in some way to the mass of the blood, and poisons the system. The nature of this poisoning material has not yet been detected, but there is reason to believe that it flour- ishes where drinking-waters, and the air of dwelling- places, are impregnated with emanations from cess- pools, refuse heaps, waste-pipes, and unventilated sewer-drainage. The disease is propagable by con- tagion ; and one attack does not insure immunity from subsequent ones. Children are much more liable to it than adults. It is characterized by a low or typhoid type of fever, and more particularly by the development of a more or less copious deposit of what is termed false membrane on the mucous sur- faces of the throat and adjoining cavities, the air-pas- sage and nasal passages. Sometimes it extends along the gullet even into the stomach. It is likewise liable to be formed over any abraded portion of the skin. The 42 DIPHTHERIA. 43 character of the deposit varies from minute, delicate films to large, tough membranes, sometimes amount- ing to complete casts or moulds of great extent. The deposit is usually more or less diffused over the surfaces. The deposit may accumulate to such an extent in the air-passages as to produce death by suffocation ; but the more frequent cause of death in this notoriously fatal malady is extreme depression of strength and vitality, the result of the poison in the blood. The disease rarely occurs without exposure in some way to the cause of the infection, though it is some- times impossible to trace it to such an occurrence. Two to five days usually elapse between this exposure and the outbreak of the disease ; but this period may be but a day on the one hand, or be extended to two weeks on the other. The earliest manifestation to attract prominent at- tention is usually some degree of sore throat, often confined to one side, and attended with swollen glands below the ear and lower jaw of the same side, or both sides, as may be ; these parts being tender and pain- ful. Sometimes the swelling begins in the parotid gland in front of the lower part of the ear, — the same gland which is swollen in mumps. The throat be- comes swollen inside, where it soon becomes more or less overlaid or covered with a whitish deposit, usually commencing on the tonsil or the palate, and thence 44 THE THROAT AND THE VOICE, gradually spreading ; but it may begin at points out of the line of sight, and thus escape detection. Cases occur, too, in which there is no local manifestation of deposit to be detected at any time. If the air- passages are to become involved, they become covered with the membrane within a day or two of its appear- ance in the upper part of the throat, or at least, ex- cept in rare instances, before the termination of the first week. When the air-passages are involved, the special symptoms are similar to those to be mentioned under the head of croup, and which become super- added to those of sore throat. While the deposit is spreading, the patient usually becomes more and more prostrated in strength. The disease is very apt to terminate fatally, especially in delicate and feeble persons, death taking place within a few days in some cases, and towards the end of the second week in most of them; exceptionally not until four or five weeks. Manifestations of recovery are usually pre- sented between the eighth and fourteenth day in most instances. Paralysis of the throat is not infrequent after recoveries from diphtheria, and the paralysis may extend to other parts of the body, especially the legs, and may even involve the heart and lungs, when it will be fatal. The eyesight is not seldom seriously affected from paralysis of the muscle of accommoda- tion or focusing. The treatment of diphtheria must be pursued under DIPHTHERIA. 45 the direction of the physician, whose efforts are chiefly directed to sustaining the vital forces of the patient, providing for nutriment, and endeavoring to get rid of the accumulations in the throat, nose, and air-pas- sages. There are some general points, however, with which heads of families should become familiar. The patient should be isolated as much as practicable, to prevent spread of contagion ; and all the clothing, food and bed-utensils be at least partially disinfected before they are removed and carried through the house. Carbolic acid water is the most available agent for this purpose in most instances. The mode of using it may be learned from the physician. Carpets, curtains, and stuffed furniture should at once be removed from the sick-room, which ought to be at the top of the house, and well ventilated. After the case is over, this room and all it contains should be thoroughly disinfected by exposure to the fumes of burning sulphur, in order to lessen to a minimum the danger of infection for future occupants. When the deposits in the throat are dry and adherent, it is considered very import- ant, by many physicians, to keep up an abundance of moisture in the room by means of dishes of boiling water, wet cloths hanging about, and the like, in the hope of keeping the matters in a fluid state, so that they may be more easily expelled from the body. Systematic inhalations of steam are also used at ap- propriate intervals in addition. When the mem- 46 THE THROAT AND THE VOICE. branes are in the air-passages, it is very important that they should be coughed out, lest they accumulate in quantity dangerous to breathing. To favor their detachment and expulsion, it is customary with many physicians to see that a large stock of unslaked lime is in the house. When the dreaded time comes, this lime is broken into fragments the size of furnace coal, and a few of them at a time are slaked by the bed- side, the fumes from the lime being directed towards the mouth of the patient by some extemporized method, such as covering the vessel with a big paper bag, as a flour bag, with one of the corners torn out so as to direct the fumes through it. This process is repeated every half-hour, hour, or at longer intervals, as may be required. Sometimes, in addition, a piece of lime is kept in a vessel of heated water by the bed- side, so as to maintain a continuous evolution of steam and lime particles. The lime gets into the air-pas- sages and detaches the membranes, and the steam gets beneath them through these inlets and loosens them, so that they can be coughed up. The masses may accu- mulate in the throat and mouth and the patient be unable to eject them ; and they may require removal with the finger of the nurse or attendant. In some cases where the upper air-passage becomes so occluded, or so paralyzed that sufficient air cannot get through to sustain life, it becomes necessary for a surgeon to cut a hole into the windpipe, and keep it DIPHTHERIA. 47 open, until the passage above becomes sufficiently pervious again. This operation (tracheotomy) is not always successful. More than half the children oper- ated upon die in spite of it, and it is very rarely indeed that it saves the life of an adult. The reason is that the air-passage of the adult is so large in proportion, that the disease in the smaller tubes is too far ad- vanced for recovery before the larger calibre of the air-passage gets obstructed. The operation is per- fectly justifiable in children, however, and hundreds are saved by it from otherwise inevitable death. It permits them to breathe while they are going through the course of the disease towards death or recovery, as may be, but is not in itself curative. The earlier it is performed, after it appears requisite, the better the chance of saving life by it. The importance of this operation is so great, that it is questionable, in many instances, whether parents are not culpable in refusing to allow their children this chance for life when urged upon them by their medical advisers. The fact that no certain promise of success can be given by the surgeon in any one case, does not begin to counterbalance the fact that lives are often saved by it, even under conditions apparently utterly hopeless, occasionally even directly after the patient has ceased to breathe. Even when unsuccessful in saving life, the operation often ensures freedom of breathing, and saves a dreadful death by 4 8 THE THROAT AND THE VOICE, suffocation. The ease which follows, justifies the op- eration merely as an alleviator of distress. Another point which should be realized by parents is the great danger of lifting a patient, low with diphtheria, in disobedience to the physician's injunc- tions. The heart becomes so feeble, at times, that the extra exertion necessary to pump the blood into the upper part of the body against gravity is too much for it, and it ceases to beat. The physician knows when this is imminent, and tells the attendant not to allow the patie?it to rise or be raised for any purpose whatever, until he deems such precaution no longer necessary. CHAPTER V. CROUP. THERE is a spasm of the air-passage sometimes called pseudo-croup or false croup, (see page 78 ;) but it is of nervous origin altogether, and has no af- finity with croup other than that the main symptom is always spasm, which also occurs in some cases of croup, but is by no means a constant manifestation. True or membranous croup is chiefly an inflamma- tory disease of the upper air-passage, attended with the deposit of a membrane like to that which accu- mulates in the air-passages in diphtheria. The de- posit may extend along the windpipe, and even great distances along the bronchial tubes and their ramifi- cations. There are no reliable chemical or micro- scopic tests which can distinguish between the deposits in croup and in diphtheria. On this account many physicians consider the two diseases to be identi- cal. Others, among them the author, believe that they are not identical, and that there is no primary or special blood-poison at work in croup as in diph- theria, and that the danger to life in croup resides 5 D 49 5 ever, as above stated, the Vocal Bands Separated Be- hind, as in Ordinary Breath- vocal bands are brought to- ing. gether posteriorly to the /^\ middle line, and held there / ^hBL\ as long as the sound is being I ML w^l\ ma d e (Fig. V.); separating \Jk Ilk ' again when a deep inspira- ^^^B^S^ tion is to be made (Fig. VI.); "" for Xe'Brfa^ 5 ' "" *** ^^ the P rocess bein 8 repeated as long as vocalization is con- tinued. It is thus that the ordinary expiratory cur- rent of breathing is utilized in the normal production of the voice. A vocal sound can be produced by the inspiratory current likewise, if a special effort is made to do so, as sometimes practised by ventriloquists; but the sound is rough, coarse, and disagreeable, and the effort soon becomes tiresome and difficult. In cases of spasmodic approximation of the vocal bands, as occurs in certain cases of false or spasmodic croup, and in a number of diseases of the upper por- tion of the air-passage, this unnatural vocal sound is actually produced at every forcible effort of inspira- tion, and constitutes a special alarming and heart- rending sound which is known as stridor. CHAPTER II. ACOUSTICS OF VOICE. THE physical laws in accordance with which voice is produced are just the same as those which control the physical production of all other sounds. If, therefore, the general laws of sound (acoustics) are reviewed, and then the mechanism of those por- tions of the human organism concerned in the pro- duction of vocal sound is studied afterward, consid- erable insight will be gained as to the nature of the voice. What is sound? "Something we hear/' some bright little reader may mentally reply. And so it is, — something that is heard. And it is only by hearing it, that it can be comprehended. The deaf-mute has no conception of the nature of sounds. If he were standing alone by the Falls of Niagara, there would be no sound, for there would be no organ of hearing to interpret as sound the commotion in the water and in the atmosphere produced by the great cataract. The sensation of sound is due to a certain motion or tremor produced in the molecules of the extreme 8* 89 gO THE THROAT AND THE VOICE. filaments of the nerve of hearing, and vibrating syn- chronously or in unison with the sonorous body. The motions of the sounding body are transmitted in pulses or waves through the air, or whatever other medium it may be, into our ears, and thence along the nerve of hearing into the brain, by which it is perceived and interpreted, and upon which it makes the special impression which we designate sound. Now, whether this motion is communicated from without, as in the ordinary sounds to which we are daily accustomed, or whether it exists primarily in the filaments of the nerve of hearing, the result, in either case, is sound. A blow upon the side of the head often shakes the auditory filaments and produces sound. A current of electricity passed through the organ of hearing likewise produces sound. There is reason to believe that the singing in the ears occa- sionally heard by nearly every one, and the noises of wind and water, sometimes of music, and so on, to which certain invalids are subject, are all of them the result of a physical motion or tremor set up in the auditory apparatus. The peculiar form of motion which gives rise to the sensation of sound is that form known as oscilla- tion or vibration ; a motion that repeats itself at reg- ular intervals, — a motion to and fro, up and down, forward and backward, — the motion of a pendulum, of the balance-wheel of a watch, of the strokes of a ACOUSTICS OF VOICE. 91 trip-hammer, of a ball kept tossing in the air, etc. The effect upon the air is to produce alternate con- densation and rarefaction in spherical waves or undu- lations, radiating from the centre of disturbance. When this sort of motion is not excessively rapid, that is to say, when it recurs with less frequency than sixteen repetitions in the second of time, it is too sluggish to rouse the organ of hearing, and produces merely some of the ordinary manifestations of me- chanic force, as we see in the industrial arts. But when it is more frequent than sixteen times per sec- ond, there is special manifestation of sound, what- ever the physical work that may be going on ; and the pitch, intonation, or acuteness of the sound rises in direct proportion to the increased frequency of the motion,* until, at the rate of from thirty thousand to forty thousand repetitions per second, the effect be- comes so shrill and sharp as gradually to transcend human powers of hearing it ; when all sound ceases, and our ears are silent to the increased motion. There is abundant evidence, however, to show that vibrations even still more rapid can be heard by insects and other animals. The physical reason that such rapid vibrations fail to impress the organ of hearing, is probably due to the fact that they are too rapid for the weight or density of the nerve-fibres to respond * Listen to the musical whiz of a steam-saw when sawing lumber, for example. 92 THE THROAT AND THE VOICE. to, and that before these fibres have time to recover, as it were, from the forward motion of one oscillation, the others come on behind with such rapidity as to keep the nerve-fibre pressed still, or dampened, as it were, so that it has no opportunity to vibrate, and is consequently silent. Away beyond the limits of audition, among vibra- tions the rapidity of which we cannot realize, amount- ing to tens of millions per second, the special physical manifestation is perceived as electricity \ and far be- yond the limits of electric excitation, where the motion begins to be executed in hundred of millions of vibra- tions per second, the manifestation of the motion is heat ; and when the frequency of vibration amounts to several hundreds of millions per second, the mani- festation is light ; and beyond the limits of light, the motions produce those still occult forces of decom- position and recomposition known as chemical action. Hence, chemical action, light, heat, electricity, sound, and mechanic force are all manifestations of one uni- versal force — motion. As these manifestations are to a certain extent convertible one into another, we are led to the comprehension of a grand fundamental principle of science known as the correlation of forces. Strike a match, — one of the most wonderful inven- tions of human ingenuity, by the way, — and you may demonstrate several of these points at one stroke ; a trite ACOUSTICS OF VOICE. 93 experiment, it is true, but striking and brilliant, both literally and intellectually. The friction — mechanic force — develops a rapid vibration of the air around the head of the match, producing one kind of sound, while the explosion produces another ; heat is com- municated to the wood of the body of the match, which becomes warm to the fingers that hold it ; light is produced by the explosion and subsequent ignition of the match, and the wood burns ; and chemical ac- tion results, as evinced by the cloud of phosphoric acid, and the oxidation of the hydro-carbon of the burning wood ; while, furthermore, the presence of electricity, always generated in chemical action, might be demonstrated were an electroscope or electrometer in proper connection with the match. Here, then, we have a variety of motions excited, illustrating the entire series of forces. Rapid vibrations (at a rate exceeding sixteen per second), then, produce a peculiar effect, which excites that special sensation which is termed sound. At this rate of sixteen vibrations per second, the sound is a low rumble, which almost admits of perception of the coalescence of the sixteen vibrations into a deep tone, as in the sound from the longest organ-pipe, excep- tionally used in very large organs, which is thirty-two feet in length, and gives the C* of i6J vibrations per second. The more rapid the vibrations, the higher in pitch 94 THE THROAT AND THE VOICE, becomes the sound, until a rapidity of motion is ac- quired which the ear fails any longer to appreciate ; this limit varying in individuals according to the sensitiveness of their hearing apparatus. When these vibrations are- equal-timed, — isochronous (isos, equal; chronos, time), periodic or rhythmic, — the effect of the sound is pleasant, and termed musical. When they are irregular or unperiodic, the effect upon the ear is unpleasant and disagreeable, analogous to the optical effect from an irregularly flickering flame, and the sounds that result are termed noisy. Music and noise, therefore, are similar in their physical qualities ; and they present points of mutual approximation, although their extremes differ greatly. The limits of noise and of music, respectively, depend solely upon the degree of pleasurable or dis- pleasurable sensation produced upon the hearer, and vary, therefore, in different individuals, according to the delicacy or sensitiveness of their auditory nerves. Music, the result of rhythmic or equal-timed vibra- tions, is audible at greater distances than noise, the result of irregular or unequal-timed vibrations. This greater reach of music is intuitively utilized in the street cries* of large cities, in the auctioneer's rattle- * Such as those of the rag-men, venders of fish, fruit, hot-corn, etc. Philadelphians will recall the great reach of the peculiar, musical cry oi' the "hominy man." ACOUSTICS OF VOICE. 95 like announcement of bids at a public sale, in calling out to persons at a distance, and the like. Music and noise are convertible, also. Sounds which in themselves are musical, as the successive tones of the gamut rapidly produced from the piano- forte, for example, become discordantly transmuted into noise if struck together simultaneously. When this is done, the rhythmic vibrations of each string conflict in part, and thus excite irregular move- ments. On the other hand, again, sounds which are simply noises as long as they remain isolated, such, for ex- ample, as sounds produced by striking a piece of wood, or a paving-stone, may be transmuted into music by striking them in series arranged to yield the tones of the gamut, as in the xylophone, or wood piano, the glass harmonicon, and similar instruments. The musical character of the tones evolved by the rammers of the street-pavers when a series of them are engaged in hammering the cobble-stones of our streets, is well known to residents of cities. It is on record that a series of animals have been utilized as musical instruments. Thus, we read that at Brussels, in 1549, during a celebration in honor of a miraculous image of the Virgin, a bear performed upon an organ of cats. This organ was composed of twenty live cats — with cries giving consecutively the tones of the gamut — confined separately in narrow boxes, over which their g6 THE THROAT AND THE VOICE. tails passed ; these appendages being secured to cords which were fastened to the registers of the organ, and corresponding to the keys of the instrument. Each time that the bear struck his paw upon a key, he thereby pulled on the tail of one of the unfortunate prisoners, and thus forced the series to miau through the whole gamut. Conrad van der Rosen, the jester of the Emperor Sigismond, is said to have succeeded in curing his master of a black melancholy, by executing melodies upon an organ of cats, ranged in gamuts, whose tails he pinched in striking the keys. As sen- tentiously observed by Radau, from whose volume on Acoustics the above anecdotes have been taken, " Cats were not happy at this epoch." Sounds, vocal and otherwise, differ in three impor- tant characteristics — intensify, pitch, and qualify. Attention may be called, in addition, to a subdivision of quality, especially as regards the voice, — reach or penetrant power over distances. Intensity means loudness, and is independent of pitch or quality. Pitch is the degree of acuteness or gravity, the intonation, or the position of the sound in the musical scale, and is independent of intensity or quality. Quality {timbre, tone-character) is that peculiarity by which the sound of any one instrument or one voice is distinguished from other instruments or other voices, and is independent of intensity or pitch. ACOUSTICS OF VOICE. 97 Intensity. — Intensity is due to the extent of the vibration to and fro, consequently to the size of the sound-waves or undulations, set up in the atmosphere. Now, bodies vibrating in larger excursion to and fro from their point of rest, set larger masses of air in motion than when that excursion is more limited ; and the greater the extent to which the disturbance in the air — really a condensation and rarefaction — ■ reaches, the louder the sound. If we pull lightly upon the cord of a piano, it will vibrate but a short distance to and fro, and the sound will be feeble ; but if we pull it more forcibly, it will move over a greater space, and the sound will be louder because a greater mass of air is set in motion, and larger waves of sound generated in consequence. The same thing takes place in the human voice. If the vocal cords (as they are unfortunately called, for they are not cords but bands) are only moderately tense, they can move over a larger extent of space than when they are held more tense. Hence the sound is louder, and the sound-waves being larger, they are felt, in certain portions of the scale, as they strike the walls of the windpipe, bronchial tubes, and air-cells of the lungs, — for sound-waves travel spherically in every direction from the point of disturbance — producing that peculiar vibration of the chest-walls which has given rise to the denomination of chest-tones in the lower portion of the vocal register. The intensity 9 G 98 THE THROAT AND THE VOICE. of the voice depends upon the force of impact of the escaping current of air, and upon the elasticity of the vocal bands. Pitch. — The range of sound of which the human voice is capable — its compass — consists in round numbers of from two and a half to three octaves ; less than that in most voices, more in some rare instances ; the entire range, taking male and female voices to- gether, being about five octaves. The extreme limits of human voice observed, however, are said to be the F 1 of 43J vibrations per second, in the voice of ^ Fisher, ■ ~J — , to the c 6 of 2100 vibrations in the voice of La Bastardella, Q \ ~- — . Now, for i the production of every note in the register of a voice, there is but a short pipe, the windpipe, the length of which, by the elevation of the larynx as the sounds rise in pitch, can be so slightly varied as to count for little in the mechanism, and a pair of elastic mem- branous bands (reeds, tongues, vocal cords), each less than an inch long and less than a quarter of an inch broad, and with but one free surface or edge. The modification of pitch is chiefly effected by progressive variations in the tension of the membranous vocal ACOUSTICS OF VOICE. 99 bands, and by slight variations in the shape of the elliptic fissure between them ; a number of complex muscular actions being concerned in bringing this about. This is supplemented by variations in the position and shape of the walls of the larynx and windpipe, pharynx and mouth ; but to what extent, or in what manner, is as yet undetermined. The force of the current of air will likewise affect the pitch to a certain extent, as in wind instruments generally. It is known that if a violin string or a drum-head be stretched, so that its tension is increased, the sound it will yield when struck will be higher in the scale the greater the tension ; while the pitch falls as the string or membrane is slackened, because its tension is being decreased. So it is with the human voice. When the laryngeal muscles stretch the vocal cords, increasing their tension, the pitch ascends; and when the muscles are relaxed so that the tension is dimin- ished, the pitch falls. It is likewise known that if a string or membrane is slackened too much, it will not vibrate at all, and will yield no sound ; and if stretched too much, it will be ruptured and become incapable of sound until readjusted or repaired. Mere stretching of the vocal bands, being practicable only within moderate limits, will only increase the pitch to a cer- tain extent ; and for the further extension of the reg- ister, another action of the muscles is requisite, which progressively shortens the free surfaces of the cords 100 THE THROAT AND THE VOICE. at the same time that they are rendered tense. If we examine the strings yielding the higher tones of a piano, we see that they are shorter and shorter as these tones rise in the scale; and we know that if the length of a string on the violin is practically shortened by placing a finger on it, stopping it, its tone rises in pitch, and that the shorter the string the acuter is the sound. Thus it is apparent that the processes in the human organ, stretching and shortening of the vocal bands, are the same physically as those employed in artificial musical instruments for raising the pitch. The pitch of a sound, as has been said, depends on the number of vibrations that the generator of the sound sets up in the air in a given time — the greater the number of vibrations per second, the higher the pitch ; and it is evident, on a moment's thought, that the shorter anything is, the more rapidly it can be moved, and that the tenser it is the more rapidly it can be moved. The physical laws that preside over the production of the human voice do not differ in any particular from the physical laws governing the production of sound from any other source. Quality. — It is a point of universal observation that of several notes of the same pitch and of equal intensity, one may be distinguished as coming from 9. harp, another from a violin, a third from a flute, a fourth from a human voice, and so on. A musical ear will distinguish one flute from another, one violin ACOUSTICS OF VOICE. 101 from another, one voice from another. Nay, more ; it will distinguish the peculiarity of different per- formers of equal skill upon the same identical instru- ment, the peculiar ring of the same voice as it is at its be-.t or otherwise. This difference is quality, or timbre. It is that characteristic by means of which we distin- guish the voices of our friends, whom we can thus recognize in the dark, or under a change of feature, or of dress after long separation. The physical cause of quality is difficult of comprehension. It has so important a bearing upon the cultivation of the voice, that an attempt must be made to explain it, even in a little popular volume like this. The quality of a tone depends, physically, upon the shape or com- posite conformation of the series of undulatory waves of sound which collectively produce it. Variation in the shapes of sound-waves of like pitch and intensity, or of varying pitch and intensity too, for that matter, depends upon the fact that all sounds are composite. Indeed, they are susceptible of being analyzed exper- imentally into their component factors, by shutting off the appreciation of portions of the series, on a principle analagous to that by which a ray of white light may be decomposed into the prismatic colors *f the spectrum. In any sound, as that from one note on the piano or violin, there is a fundamental or ground-tone, which determines the pitch, — that tone which strikes 9* 102 THE THROAT AND THE VOICE. our attention prominently. If we listen attentively, however, knowing beforehand what we are to try to detect, we find, commingling with it, other and feebler sounds which are higher in pitch,* and which bear to it certain simple relations of harmony, f Where the harmony of these additional tones — 1 ' upper-tones " or ' ' over-tones, ' ' as they are termed — is perfect, the effect is very agreeable ; and where there is an element of discord, the sound is less pleasant. If we listen to the striking of a bell, such as is used in a town-clock, for example, we shall be able to detect some of these sounds, especially as the ground-tone of the bell is fading. J But they exist in all other sounds likewise. They may readily be de- tected in the graver tones of the piano. It is the relations which these over-tones bear to the funda- mental tones, different in different instruments and voices, and dependent in great measure on the shape and character of the instrument and vocal apparatus, * Some are lower, also, and the two sets produce new com- binations of summation-tones and difference-tones ; but these are not alluded to in the text, for fear of rendering the elucidation too complex for most of the readers of a scientific primer. f These comprise the octave above, the 5th of that octave, the second octave, the major 3d of that octave, etc., being due to vibrations of 2, 3, 4, 5, etc., times as many as the fundamental tone. J A globe such as is placed over a gas-jet gives the same re- sults when struck. ACOUSTICS OF VOICE. I03 which decides the timbre. Each over-tone makes its own impress on the air, as well as the fundamental tone does ; and the shape or form of the vibration is made up of the combined effect. Take these over- tones away from the fundamental tone, or conceal them, as can be done by certain experiments, and the fundamental tone of every instrument has exactly the same quality. These over- tones are less prominent in large open organ-pipes than in any other instruments of music ; and that is the reason why their sounds are dull and unsatisfactory to the ear.* The organ-builder is aware of the fact that the sounds of large organ-pipes are unsatisfactory, though he may not be aware of the reason; and he has found out empirically — by expe- rimental investigation — that the defect can be rem- edied by adding a series of pipes of higher pitch, giving the harmonics, as they are termed. And these additional pipes are so arranged that they are all opened simultaneously with the fundamental pipe, so that they all sound together and enrich and reinforce the dull or pitch pipe. This arrangement is called a furniture. In fact, it furnishes the very upper-tones which are deficient in the tone of the large pipe ; and when the entire series are sounded together, the com- bined quality satisfies the ear. * An idea of what is meant can be obtained by blowing over a bottle. The over-tones are weak, and the pitch appears graver than it really is. 104 THE THROAT AND THE VOICE. Quality or timbre, then, results from the harmonious commixture of a fundamental or ground-tone and its over-tones and their combinations. The delicacy or shade of the clang of the tone varies with the number of these over-tones, their position in the musical scale, and their relative intensity as main- tained during the continuance of the tone. The clang is an accord, a sort of orchestral combination in miniature. The ground -tone of a tuning-fork, as the easiest example to be cited, may be isolated from its over- tones by causing it to vibrate over a rather wide bot- tle, resonance-tube, or box, the deepest tone of which corresponds in pitch to that of the fork. As the higher tones of the fork differ from the higher tones of the resonance tube, the ground- tone alone becomes intensified, and the over-tones of both are unheard. The mixture of the two ground- tones then results in a simple tone, to all intents and purposes. With this explanation, it is hoped that the reader can understand that any influence which interferes with the precision with which both vocal bands should be adjusted, in equal strain and tension, will disturb the harmony of the fundamental and upper- tones of either band, or both of them, and thus impair the quality of the voice. This precision of equable ad- justment is really greater in a well-trained voice than that acquired in playing upon any artificial instrument ACOUSTICS OF VOICE. I05 of music, and is the main reason of the superiority of execution acquired by a skilled vocalist over that of an instrumental performer. The automatic control of adjustment attained by Madame Mara, whose voice had a compass of three octaves, is said to have been such that she could effect as many as twenty-one hun- dred changes in pitch, 100 between each two notes of the 21 in her compass. The ordinary capacity of a voice in good culture is stated to be equal to about two hundred and fifty changes, ten or more for each tone of a compass of two octaves, or a little beyond. As each change in the tension of the vocal bands would not vary their length more than the one-fif- teen-hundredth part of an inch, we can faintly estimate the extreme delicacy of adjustment of tension of which the muscular apparatus of the vocal organ is suscep- tible ; a delicacy greatly in excess of that acquired in the trained fingers of the most skilled workman. In Madame Mara's case, the variations of tension be- tween the tones that she could produce would repre- sent a successive lengthening and shortening of the vibrating edges of her vocal bands in successive pro- portions of one-seventeen -thousandth of an inch, — a marvellous and almost inconceivable delicacy of precision of touch. The capabilities of well - cultivated phenomenal voices are almost incredible. Thus, among a number of instances alluded to by Mrs. Seiler in her excellent I06 THE THROAT AND THE VOICE. manual on " The Voice in Singing," it is related of Farinelli, among other things, that " on one occasion he competed with a trumpeter, who accompanied him in an aria. After both had several times dwelt on notes in which each sought to excel the other in power and duration, they prolonged a note with a double trill in thirds, which they continued until both seemed to be exhausted. At last the trumpeter gave up, entirely out of breath ; while Farinelli, without taking breath, prolonged the note with renewed volume of sound, trilling, and ending, finally, with the most difficult of roulades." Reach is the penetrant power of a sound over dis- tance and obstacles, such as other sounds, and is due to the purity of the tone, which, in its turn, is de- pendent on the accuracy with which it is produced. It is well known that at the great musical Peace Jubilee at Boston, in 1869, the pure tones of the voice of Madame Parepa-Rosa were distinguishable above the accompaniment of a chorus numbering nearly twelve thousand voices, and an orchestra of more than one thousand instruments; and this with audiences esti- mated at over 40,000 people. A voice, the tones of which are accurately poised, will travel a great dis- tance, independently of its intensity or loudness; and this accounts for the remarkable facility with which some people are heard, even with relatively feeble voices. ACOUSTICS OF VOICE. I07 The quality of the voice, due, as we have seen (page io4\ to the harmonious relation between the funda- mental tone of the vocal bands and its upper-tones or harmonics, is largely dependent upon the reso- nance of the cavities of the throat, mouth and nose, through which the expiratory current of air passes out, and the waves of sound likewise, after the vocal bands have been set into vibration. The vocal bands are the generators of tone ; but if the waves set up were not reinforced by the cavities above, the sound would be much like that of the reeds of mechanical toys. This is observed in individuals who have cut their throats in such a manner as to expose the vocal bands to direct inspection. The air, and the sound- waves escaping by the wound in these cases, have not that peculiar resonance imparted to them which they re- ceived when they passed through the natural passages ; and thus the peculiar or familiar vocal sound is not produced . When the tonsils are enlarged, as in quinsy, for example, this peculiar resonance is impaired, and the voice acquires a characteristic dull and disagree- able timbre or quality, which disappears when the parts resume their normal dimensions. So, too, when the nasal passages are occluded ; whether by design, accident, or disease. The influence of loss of teeth on the quality of the voice is well known, and the change is easily apparent when a set of false teeth is removed from the mouth, or used for the first time. 108 THE THROAT AND THE VOICE. It may be mentioned, here, that the prejudice, exist- ing to a certain extent among vocalists, against re- moving the exuberant portions of chronically enlarged tonsils, for fear of impairing the voice, is a chimerical one ; the fact being the reverse. Clipping off the excess of a permanently elongated uvula, likewise, far from injuring the voice, occasionally improves it, though there is usually no effect noticeable. The irri- tation excited by leaving it undipped, on the other hand, may impair the voice considerably. When the cavity resounds to the fundamental note of the vocal bands, or to one of its higher harmonics or over-tones, the sound is reinforced in a peculiar man- ner. The interior of the throat, mouth, and nose is to the vocal bands what the case of the violin is to its strings, the sounding-board of the piano to its strings, the body of a reed instrument to the reed, and so on. The sounds of the strings and reeds in unison with the sound yielded by striking the case, sounding-board, or pipe, or in unison with their over- tones, are those most strongly reinforced. So, too, with the voice. The sounds of the vocal bands in ac- cord with the sound proper to the shape of the reso- nant cavity of mouth and throat at the moment are those which are most reinforced ; and as the proper sound of the resonant cavity of the voice varies with its shape, so, for the time being, the sounds vary which it can reinforce at the moment. If a series of fillips ACOUSTICS OF VOICE. IO9 are given to the cheek with the finger, while the mouth is opened wider and wider, a different pitch will be given to each sound produced. The trick of imitating the flow of liquid from a bottle in this manner is a familiar instance. The pitch at any given moment of the experiment is the pitch of sound of the vocal bands which will be most reinforced by that position of the mouth. The motions of the mouth, tongue, palate, and throat vary the shape of the cavity, and its capacity of resonance, for different portions of the scale. This fact explains the impossibility of making certain sounds of certain pitch, unless the mouth and its contents are maintained in a suitable position attuned to that pitch. The influence of the pitch of a sound in exciting a silent instrument attuned to the same pitch is well known to musicians. The response of a glass gas- globe to certain tones of the voice, for example, or the rattling of a pane of glass from a similar cause, must be familiar to all. The waves of sound set up in the first instance are powerful enough to start the vibration of the responding body. The effect is mechanical altogether. It is similar to the effect of rhythmic vi- bration of a suspended bridge which may accumulate force enough to throw it down. Hence marching in time is prohibited upon suspension bridges. There is an old saying that a bridge of this kind could be de- stroyed by continuous fiddling on a note of the same 10 IIO THE THROAT AND THE VOICE. pitch as that of the bridge, from mere accumula- tion of force in the sonorous waves. Heavy bells are started by commencing with gentle impulses in rhyth- mic accord with the proper oscillation of the bell. To quote from an excellent novel (Middlemarch, Chap. XXX.): " How will you know the pitch of that great bell Too large for you to stir? Let but a flute Play 'neath the fine-mixed metal ! Listen close Till the right note flows forth, a silvery rill: Then shall the huge bell tremble — then the mass With myriad waves concurrent shall respond In low, soft unison." The shape of the resonant apparatus (cavities of the throat, mouth, and nasal passages), therefore, has great influence on the quality of the voice. Altera- tions of configuration by disease impair the voice, and alterations of shape by design modify it. The peculiar vowel sounds of spoken language are found to be due to the shape given to the resonant cavity in their emission. Thus, with the mouth wide open, the only sound that can be made by the vocal bands alone, is the vowel sound ah (or #, as in father) ; and as the mouth is gradually closed up more and more in front, it becomes possible to make the vowel sounds e (or a, as in rftzte), i (or e, as in m BENNETT ON NUTRITION. In Health and Disease. Second Edition, Re- vised and Enlarged BENNETT ON CONSUMPTION. Its Treatment by Hygiene, Climate and Medicine. Octavo 2.50 MADDEN'S HEALTH RESORTS OF EUROPE AND AFRICA, including Climatology, the Use of Mineral Waters, etc. New Edition 2.5c ACTON'S FUNCTIONS AND DISORDERS OF THE REPRODUCTIVE ORGANS in Childhood, Youth, Adult Age, and Advanced Life. Fifth Edition 2.50 WILSON'S GEORGE, M.D.> HAND-BOOK OF HYGIENE AND SANI- TARY SCIENCE. The Third Revised and Enlarged Edition, with Illus- trations 3.00 WILSON, DOMESTIC HYGIENE. 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