The Singing Voice Improved by Nasal Treatment

1893 Boston Medical and Surgical Journal  
edges. The child baa no laryngeal symptoms, ano simply requires active medicinal and local treatment If dyspnoea ensues early in the disease (within fortyeight hours), intubation should be performed. If the difficulty in breathing comes on late in the disease especially if the edges of the membrane are not welldefined, or where there ia great enlargement of the cervical glands, tracheotomy is indicated. Fifth Class. -A robust child in seemingly perfect health has a sharp attack of vomiting and
more » ... erhaps a chill. The child is extremely feverish, restless aud complains of slight sore throat. A slight redness on the fauces is all that ia noticed. On the second day there appears in the fauces membrane of a leathery consistency, grayish and sloughing, with marked enlargement of the cervical glanda. The child has become pale and pinched, the pulse is small, temperature quite high, and possibly there is diarrhoea. Tho nares are frequently filled with grayish membrane, and there is a sickening odor about the child. There is quickened respiration, slight Btridor, but there is only alight retraction of the epigastrium and intercostal spaces. We all know how powerless we are to meet this condition. It makes but very little difference whether tracheotomy or intubation are performed ; they can simply relievo temporarily. Of the two operations whore they are performed for euthanasia I prefer tracheotomy, for it enables the operator to more thoroughly clear the membrane from the trachea. Sixth Class. -(Edema of the glottis from steam or fire is per se a condition indicating intubation. The scarification of the epiglottis is, of course, attended by marked relief; but where the patieut is to be left for any length of time without skilled assistance intubation is a valuable resource. The lodgment of foreign bodies in the larynx or trachea indicates tracheotomy. Tho relief from dyspnoea which is necessitated by deep-seated cervical suppuration or growths pressing upon the larynx demand tracheotomy. Where pressure upon the recurrent laryngeal nerve exists, it is a question which operation is demanded. These six classes of cases are distinct in the writer's mind ; aud the division, while necessarily arbitrary, must be controlled by each individual caBe. Each patient with dyspnoea should be approached in an inquiring spirit as to the causation. It is absurd to do an intubation upon a child whose trachea and bronchi are lined with membrane. It is also unnecessary to perform a tracheotomy where the membrane simply covers one tonsil, and has slightly encroached upon the epiglottis. In a general way the younger the patient, intubation is more frequently indicated, from the fact that the larynx is relatively smaller under three years of age ; in a general way when the membrane is below tho vocal cords tracheotomy is indicated. We can undoubtedly nourish bettor after tracheotomy than in intubation, although by means of blancmange, ice-cream, bananas and cream, bread-pudding, pulp of orange, jellies, soft-boiled eggs, beef-pepotuoid jelly, and nutrient enemata, the nutrition of an intubod child can be well kept up. Children differ iu their adaptability to feeding after intubation. They will take sherry, champagne, taragona, milk-shake and brandy. After tracheotomy, on the other hand, there is occasionally difficulty in feeding, but, of course, iu each instance resort may be had to the use of a feeding tube. Indications for tracheotomy : dyspnoea, caused by pressure from new growths, enlarged glands, cellulitis of the neck, pressure on the recurrent laryngeal nerve (?) foreign bodies in tho larynx or trachea ; where new growths, fracturea of the larynx or trachea (?), or where membrane (either diphtheritic or fibrous) has extended well below the vocal cords. Indications for intubation : in the early stages of croupy children ; in the casea of diphtheria where the membrane ia principally in the faucea ; in caaes of dyspnoea in children dying of diphtheria, where the parents will not consent to a tracheotomy. It may be noted that tho writer has carefully avoided any reference to statistics in the two operations. The conditions under which the operations are, have been, and will bo performed are so essentially different that such a comparison is, from my point of view, useless. Each operation has its field, and that in the bands of the general practitioner. It, of course, is always belter if an operation can be performed by an expert. The classification which I have given may be modifled by further experience, but is submitted for criticism to the profession as a step in the direction of defining the indications for these two most valuable operations. Every general practitioner should bo able to perform both operations. They are each life-saving measures. They both require accurate anatomical knowledge intubation requiring greater manual training and dexterity than tracheotomy. They should be applied in selected cases. ._-Aural Surgeon, Maasachusetts Charitable Eye and Ear infirmary. As the quality of musical tones depends upon the presence or absence of partiale in those tones, so the quality of the singing voice is varied by tho character of the tones produced in the resonating chambers of the upper air-passages. The importance of having clear nasal chambers for the production of tho best tones is evident to all who are experienced in training or exercising the vocal organs. By the laryngologist and by the modern aurist this function of the noae ia daily recognized aa of supreme importance. By neither of these specialists, however, ¡8 the extent of the nervous relationship between the parts concerned iu phonation and those employed in respiration fully known. There are, and always will be, some things which cannot be found out, but this statement is substantiated daily in the practice of either specialist. The specialist of the heroic order, who sacrifices tissues aud structures regardless of functions, will certainly achieve something, if, in his efforts to remedy diseased conditions, he removes the offending structures altogether. For such an one, however, I have no suggestions. There is an intimate and deep connection between the nervous supply to the tissues composing the socalled posterior turbinate body and those of the vocal organ or larynx. It ia already known that this exists in the vaso-motor supply of sympathetic nerves through the cervical ganglia and their connections in some way with the thyroid gland whose function of regulating
doi:10.1056/nejm189304061281403 fatcat:zuwehklqvndupbn5n3275i53oa