Like the respiration, the alimentation ought to be watched by the singer. As much as possible during the process of digestion no violent or prolonged singing-exercise should be undertaken. Digestive troubles are often the cause of deterioration of the voice, either because the swelling and distension of the stomach by gas trammels the play of the diaphragm, and consequently that of the lungs, or because intestinal troubles bring on constipation or diarrhoea.

Very nutritive and very digestible food should be chosen for a singer, and a mixed alimentation should be employed. Among drinks preference should be given to wine and beer. Alcoholic liquors, Dr. Poyet thinks, should be absolutely forbidden. However, he advises a singer in the course of a fatiguing performance sometimes to moisten the throat with, and even to take a few mouthfuls of, cold water, to which has been added a little old cognac or "vin de coca"; but never, on any account, to take an iced drink just after singing.

Everybody who sings ought first to observe in the strictest manner the rules of general hygiene. Thanks to this hygiene it is possible completely to develop all the faculties of the larynx and to regulate the voice in such manner as to assure its regular operation. General hygiene, moreover, will permit the singer to preserve himself from the external influences which may bring about aphony or dysphony, that is, loss of voice or difficulty of voice.

A person who sings should always assume a natural attitude, since this aids the play of the respiratory organs. This play should be mixed, that is to say, costal and diaphragmatic. The respiration should be well regulated. The singer ought never to take too sudden inspirations, for he would thus run the risk of rapidly irritating the vocal cords. When it is a question of vocal exercises, one always should proceed from the simple to the complex, taking care not to prolong the exercises at the beginning. That is, the first singing-exercises should not be too prolonged. Moreover, in these first exercises the singer should never attempt to attain the extreme notes of his vocal range. The exercises should lie in the middle register.

Keen impressions, whether of joy or pain, are, in Dr. Poyet's opinion, bad for the voice. Great fear may cause a passing but instantaneous loss of voice. "Vox faucibus haesit." The emotion of singing in public, as everyone knows, prevents many artists from showing their full capacity. Only custom, and sometimes reasoning, can free them from "stage-fright."

People who sing, and who desire to preserve the integrity of their voice, should abstain from smoking. Because some singers—Faure, in particular—have had a brilliant career despite the inveterate use of tobacco, there is no reason that this example should be followed. Tobacco irritates the pharynx, reddens the vocal cords, and may cause heart troubles harmful to singing.

Pungent scents should be proscribed for singers. The odors of some flowers are for certain artists the cause of persistent hoarseness. Mme. Carvalho could not endure the scent of violets, which instantly caused her to lose her voice. Scents often determine a rapid congestion of the mucous membrane of the nose to such an extent that in certain persons they cause veritable attacks of asthma. Dr. Poyet also puts singers on their guard against scented toilet powder. "I knew," he says, "a great singer who was obliged to renounce the use of the toilet powder called 'a la Marechale.'"

In ending the interview, he calls attention to the fact that the larynx, while very delicate, is an extremely resistant organ, since it can face fatigues that no other human organ could support; but because it shows signs of fatigue only by hoarseness, is no reason to call on it for too prolonged efforts. "To work two hours a day, either in study or in singing, seems to me a maximum that should not be overstepped by a person careful of his vocal health."

Another distinguished foreign specialist is Dr. N. J. Poock van Baggen, of The Hague, Holland, who has contributed to the Medical Record a series of articles on throat diseases caused by misuse of the voice, and their cure.[A]

[Footnote A: These articles have been reprinted in four slim but interesting pamphlets published by William Wood & Co., New York.]

Clergyman's sore throat, as Dr. Van Baggen says, is a disease known to every throat specialist. "It is produced by misuse of the voice, and the same disease, often in more aggravated form, is produced in the singer and by the same cause. The patient, after singing, will experience a dry and hot feeling in the pharynx and larynx, irritation, and a frequent cough. Examination of the patient discloses catarrh of the pharynx and of the larynx; congested and swollen mucous membrane; pillars of the fauces swollen and unduly developed; all these symptoms accompanied by paresis of the vocal cords, which are red or yellow and do not approximate well. To this paresis of the cords is united a paresis of certain muscles of the larynx; to which is added, in serious cases, a swelling of the aryepiglottic ligament."

That this disorder is not organic, but functional—not caused by enlarged tonsils, adenoids, nasal polypus or malformation of the tongue, but by misuse of the voice—can be proved by the beneficial effect produced upon the organs by complete rest from singing; the symptoms sometimes disappearing entirely, only to reappear, however, when singing is resumed—further proof that misuse of the voice is at the root of the evil.

"Dividing the muscles into those used in breathing, in articulation of consonants and in vowel enunciation, the physician will find that in his patient there is no proper coordination between these three groups of muscles—that through faulty respiration and articulation the respiratory and articular muscles fail to support sufficiently the vocal muscles, with the result that the vibration of the vocal cords is weakened. One fault begets another. The faulty use of the respiratory muscles directs the vibrating air-column to the soft palate, where the tone is so smothered that the singer has to over-exert himself to be heard, instead of directing it against the hard palate, where it would gain vibrance and carrying quality."

The faulty use of the muscles of articulation is disclosed when the back of the tongue rises like a flabby partition between the opening of the mouth and the pharynx, the consonants being formed thereby far back in the mouth, instead of forward with the tip or middle of the tongue leaning against the hard palate. The articulation is, in consequence, thick and dull. The vocal muscles are contracted to an unnatural degree, and every vocal tone is accompanied by an audible shock or spasm of the glottis. All this adds to the exertion required of the singer to make himself heard, an exertion and strain which eventually result in the symptoms that have been described, and which most singers believe due to colds and other troubles, whereas they are the result of the singer's own misuse of his voice.

I have said that correct breathing is one of the fundamentals of correct voice-production. No wonder, therefore, that incorrect breathing is one of the most potent factors in the misuse of the voice that sends the singer as a patient to the physician. I have stated that there are three kinds of breathing—clavicular, costal and diaphragmatic; and these have been described. It has also been pointed out that the teacher who instructs in one kind of breathing to the exclusion of the other two makes a serious mistake. For in correct breathing, all three are coordinated. Usually it is spoken of as mixed costal and diaphragmatic. In truth, however, it is mixed costal, diaphragmatic and clavicular; but, aside from the awkwardness of combining all three terms in characterizing correct breathing, the clavicles play a less important part in it than the diaphragm and the ribs. In their relative importance to correct breathing the diaphragm comes first, the ribs next and then the clavicles. I feel certain that Dr. Poyet means the coordination of the three when he speaks of mixed costal and diaphragmatic breathing, and that Dr. Van Baggen also means this when he speaks of diaphragmatic breathing. In fact, his description of diaphragmatic breathing involves the ribs; and if he omits mention of the clavicles, this may be explained by the slight part they play in correct breathing, merely topping off, as it were, the action of diaphragm and ribs.

Dr. Van Baggen, in the breathing-exercises which he describes as beneficial for restoring a voice impaired by misuse, lays emphasis on the control of expiration and on the brief retention of the breath before exhaling it. In his first exercise the abdomen is pushed forward and contracted, the idea of breathing being excluded in order to concentrate attention upon making the movements correctly.

The second exercise consists of these same movements, but now combined with inspiration and expiration through the nostrils. When first started, the exercises are limited to a few minutes four or five times a day. When this method of breathing has become natural to the patient, there is added the brief retention of the breath and expiration under control—that is, gradual expiration. This constitutes the third exercise.

In this it is recommended to inhale slowly through the mouth, which should be in position to pronounce f, that is, not too open. Hold the breath while mentally counting three. Exhale, pronouncing a prolonged s and finishing on t. The pronunciation of f during inhalation and of s and t during exhalation is advised in order to provide evidence that inhalation and exhalation are carried out evenly and without shaking or breaks.

Built upon this is the exercise for teaching the vocalist to inhale quickly, hold his breath a brief space, and exhale as slowly as possible, as must be done in singing. The inspiration now is through the nostrils; the pause is not quite so long, but the expiration on s and t is longer—say as mentally counting 40 would compare with counting 10.

Whoever has read carefully the chapters on breathing in this book will have discovered by this time that the breathing-exercises just described lead up to the principles of artistic breathing set forth in those chapters; and that whoever has read them and will carry them out never will require breathing-exercises to correct misuse of the voice from that source, because his breathing will be absolutely correct. The same is true of the exercises given by Dr. Van Baggen to make the breathing-muscles cooperate with the articulation and vocal muscles. Nevertheless, since there are people who do not read carefully, or who go along in the same old faulty way until brought up suddenly by the dire effects of misusing the voice, I may add that Dr. Van Baggen's exercises for articulation will be found in detail in the pamphlets mentioned.

When a singer who is suffering from misuse of the voice comes to a specialist for treatment, the specialist must for the moment become a singing-teacher and instruct the singer in the artistic coordination of breathing, articulation and vocal muscles. The patient, having gained proper breath-control and having had impressed upon him the importance of forward placement and of the normal position of the tongue to correct articulation of consonants, is ready for correction of the faulty action of the vocal cords. This faulty action is due chiefly to faulty attack—a faulty coup de glotte—manifest mainly on initial vowels in an audible stroke, shock or check and in the emission of unvocalized breath. This latter is the so-called spiritus asper, because the emission of unvocalized breath which precedes phonation gives an aspirated or h sound, so that, instead of ah, we hear haa. The spiritus asper is caused by a too slow contraction of the vocal cords and their too gradual approach for phonation.

In the audible shock of the glottis (sometimes called the "check glottid") the vocal cords are pressed together and the retained breath causes a shock or explosion. Dr. Van Baggen says that the vowel which is thus formed might be called an articulated vowel, which accurately describes the effect, the vowel being enunciated with the circumstance of the articulated consonant instead of with the ease of the phonated vowel.

With a normal attack—the spiritus lenis in contradistinction to the spiritus asper—the glottis is in position for phonation at the moment breath passes through it. No unvocalized breath precedes it and no explosion follows it. The vowel-attack is clear, precise and distinct. Not only is the voice-emission pure, but there is no needless fatigue of voice, because all superfluous movement of the glottis is avoided.

The "check glottid" or glottic shock, on the other hand, involves an undue effort of the vocal muscles, and the compression of the vocal cords causes irritation. The audible shock of the glottis cannot be avoided when it is necessary to accentuate a word beginning with an initial vowel. Constantly used, however, it is part of the misuse of the voice. Dr. Van Baggen recommends, as a method of correcting the too frequent use of the audible shock, that when a word beginning with an initial vowel appears in the middle of a phrase, this word should be united to the preceding one, somewhat after the manner (but more lightly) of the French verbal "liaison," in which the final consonant of a word becomes the initial consonant of the following word beginning with a vowel. For example in "vous avez," the s of "vous" is drawn over to and pronounced with the a of "avez," the effect being "vou-z-avez." If the phrase that is to be sung commences with a word beginning with an initial vowel, care must be taken to employ the normal coup de glotte, or spiritus lenis.

Although I have devoted two chapters to the registers of the voice, I shall also quote Dr. Van Baggen on the faulty use of these and the physical ills that result therefrom, since there are but few singers who do not know the difficulties which the registers of the voice offer; and many who spoil their voices forever by the misuse of those registers. Generally, the misuse consists in the exaggeration of a lower register at the expense of the higher; that is, in order to produce "big tone," forcing a register up instead of bringing the higher one down. Especially with dramatic singers, this fault is frequent. There is no voice, however strong it may be, which can endure this overstraining of the registers, and sooner or later the singer must experience the disastrous results of his or her fault—hoarseness, fatigue, roughness, and impureness in singing, and last, but not least, premature wearing out of the vocal organs.

The exaggeration of the registers is generally united with faulty breathing, which first of all must be corrected. Only after good results have been obtained with regard to breath practice, can exercises for the correction of the use of the registers be made with success.

When the fault consists in the exaggeration of the low register, the singing in this register must be avoided for some time; when both the low and middle registers have been used beyond their limit, exercises can at first be sung only in the high register.

The pupil, while practising (in the first case in the middle and high register, in the second only in the high register), must limit himself to a few tones, singing always downwards and very softly. The tones will be weak, husky, and often impure in the beginning; by and by, however, they will improve. When those few tones are pure and clear, the pupil may extend the exercises downwards, always singing pianissimo and avoiding the lower register. The high and middle registers, or only the high register, must be extended downwards as far as possible. Only after all the tones, sung as indicated, are clear and pure and have gained sufficiently in strength, may the low or the low and middle registers be used again, but even then not more than is strictly necessary.

The extending downwards of a higher register is also an excellent help in smoothing out the break in the voice at the passage from one register to the other. This extending downwards of the higher registers always can be done without any danger to the voice. The "timbre" of the voice will even gain considerably in brilliancy and fullness by exercising in this way.

Closely united to the stretching and relaxing of the vocal ligaments is the moving up and down of the larynx. Many believe that the larynx must be kept as motionless as possible and in a low position. The large number of voices which have been spoilt by this unnatural fixed position of the voice-box are a manifest proof of the evil of this way of operating, against which every singer must be warned.

The larynx must be completely free in its movement, its positions varying according to each tone and to the pronunciation of each vowel. We can easily follow the movement of the larynx by laying the finger on the prominence in the throat formed by the junction of the two wings of the thyroid cartilage, commonly called "Adam's apple." When pronouncing successively "oo, ow, oh, ah, eh, ay, ee," we shall notice that the voice-box rises and inclines slightly backwards; and, while at "oo" its position is lowest, it is highest at "ee."

Also when singing upwards we feel the larynx going up, while the inclination backwards can be observed even better than when pronouncing the vowels. Especially when singing a high tone after a low one we can feel how considerably the position of the larynx changes, and it is clear that every obstruction in its movement hinders normal voice-production.

When examining the patient the physician should observe the action of the larynx and feel if there are no spasmodic movements and if the flexibility is satisfactory. The action of the larynx can be exercised and improved by singing seconds, thirds, etc. The keynote always may be sung on oo; the second, third, etc., on ee.



CHAPTER XI

MORE VOCAL HYGIENE

Vocal hygiene is a specific system based upon well-regulated principles for a specific purpose and applying to a specific class in the family of nations. But there is the difference that, whereas the laws governing the general health of the community have legislative sanction and are strenuously enforced by official authority, the laws of vocal hygiene bear no seal of state or municipal power, save in the broadly general sense indicated, but rely for enforcement upon the individual who is most nearly involved, and who must pay swift penalty for any infringement, however slight and however innocently committed.

While this is a truism, yet it cannot be too strongly emphasized nor too often reiterated; for with all their notable precautions, singers are often taken unawares and fall when most they desire to stand. Why? They are simply paying the penalty of a broken law, and it does not help them with a disappointed club committee, or in framing a telegram of regret, accompanied by a physician's certificate, to say that they have erred through ignorance. The aphorism that ignorance of the law is no excuse is just as valid in the court of the hygienic judge as in any common law court between the oceans.

It is the prevalent practice to use the physician as the court of last resort. But it would be vastly better and far more sensible if the singer could be made to act with swift authority as an agent of prevention over the weaknesses of his or her own nature. The subject, thereby, would be vastly simplified. It would not be so profitable to the specialist; but I can vouch for it that he would not only forgive, but praise the discretion of his patient, and lend all possible aid to educate him along a new scientific path—that of prevention. Not a new path, either, for in its last analysis what is hygiene but the science of prevention? Preservation of health means the prevention of disease. This answers the cry of every artist's heart, especially that of the vocal artist, teacher and student: How can I prevent disease and weakness of the vocal machinery? Briefly and plainly: How can I keep well?

In this important matter of vocal hygiene a prominent part is played by the mucous membrane. What is the mucous membrane? It is the membrane which in this special sense covers or lines the respiratory tract from the very outlet of the nose to the terminal bronchi; in fact, to the very air-cells of the lungs themselves. Its function is that of supplying the involved passages with moisture, and it secretes a glairy or watery substance called mucus. Now, mark this well. The entire area of the respiratory tract, from the nose to the bifurcation of the bronchi, it is said on good authority equals one square foot of exposed surface, and the amount of secretion per day equals about sixteen fluid ounces, or a pint, which must be secreted by a person in the normal condition of health. It also has the power of absorption of certain diverse substances, such as alkaloids, fluids of all kinds, hence the danger of alcoholic indulgence to the singer. Alcohol coagulates. It causes the epithelium to contract and to become so disintegrated as to be utterly incapable of performing its functions until such time as the underlying tissue shall have created new cells to take the place of those which have been destroyed. To illustrate briefly the varied functions of this membrane: Whereas alcoholic stimulant destroys it, another powerful drug, cocaine, is absorbed, often to such an extent that the patient is prostrated by the poison introduced into the system by this means, and yet without impairing the membrane to any extent except through persistent indulgence.

The mucous membrane is the telltale of conditions. If a man's tongue is coated with detritus—which, anglicized, is nothing more than the products of decomposition, a coating formed by over-stimulation of the glands lying at the base of the tongue—and this has been previously superinduced by a disordered stomach, we know that the cause is indigestion. If the follicles in the back part of the pharynx or throat appear distended, and even the tonsils themselves are affected—and these again are part and parcel of this same mucous membrane—we can say this is due to one of several causes: either to a reflex condition from the stomach, due to over-eating or over-indulgence of some other equally deleterious sort, or to inactivity of the bowels, or to suppressed perspiration, or to improper or undue use of the vocal organs.

Again, let us glance for a moment at what a good many people deem a superfluous appendage, the uvula. A patient comes into my office with a badly swollen uvula. The upper tones of the voice are gone. He has no complicating quinsy, and in that case I can say without hesitation that he has outrageously misused his voice. I ask him where he was the previous afternoon, and find he was jubilantly "rooting" for the New York Giants in an exciting baseball contest. Now, it in nowise lessens the force of my illustration that this patient was not a singer and did not acquire, if you please, his swollen uvula in orthodox fashion. It is only a short time ago that a man came to me with a pronounced case of oedematous uvula, or swollen soft palate. He announced to me that he was no longer a tenor singer, although he had sung tenor for three years; that lately he had been persuaded that his voice was baritone; and, indeed, he had been singing, up to the time of coming to me, a baritone part in opera. It was this which brought him under my hand as a patient. He had changed his teacher, who had insisted that he was a tenor, within two months, and since that time had been under the instruction of the master who had declared that he was a baritone. I had known him for some time, and the only perceptible change to me in the voice was a decided tendency to cover and sombre the upper tones. Upon examination, the only thing abnormal was the condition of the soft palate and the surrounding tissue extending down both pharyngeal pillars. The soft palate was swollen to nearly three times its original size and hung down upon the tongue. The symptoms he complained of were inability to sing above F, and all high tones were husky. The production of the upper tones was accompanied with considerable pain. An emollient gargle was given and, soon after, astringent applications; but in vain. It was necessary three weeks afterward to amputate the uvula. Within three weeks more the operation was demonstrated a success in that the upper tones were fully restored; but I leave the question with the teachers whether this operation would have been necessary had not this young tenor been drawn aside on the purely theoretical issue as to whether he was not a baritone instead.

In the case of one of New York's most experienced singers, it required two years of persistent effort on the part of both patient and physician to overcome the habits of a lifetime. The case is of general importance for the reason that the habits he had formed are more or less common to all of us, though perhaps not to such an aggravated degree. He was an inveterate smoker and a confirmed coffee drinker. These habits reflected themselves upon the poor, defenceless mucous membrane, whose function was perverted as shown in the constantly congested appearance of the respiratory tract. I have seen this artist with congested vocal cords rehearse an oratorio in the afternoon at a public rehearsal and sing the same work in the evening at the regular concert performance, when, to use his own words, "I feel as if every note will be my last. I have no grip on my voice." It was a clear case of indomitable will and sheer physical strength carrying the singer over obstacles that even to my mind seemed well-nigh insurmountable. A cure was effected in this obstinate case simply by insisting upon observance of hygienic law. There is no better instance of efficacy of vocal hygiene than in the case of this man. The gradual reassertion of nature, as indicated by the clearing up of the inflamed mucous membrane of the nose, the thickened condition of the pharynx and the chronically congested cords, was an all-sufficient reward for anxious thought spent upon an important subject. You may ask what was the remedy in this case. It was simply advice given and heeded, together with needed incidental treatment. I cut off his coffee and cigars, not immediately but gradually. He had sufficient force of character to aid me by heeding the counsel. The result was a diminution of secretion of the mucous membrane and a return to normal conditions.

Right here there is another phase of the situation to which I desire to call particular attention, not alone because of its vital importance to the singer, but also because of the danger to the unschooled student of neglect of what we ordinarily term a cold in the head in its first stages. By the first stage of the cold I mean that condition which obtains before the stage of secretion is arrived at, where the mucous membrane is being congested, where it is almost impossible to distinguish what is the highest point of normal stimulation under which the membrane may be expected to do its best work. This point may be aptly illustrated by comparison with a singer under perfectly normal conditions. Then, as is well known, it is the mental impulse that stimulates nerve, muscle and membrane to do their best work. But in the other condition this result is attained without the mental impulse, as we have the mucous membrane and the blood-vessels carried to a temporary climax of effectiveness due to the systemic disturbance. By this I wish to make clear my point, that artists have often noticed an unusual brilliancy of voice under circumstances which were all the more mysterious because of the sudden collapse of the vocal organ under stress of use, and the alarming suddenness of the catastrophe which overtakes them and leaves them totally incapacitated. Then they say, "I have a cold;" whereas it requires from twenty-four to thirty-six hours for the fulfilment of these conditions. They should have reached this sensible conclusion just two days before. I take issue with those physicians who urge that certain exercises should be given to the artist when the vocal cords are in a state of congestion, for the reason that it requires a period of from ten to fourteen days for the complete relief of this inflammation. During that period, the blood-vessels are fully employed absorbing the products of the inflammation, and any attempt to interfere with this necessary process of nature can end only in disaster or in a prolongation of the difficulty. This is the law of pathology, unalterable and not to be evaded. Physicians at times resort to soothing and astringent applications in an emergency, to carry the artist through a performance; but the lack of edge to the voice for weeks following is an all-sufficient indication of the revenge nature takes for this trespass upon her domain.

The cause of the sudden disaster to the voice which I have described is not far to seek. The cold has caused over-stimulation of the mucous membrane of the larynx, and a consequent loss of voice. This cold begins in the head, and on the third day, perhaps before, it has attacked the larynx. Why? Because the mucous membrane has become so swollen that the nasal passages are obstructed and the mucous membrane of the larynx has to perform a double function, that of heating the air as it is brought to the lungs in the process of respiration, as well as carrying out its own obligation to the scheme of nature. By a strange coincidence, this membrane of the larynx is supplied with sensation by the same nerve that conveys motion to one of its tensor muscles. This is the superior laryngeal nerve. By the thickening of the mucous membrane, all the intrinsic muscles of the larynx are interfered with, and, consequently, total extinction of the voice follows swiftly upon excessive inflammation. There you have it in a nutshell. The mucous membrane of the larynx and the bronchial tubes, to enlarge upon its duty for a moment, is endowed with very fine, hair-like processes called cilia, whose action is to waft secretions from the interior of the lungs outward. Hence the danger of promiscuous spraying with all sorts of everyday nostrums, or of anything which may interfere with the activity of these minute bodies or the media in which they operate.

This intimate relation of nerve and muscle and mucous membrane is best illustrated by the sneeze. The explanation of this is an over-stimulation of a part of the mucous membrane of the nose called the Schneiderian membrane. If we analyze the sneeze, we find that it simply consists of a spasm of the pharynx, larynx and diaphragm through the reflex action of this membrane. The over-stimulation of the membrane, in the case of the singer especially, may generally be set down to an incipient cold; but any inflammation of this part of the mucous membrane of the nose alone may give rise in reflex action to vocal disability.

There are some peculiarly interesting isolated instances of disturbance of the vocal mechanism, which are unique in that, while apparently harmless and uninteresting from the standpoint of even the specialist, they have, on occasions, developed most alarming influence over the voice. They have no precedent; experience alone can determine their influence for evil. They are not a matter of record, they are simply etudes, interesting studies in the bypaths of vocal hygiene, and must be dealt with as they appear. An exceptional example was one wherein the voice of the singer was perfectly even except as to the G sharp in the medium, which was entirely wanting—as though it had never existed.

The singer in question came to me after an Easter rehearsal. I tried her voice with the E-scale before using the laryngeal mirror, and to my utter surprise found the medium G sharp missing, while all the rest of her scale was perfect even to the G sharp above. This experiment was tried repeatedly with the vowels a, e, i, o, and u, and with consonants prefixed, but invariably with the same result. Upon examination, no deviation from the normal anatomy was found, save in the left anterior nostril. Here a sharp spur of bone projected from the septum into the turbinated tissue. This condition had remained in this singer for four years, according to my previous observation, without causing her any inconvenience. A similar condition was seen by me in the case of Mr. Santley, the famous English baritone, when I made an examination, and he declared that he was not aware of its producing even discomfort—such a capital illustration of the necessity for non-interference until the laws of reflexes are disturbed, that I cannot refrain from alluding to it.

In my patient, however, in addition to her nasal trouble, I found an enlarged follicle about the size of a pea back of the posterior pillar of the pharynx, at the junction of posterior pillar and pharynx. This follicle was removed by a simple process, when, as if by magic, the G sharp responded and has since remained unimpaired. My explanation of this case is simply one of reflex action; that is, by a singular complication this follicle fell in the track of the glosso-pharyngeal, the pharyngeal-plexus, the external-laryngeal and the recurrent laryngeal nerves, which, as it were, sounded the alarm for retreat of the phonating muscles whose harmonious action was necessary to produce the medium G sharp.

There are numerous instances of affections of the vocal cords that might be cited, all superinduced by straining the voice from various causes, but especially by using the voice under improper physical conditions or of singing in rooms filled with foul atmosphere.



CHAPTER XII

NODES AND THEIR CURE

I use the scale of E as a means of revealing to the ear points wherein the voice shows signs of failure. I use this scale because within it lie all the principal resonances involved in voice-production. By this I mean that somewhere between the interval G# to C# an oral resonance is developed in the majority of voices. This seems to be coincident with the action of the lips, the tongue and the soft palate, and the other muscles that go to increase or to decrease the size of the oral cavity. From C# to E above middle C the principal changes occur which contribute to the development of the nasal resonance. Some rare voices, however, continue their oral resonance as high as F# before changing. It has occurred to me so often in the course of my practice that a peculiarly apt reason exists for making E the foundation-note of the test-scale employed in the operating room, that I lay particular stress upon it. It has seemed the most easeful note for the patient to sound, whatever his vocal condition, and I have been tempted to call it the "nature tone," because it may be said to sing itself. At least, it can be sounded with naturally open throat and without calling into perceptible use the multiplied enginery of muscular forces which are required for the formation of the higher tones of the scale.

Consider for a moment this enginery of muscular forces at the command of the singer, and which his intelligent and ripe knowledge must guide. The muscles used in voice-production may be divided as to action and location into ten groups. In these ten groups there are one hundred and seventeen individual muscles. Three of these act alone. One hundred and fourteen act in pairs, making fifty-seven pairs. Again, these muscles are controlled by nerves, some of which act alone and others in combination. In one instance, a single nerve presides over two large groups of muscles. Then, in still another instance, two separate nerves are required to control the action of one small group—the palate group. The distribution is as follows: Single muscles, 3; muscles in pairs, 114; groups of muscles, 10; nerves acting alone, 17; nerves acting with others (eight groups), 88.

By taking these figures and increasing them in arithmetical progression, it is possible to calculate what a multiplicity of nerve and muscle effort is involved in a sneeze. Everything that appertains to the vocal mechanism is spasmodically involved at once, and the enormous sum total of muscle and nerve movement, individualized, is 465,120. This shows how absurd is the theory of conscious control of the machinery of voice-production. As I have frequently pointed out, the adjustments of the vocal tract to the tone to be produced are responses to the will, physical reflexes of the tones which the singer hears mentally; so that voice is mental audition converted by responsive physical adjustment into audible tone.

Teachers and singers are aware that wrong methods of tone-production result in nodes on the vocal cords. The node, therefore, is one of the most familiar forms of vocal catastrophe.

In its simplest form the node is a superficial swelling on the edge of a vocal cord, sometimes appearing on one and then on the other and ofttimes on both, dependent entirely upon causation. For instance, the cause might be simply a severe spell of coughing, and this, of course, might befall a person who was not a singer at all. It has been known to occur to animals. The node is, in fact, an oedema or dropsy, a swelling from effusion of watery fluid in the cellular tissue beneath the skin or mucous membrane. This oedema appears on the edge of the vocal cord, as a slight tumor or swelling filled with water. If aggravated by continued use of the voice, it may develop and become exceedingly dangerous, by extending inward to the real tissue of the cord itself. The membrane is thickened by the watery secretion, and much the same thing happens as in the case of a pinching bruise or a blistering burn. Nature's cure for this state of things is by absorption of the fluid contents and a consequent diminution in the size of the node until finally a normal condition of the cord is restored and the voice returns in all its fullness. In the formation of the node it is worth remarking that the coughing node may appear at any point on the cords. It shows first at one point and then at another. The node caused by vocal weakness or abuse of the natural powers, however, displays an exasperating, and sometimes puzzling, affinity for particular portions of the vocal cords. It is generally found protruding from the anterior and middle third on one or the other side of the glottic opening, or on both, in chronic cases. The other nodes may be found at any place on the cord. In fact, it frequently happens that the coughing node, and what for convenience may be styled the "vocal node," are simultaneously present, each to be distinguished by its well-defined location, although produced by totally different causes.

There are cogent reasons for the affinity of the vocal node for certain fixed positions on the cords. They can be explained by the trick of the vibrating string and bit of paper. If the paper is laid upon the string at a certain point, it will be flirted away; while at another chosen point it will slip unagitated to the floor. Inasmuch as the vocal cords are subject to the same laws of vibration, the lesson drawn from the string and the bit of paper applies to them, the node taking the place of the paper. Note, however, the difference. The string is single, and there is no attrition. If there were two strings, the bit of paper might be caught and twisted in the miniature whirlwind of opposing vibrations. But the vocal cords are wedded in phonation, and by their attrition the node is formed. Very often strands of tough mucus appear spanning the chink or slit between the cords when they are drawn up in tone-production. The presence of these bands of mucus is an assured precursor of the node. Often they indicate the existence of a node which is hardly perceptible through the laryngeal mirror. The mucus is nature's effort to relieve the attrition, and so to ease the inflammation at the point of difficulty. The obstinacy with which the nodes caused by vocal disaster thus form in the anterior and middle third of the cords may be explained as owing to the presence in the vocal cords of a point which may be called the centre of resistance for the intrinsic muscles, and indicates that they are caused, in the majority of cases, by undue and improper muscular effort in tone-production. Consequently, the necessity for the most painstaking care on the singer's part to avoid singing under unfavorable conditions. A trifling over-exertion at an afternoon rehearsal in a cold hall, too much talking on the train, a bad night's rest in a sleeper berth, all may conspire to weaken the voice for the time and lay it open to attack. Under such circumstances, particularly, it is necessary for the vocalist to exercise large discretion and to aim for a conservative middle course, and especially so in a preliminary rehearsal.

Another cause of the node is a lack of cordal coordination. Were the human form perfect, both cords would be equally strong. As a matter of fact, in my own experience, I have found that the major portion of nodal formations appear on the left cord, indicating that it is the weaker. The fact that one cord is slightly lax while the other vibrates at full tension along its face causes trouble. Another source of difficulty is subglottic, owing to inflammation of the mucous membrane in the trachea, which extends upward and involves the cords. The inflammation, passing upward, may easily affect the voice. Such inflammation is discovered by a tickling sensation in the trachea, causing a dry, harsh cough about the third day after a cold has found lodgment "in the head," as the phrase goes.

The node has been the cause of vocal catastrophe from opera houses to concert halls, yet a reasonable amount of precaution will minimize the chances of attack. Singing in a room where there is smoking is a prolific source of node formation. Breathing dust-laden air, continued effort to carry on conversation on the cars or amid street noises, are fruitful causes of vocal disorder.

The mucous membrane of the vocal cords obeys natural laws in restoration. A node may disappear in three days, if not teased with effort. More often, however, it requires from seven to ten days for it to disappear without treatment. If the singer foolishly persists in using the voice, the node will extend into the cord tissues, and result in a most unfortunate condition. The cord loses its elasticity. It refuses to respond. It will neither act nor will it consent to be acted upon. It is in a state of collapse, and the voice for singing purposes has gone, never to return.

Let me illustrate what rest will do for a node. A singer came to me with a node of three months' standing, on the left cord. She had been singing with her teacher in the regular course of her lessons at an unfortunate time, when, too, she was vocally weak. In singing up the scale, and at the C (as nearly as she could remember), she became hoarse, and, as she described it to me, "the voice had a hole in it." Throughout the remainder of the lesson, unless she exercised great care, she would always break at the point named. Her nose seemed stuffy, and she compared her nose and throat to a cornet lined with velvet. After the break, and for the remainder of the lesson, her voice was husky. Her teacher advised her to seek expert advice. Previously, the voice had been clear, though she was a novice in singing. After remaining away from her lessons for two weeks or more and finding that recovery was not rapid, she came to me. The node could be plainly seen on the left cord. Before examining her, I tried the voice with the E scale, wrote down the diagnosis and handed it to her to read. My written conclusions were verified with the laryngeal mirror. I found no trouble except with the left vocal cord, the node being in the anterior middle third. On the summit of the node the mucous membrane appeared very red, budded, and almost warty. I cocainized the cord, and immediately applied pure alum in solution to the node itself, but to no purpose. This treatment was continued for two weeks, without any perceptible change for the better. Then I ordered the patient to remain quietly in a closed room; she was to see no one, she was not to talk at all, she was not to laugh. As harassing as was the experience, she faithfully observed the directions, and on the fourth day every vestige of redness had disappeared. Only a slight elevation remained on the cord where the node had been. The treatment was continued three days longer. At the expiration of that period no trace of the node could be seen. Now no one would suspect that a node had once affected her voice. Experiences like this indicate why I counsel against use of the voice under diseased conditions.

As a general proposition, all throat spraying is dangerous. A New York singer, suffering while on a concert-tour from a case of sub-acute laryngitis, sought advice from a physician who honestly tried to aid him, but shot wide of the mark through injudicious use of a spray, in which he used menthol and eucalyptus, a combination much affected by a certain well-meaning class, and which for a time gives to the throat a delightful sense of coolness. The singer became afflicted with a violent, explosive cough, which caused the formation of a node. He gave up singing, losing nearly $1,000 in engagements. He went to his own room and to bed. He remained in his room for three weeks. The temperature was carefully watched. He did not expose himself in the slightest degree, nor did he use his voice. The result was a perfect cure.

Another case is that of a church singer whose throat during a religious festival service became filled with the smoke of incense. The irritation caused a troublesome cough, and she lost her voice entirely above the top F#. It required fourteen days to effect a cure. She stopped singing for six days and then sang in church, with the result that the difficulty returned, augmented. She sensibly rested the succeeding week and perfected a cure. Rest did far more than any amount of medicine, however it might have been administered.

Paralysis of the vocal cords constitutes a second form of vocal catastrophe. It should need no definition. In reality, however, the paralysis does not lie in the cords themselves, but in the leading muscles that control in phonation. There are many forms of this particular example of vocal catastrophe, though I am now dealing only with those which are liable to attack a singer, and which are most frequent in my own experience.

With the singer one form is common, viz.: paralysis of the left adductor muscles, or those which inspire the arytenoid cartilage in drawing the left vocal cord forward to meet its fellow for the production of tone. No one can ever forget the sight presented by the left cord in its helpless condition: the arytenoid, tipped with its cartilage of Santorini, extending far over the median line of the glottis and drawing after it the right vocal cord in a vain endeavor to put it in position where it can aid its injured mate.

The paralysis may, of course, occur on both sides, and then it is that, on the side which is most exercised, there is felt a sense of distress, of pain and sudden fatigue. This condition generally arises from prolonged singing, and many of the cases I have seen have been the result of overwork during Easter and Christmas; and all of the cases which have come under my observation were associated with rheumatic constitutions. Fortunately for these singers, when the conditions were made known to them, they were in a position, or at least were perfectly willing, to rest, because of the fear that a knowledge of their condition instilled. Indeed, the situation is always one to cause serious alarm. The beautiful symmetry of the arytenoids is impaired and the agility of the voice is destroyed. If the singer persists in his vocation, total disability results. As a rule, complete rest is enforced by reason of inability to sing at all. If the voice is continued in use, the affection becomes permanent and there is one more case of irremediable vocal collapse. The remedy is rest, and that, too, before the disease has passed recoverable ground. If the singer experiences pain on either side of the thyroid cartilage, or on either side of the Adam's apple, then let him by all means have a care, for those are the symptoms of this peculiarly menacing form of paralysis. In the voice a palpable hoarseness is manifest. The voice becomes "fuzzy" throughout its entire compass. A pronounced disability to make a crescendo arises, and when the effort is made (for in the described circumstances use of the voice is attended with undue effort), the tone becomes coarse and uncontrollable. The range of the voice is lessened and the singer finds difficulty in reaching the upper tones. In the general debilitation the singer tries, or rather is compelled through weakness, to poise the voice from the cords themselves and not from the diaphragm.

Of the other forms of vocal-cord paralysis there is one of great interest, known as hysterical paralysis. It is usually only temporary, and is sometimes produced in singers whose nervous condition grows upon itself until the system passes into the trying disturbance diagnosed by the rudely critical public as "stage-fright." Artists of marked pretension have been compelled to abandon a public career because of this affliction. There are other examples of it even more difficult to understand. I have in mind a case of a singing-teacher in a conventual school, who was under a peculiar strain of preparation for the commencement exercises of the school and of her own class and their appearance in public. She brought her class up to the appearing-point. Then her nervous system gave way, and when she came to me she was absolutely voiceless. Sometimes in coughing her vocal cords could be seen to move. With rest she recovered, but she has a recurrent tendency to the same trouble every year. The case would seem to illustrate the uselessness of all effort on the part of the person so affected permanently to overcome it. The remedy is at hand, however, in numerous cases, in resort to a careful and uninterrupted upbuilding of the nervous system.

I will mention some other cases of vocal disorder and cure. An operatic tenor came to me with a tendency to break in scale-sounding, and with a nasal or catarrhal color to all his tones above E. I found attached above and back of the soft palate a mass as large as a hickory nut and completely blocking up the dome of the pharynx. A little cocaine was applied, and with a single sweep of the curette he was minus an adenoid on the third tonsil, a tonsil of Luscha. Within ten days his voice was completely restored.

Sometimes the physician is obliged to seek far for the cause of catastrophe to the voice. A fine and thoroughly well-trained tenor singer came to me with a singular tremor in his voice. The entire scale was tremulous. I found nothing the matter with any part of his vocal tract save that, on closely studying the condition of his mouth, there was a rapid muscular contraction of the soft palate and surrounding tissues. This led me to examine him from head to foot for possible nervous disorder, of which, however, I found no trace. Then, satisfied that there must be a more remote physical cause, I pushed the examination further and discovered traces of kidney affection. He was successfully treated for this and, with its cure, his voice also was restored. This case shows the close relationship between parts of the physical constitution and the voice, and illustrates the importance to the singer of a generally healthy physical condition.

Another case illustrates a further and somewhat peculiar phase of the subject. From the posterior nasal passage of a singer I removed nine large adenoid tumors. He was a tenor, and within a few days his upper tones were perceptibly freer and fuller. He had recently changed his instructor; and subsequently I found that he was attributing to this teacher the marked improvement in his voice. The physician was receiving no credit as a voice-builder whatsoever from either of them—which shows that in addition to a keen knife, the specialist should also possess a keen sense of humor.



Transcriber's Note

Some spelling variation exists in this ebook (e.g., collar-bone and collarbone, chest-cavity and chest cavity, mucus and mucous). These variations have been retained to match the original text.

Minor corrections to punctuation have been made without note.

The following additional typographical corrections have been made:

Table of Contents: Changed 170 to 169 to accurately reflect page number in text

Page 75: Changed larynogoscopists to laryngoscopists (by amateur laryngoscopists)

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