HYGIENE OF THE VOICE THE MACMILLAN COMPANY 
FEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 
MACMILLAN & CO., Limited 
LONDON • BOMBAY • CALCUTTA 
MELBOURNE 
THE MACMILLAN CO. OP CANADA, Ltd. 
TORONTO HYGIENE OF THE VOICE 
BY 
IRVING WILSON VOORHEES 
M. S. (Princeton); M. D. (Columbia). 
FELLOW OF THE NEW YORK ACADEMY OF MEDICINE; MEMBER OF THE AMERICAN 
ACADEMY OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY; FELLOW OF THE AMERICAN 
LARYNGOLOGICAL, RHINOLOGICAL AND OTOLOGICAL SOCIETY; ASSISTANT SURGEON 
TO THE MANHATTAN EYE, EAR AND THROAT HOSPITAL; CONSULTANT 
TO THE TARRYTOWN AND TO THE ROCKAWAY BEACH HOSPITALS ; 
ADVISER TO SINGERS OF THE METROPOLITAN, CHICAGO, 
AND CENTURY OPERA COMPANIES, 
ETC. 
gorfe 
THE MACMILLAN COMPANY 
1923 
All rights reserved PRINTED IN THE UNITED STATES OF AMERICA 
Copyright, 1923, 
By THE MACMILLAN COMPANY, 
Set up and elect rotyped. Published August, 1923. 
THE FERRIS PRINTING COMPANY 
NEW YORK To 
IRVING WILSON VOORHEES, Junior 
IN THE HOPE THAT THE MANTLE OF ELIJAH MAY FALL 
UPON THE STRONG YOUNG SHOULDERS OF ELISHA, 
AND THAT HE WILL DO HIS UTMOST TO 
HELP WIDEN THE FIELD OF 
MEDICAL SCIENCE FOREWORD 
This little book has grown up very gradually out 
of the Author’s experience in examining, advising 
and treating singers and speakers. For many years 
he has made brief notes on many of the topics herein 
set forth in extenso, and has filed them away for 
reference. There was no thought of putting them 
into book form because of the many volumes that 
have already been written dealing with the singer’s 
problems; but, in looking this copious amount of 
literature through, it was very evident that most of 
the writers have considered chiefly the technique of 
singing, and have tried to formulate rules and 
precepts which would help both the teacher and 
pupil to turn out a finished vocal product. 
Now, with the technique, the savoir jaire of sing- 
ing, I have no very great concern. To be sure I 
have some sense of musical appreciation, and can 
differentiate readily between good and bad vocal 
production; but I do not presume to tell either 
teacher or pupil how a given method should be 
changed to bring about the desired result,—that is 
something which belongs exclusively to what one 
might call “Voxology,” if the Latin-Greek hybrid 
will not offend the sensibilities of some Classical 
student or scholar. The singing teacher is just as 
much of a specialist in his line as the rhino-laryn- 
gologist is, in all that pertains to normal and ab- 
normal conditions in the nose and throat. We both 
have our distinctive fields and should hew close to 
the line without invading each other’s special prov- 
VII VIII 
FOREWORD 
ince. To my way of thinking, the voice physician 
has no moral right to usurp the place of the teacher; 
and, on the other hand, the teacher who advises the 
pupil as to gargles and sprays, and even “touches 
up” a throat now and then with some black and bad- 
tasting medicine from the corner drug store, is not 
only an invader and usurper, but he is practicing 
medicine without a license and ought to be held 
accountable. 
The consummation so devoutly desired is the very 
thing that has nearly always failed to happen; 
namely, close co-operation between voice teacher 
and voice physician. On this subject I have dis- 
coursed in various periodicals, and have made it the 
burden of many an address before teachers and 
doctors. The matter is again referred to in the body 
of this book, but perchance, to little purpose, be- 
cause of deep-rooted prejudices on both sides of the 
divide. We shall probably have to get on as we do 
now, cat and dog fashion, for many years to come, 
to the great detriment of all concerned. What a 
pity that human nature in the mass is so blind and 
stupid as to destroy its laborious efforts by its 
wanton follies,—efforts that have been paid for in 
the blood and sweat of all the generations of man- 
kind that have ever lived! In which direction lies 
progress? Whence shall come the man who some 
day is going to be born with a great magic wand 
which shall unify and intensify and ultimately 
glorify all of our efforts? Will such a Leader ever 
be able to do away with the chaos now reigning in 
the fields of Medicine and Music? God grant it 
speedily! 
It is obviously impossible to mention all the 
sources of information which have come to the FOREWORD 
IX 
Author in the course of his reading; but the debt is 
fully acknowledged, and heartfelt thanks are offered 
to all those who have shed some light on disputed 
points, and have laid the fundamentals upon which 
our thought processes can erect a fitting super- 
structure. 
Many of the data used in this book were pub- 
lished as original contributions by the Author in the 
Musical Courier, Musical America, The Etude, The 
Musician (Ditson Company), Musical Observer, 
and The Ladies’ Home Journal. Articles appealing 
to physicians interested in the singing voice have 
appeared in the N. Y. Medical Journal, Medical 
Record, American Medicine, Boston Medical and 
Surgical Journal, The Laryngoscope, Annals of 
Otology, the Acta Laryngologica, and the Journal of 
the American Medical Association. 
Of the authors consulted, special mention must 
be made of Sir Morell Mackenzie whose Hygiene of 
the Vocal Organs is probably one of the best if not 
£/mbest book ever written on a similar subject. From 
this great voice physician many hints have been 
derived which are worked out in the light of more 
recent scientific findings and published herein. Sir 
Morell was a great pioneer student of vocal con- 
ditions in both singers and speakers at a time when 
the science of laryngology was still young and men 
were not moved to develop any particular corner of 
their specialty, such as bronchoscopy or plastic 
surgery, but contented themselves for the most part 
in syringing and wiping and spraying. All honor, 
then, to the man who became the foremost diagnostic 
laryngologist of his day, and set down conclusions 
and opinions which cannot be gainsaid. The world 
owes him its gratitude. X 
FOREWORD 
Other helpful authorities are: Holbrook Curtis, 
F. E. Miller, Wesley Mills, W. W. Shaw, Edmund 
Meyer, Thomas Fillebrown, and, of course, Emanuel 
Garcia, that great vocal teacher who gave to us the 
little mirror known as the laryngoscope. Among 
foreigners I must mention Imhofer, Flatau, Gutz- 
mann, Ernst Barth, Morris Schmidt, Hajek and 
Schnitzler (the latter is father to Arthur Schnitzler, 
the doctor-dramatist), and the anatomist, Zucker- 
kandl of Vienna. All of these, and, perhaps others, 
whose names escape me for the moment, have con- 
tributed some little grain of truth, or have provoked 
thoughtful discussion. 
In order to facilitate the reader in finding what 
he especially wishes to know, the book has been 
divided into two parts. Part I is for the general 
reader, teacher or pupil, who is not trained medi- 
cally; therefore, technical terms have been avoided 
as much as possible, and every statement reduced to 
its lowest terms for the sake of clarity at the risk of 
being considered “unscientific.” Part II is more 
difficult for the general reader, and is intended to 
serve physicians, or those with some knowledge of 
anatomy, physiology, pathology, etc., who might 
like to pursue their studies further later on in a more 
exhaustive and comprehensive volume. The chapter 
dealing with the diaphragm and the physiology of 
breathing is, of necessity, difficult and requires more 
than mere casual reading. 
In conclusion I wish to thank Mr. J. N. Myers of 
the Macmillan Company who has helped much with 
his advice in seeing the book through the press. CONTENTS 
CHAPTER PAGE 
I. The Beginner 1 
II. The Singer’s Environment 13 
III. Range of the Voice in Speaking and Singing . . 18 
IV. Some Vocal Habits Which Handicap 23 
V. The Importance of Good Hearing 36 
VI. Colds—Their Cause and Cure 44 
VII. Voice Fatigue (Phonasthenia) 55 
VIII. Voice Teacher and Voice Physician 67 
IX. Vocal Hygiene 78 
PART I 
X. Examination and Diagnosis 89 
XI. Physical Defects 101 
XII. Vocal Nodules 110 
XIII. On Certain Nose and Throat Disorders in Singers 
and Speakers 116 
XIV. The Tonsil Question 136 
XV. Hay Fever or Pollinosis 151 
XVI. Management of Acute Infections of the Airways 159 
XVII. Management of Chronic Infections of the Lower 
Airways 170 
XVIII. Functions of the Diaphragm and Some Notes on 
the Psychology of Breathing 182 
APPENDIX A 
Fundamental Principles of Breathing 194 
APPENDIX B 
Fundamental Principles of Voice Production . . 197 
PART II PART I 
CHAPTER I 
THE BEGINNER 
The first question that every candidate for vocal 
honors should ask himself or herself is: “Is my voice 
worthy of cultivation?” It is almost impossible to 
decide this for one’s self. In fact it is often diffi- 
cult for those best fitted to help decide; for no 
wider differences of opinion are to be found in any 
field than obtain among self-constituted judges of 
voice. A voice is either pleasing or displeasing, and 
yet there are those who uphold absolutely contrary 
opinions even where so-called great artists are con- 
cerned. 
Another question of great importance is: “What 
is my purpose?” “Is it for personal delight or to 
achieve fame?” If there is no intention of becoming 
a “virtuoso,” but merely to give pleasure to friends 
and acquaintances, there can be no harm in “trying 
out” the voice. 
The age at which a pupil should begin must be 
thoughtfully considered. There seems to have been 
no fixed rule as to this; for one hears of pupils 
“taking up” active vocal training anywdiere between 
five and thirty-five years. These are doubtless the 
extreme limits in either case. All things considered, 
it is best to wait until adolescence is well estab- 
1 2 
HYGIENE OF THE VOICE 
lished. This holds true for both boys and girls. 
As every one knows, all voices are high up to the 
period of adolescence, when there is often a marked 
change for boys, and a less marked but distinct 
change for girls, if one watches the voice closely. 
The weight of authority is in favor of deferring 
vocalization till after puberty, especially in girls. 
Indeed many teachers refuse pupils before that 
period of life. The reasons given are that training 
at an earlier age would be likely to damage the voice 
by straining it while still unformed, and to endanger 
the general health by subjecting the system to 
fatigue beyond its powers. 
There is, however, no strong argument against 
proper vocal discipline for the purpose of correct 
and pleasing speech as well as song, as early as five 
or six years of age. It is perfectly natural for most 
children at this age to desire to sing; and, taking 
advantage of this natural tendency, nothing but 
good should come from thoughtful, intelligent direc- 
tion of it. Only simple little airs of limited compass 
should be sung, and the coordination of the laryn- 
geal muscles with the ear (which is the conscience 
of the voice) should be thoroughly established. 
This can easily be done by invariably correcting 
every note about which there may be any suspicion 
of falseness. There is a better chance also of get- 
ting rid of throaty or nasal production at the very 
outset than when these defects have become in- 
grained by long habit. 
So far from injuring the general health, the 
teaching of singing in childhood is likely to prove 
highly beneficial, especially in cases in which there 
is a tendency to delicacy of the lungs. By the THE BEGINNER 
3 
healthful exercise of these organs in singing, the 
chest is expanded, the muscles of respiration are 
strengthened, and the lungs themselves are made 
firmer and more elastic. Of course, it must be un- 
derstood that the vocal exercises are to be strictly 
moderate both as to quality and quantity; that is 
to say, the lessons must be very short, and at most 
only the ten or twelve notes which form the average 
compass of a child’s voice should be used. On no 
account must there be the least forcing or fatigue. 
It may be added that some of the very best among 
living signers have been trained in quite early life. 
One need only mention the names of such “bright 
particular stars” as Mmes. Alboni, Jenny Lind, Ade- 
lina Patti, and Albani. 
Training during the first years of childhood is, 
however, quite a different thing from training dur- 
ing the so-called period of mutation. In general 
I am opposed to singing during this changing period, 
and wish to align myself with the “old-timers,” 
notably the late Manuel Garcia, that great teacher 
of singing who invented and gave to us the laryn- 
goscopic mirror without which the science of laryn- 
gology could never have developed. On this ques- 
tion of singing during “the change,” Sir Morell 
Mackenzie and Professor Garcia differed widely, and 
published their opinions in extenso. The debate, 
while lively, never became unfriendly, but served to 
illuminate the subject so that those interested may 
draw their own conclusions. 
Garcia says: “Mackenzie pleads for singing exer- 
cises during the whole time of this critical period, 
and cites several celebrated persons in support of 
his views. I can bring forward a case which has not 4 
HYGIENE OF THE VOICE 
yet been referred to. My father went through the 
transition time without ceasing to sing, and without 
having done himself the least harm. But both my 
sisters, Mesdames Malibran and Viardot, were 
obliged to wait a year. I continued singing myself, 
Fig. 1.—Larynx and trachea seen from the front. 1. Thyro-hyoid; 
2. Omo-hyoid; 3. Sterno-hyoid; 4. Crico-thyroid; 5. Pharynx constrictor; 
6. Conoid ligament; 7. Tongue; 8. Hyoid bone; 9. Thyroid cartilage. 
and my voice was ruined. With all respect for Dr. 
Mackenzie’s great experience in these matters, I 
cannot but believe that the old rule which has pre- 
served so many voices, should not be thrust aside on 
account of some rare exceptions.” 
Laryngolgists have noted that at puberty the THE BEGINNER 
5 
larynx begins to grow quite rapidly. As a result the 
vocal cords fail to obey the normal voluntary im- 
pulses; therefore, in order to produce the desired 
effect, the pupil is obliged to squeeze the throat 
muscles tightly, and force the air through the nar- 
rowed chink between the cords (chink of the 
glottis). This rapid growth and resultant relaxa- 
tion goes on for some months, during which time 
the voice cracks or breaks and seems hoarse. There 
is recession toward deeper or even low voice, to be 
followed by a progressively upward trend until the 
final level is reached. 
The anatomical features of the change may be 
summed up as follows: Increase in size of the larynx 
in all dimensions; enlargement and consolidation of 
the cartilages (thyroid, cricoid, and arytenoid); the 
angle formed by the two wings of the thyroid carti- 
lage in front becomes sharper and more marked, so 
that it is more prominent in the neck; lastly, the 
vocal cords become longer and thicker. In the 
female similar changes or physical modifications 
take place also, although to a much lesser degree; 
the voice gains a tone or two in compass, besides 
becoming stronger, richer and sweeter. This main- 
tains throughout life, growing fuller, however, up 
to thirty or thirty-five. 
In men, a second change occurs between fifty and 
sixty, or even earlier; the laryngeal cartilages stiffen 
and become wholly or partly calcified, and the soft 
tissues lose some of their elasticity. The voice then 
loses in power, volume and quality, until, in extreme 
old age, it becomes shaky and rather unpleasant. 
On the basis of anatomical knowledge not only, 
but on the well-known and convincing grounds of 6 
HYGIENE OF THE VOICE 
experience, I maintain that singing during mutation 
should not be indulged in to any extent. If it is, 
the results are likely to prove disastrous to all future 
efforts at training. Why is it that so few choir boys 
ever develop a voice that amounts to anything? 
What happens to the boy soprano prodigies? At 
the moment I cannot recall any of them who has 
ever achieved a considerable measure of vocal suc- 
cess. 
Both parents and teachers of singing have over- 
looked this important fact in the past. Some physi- 
cians have even advised “a little singing exercises to 
keep the chords from becoming stiff.” Such advice 
is, of course, based on ignorance of the exacting con- 
ditions present. Not frequently choir boys suffer 
from a form of voice trouble known as “phonas- 
thenia,” of voice weakness, a condition which will 
be fully described in another chapter, which is 
brought on by straining the throat at a period of 
life when it obviously should be kept as completely 
at rest as possible. 
It is only fair, however, to present Dr. Mac- 
kenzie’s side of the argument. He says: 
‘'I pointed out some years ago that in all cases 
in which the voice is ‘broken,’ the vocal cords are 
seen, with the laryngoscope, to be much congested. 
They are often, however, somewhat red even when 
there is no particular harshness in the voice. The 
change sometimes takes place with startling sudden- 
ness as in the case of Lablache, who is said to have 
passed from alto to deep bass in a single day, but 
it is generally a gradual process which may take 
years to complete itself. Thus beginning, as a rule, 
about fourteen, it goes on steadily till the age of THE BEGINNER 
7 
eighteen or thereabout; after that, the development 
still continues, though much less perceptibly, and 
the voice is not usually full-grown, so to speak, 
before twenty-eight or thirty. 
“If due care be exercised, there is no reason why 
the voice should not be used in singing during the 
transition period; but the training must be carried 
out within certain limits, and under strict super- 
vision by a competent person. If a boy is found to 
have become slightly hoarse or uncertain in one or 
two upper notes, he must not be allowed to attempt 
them. In fact, he should be restricted to his mid- 
dle notes, so as to avoid straining at the upper end 
of the scale, and give the organs time to mature 
themselves for the utterance of the newly-acquired, 
graver tones. For it will generally be observed that 
as the boy loses a high note he gains a low one, and 
these notes must be carefully but regularly trained. 
“Unless, therefore, the larynx is much congested 
and the voice hoarse at the period of change, I am 
strongly of the opinion that vocal training should 
be continued—of course within certain limits—un- 
der competent supervision and with due precautions 
against overwork.” 
Prof. Mackenzie in answering M. Garcia has 
chosen to give us a few interesting notes on the 
Garcia family from which I quote the following: 
“M. Garcia’s father was a Spaniard, his real name 
having been Manuel Visconte Popula Rodriguez, but 
like many artists he changed it when he adopted the 
stage as a profession and took the name of Garcia. 
This gentleman was a native of Seville, but was 
taught as a chorister by an Italian maestro di 
capella. Senor Rodriguez had a great success in 8 
HYGIENE OF THE VOICE 
Italy, where he was known as Lo Spagnoletto. His 
daughters, Madame Malibran and Madame Viardot, 
became the most celebrated artists of the day, whilst 
his son was the celebrated Manuel, who is so fre- 
quently referred to in this work. His grandson, 
Gustav Garcia, inherits the traditions of the school, 
and is a highly successful maestro.” 
It is very important to know just when the 
adolescent period begins. An industrious student 
of this matter, Dr. Theophilus E. Fitz, has shown 
that one can predetermine to a great extent just 
what the voice is likely to be, that is, whether 
soprano, alto, etc. It is a remarkable fact that in 
both sexes those who mature early have high voices, 
and those who mature late are inclined to have low 
voices. That is, if a female shows signs of passing 
on to womanhood at twelve or thirteen the voice 
will probably be a high soprano of dramatic or color- 
atura type; if sex maturation takes place at fourteen 
or fifteen the voice is likely to be contralto or alto. 
In cases where no change in the voice can be de- 
tected the high quality persists. Strongly sexed per- 
sons often show remarkable vocal qualities. 
In boys the same rule holds good. If a boy ex- 
periences no “break,” or at most a very slight break, 
he is likely to become a tenor. If the break takes 
place at twelve or earlier, the voice will be high; if 
at fifteen or later, the voice will be low. Nearly all 
boy sopranos become baritones or basses if any voice 
persists at all. 
In Appendix C there is a chart showing the Fitz 
method of vocal measurements, and how to estimate 
what may properly be expected of any candidate for 
vocal culture who submits to the tests. THE BEGINNER 
9 
When a child is old enough, it is an excellent 
plan to take up a course in interpretation or expres- 
sion, whether singing lessons are to be taken or not. 
Some years ago public speaking or “elocution” was 
a regular part of every school and college course. 
It has been nearly forced out of the curriculum by 
Fig. 2.—Larynx seen from behind. 1. Cricoid cartilage; 2. Cartilage 
of Santorini; 3. Cuneiform cartilage of Wrisberg; 4. Epiglottis; 5. 
Lingual tonsil; 6. Lateral epiglottic ligament; 7. Crico-arytenoideus 
posticus; 8. Interarytenoid muscle showing oblique and transverse fibres. 
manual training, cooking and many other desirable 
auxiliary branches of a good general education; 
nevertheless it is most important, especially in 
America, where we are roundly criticised for our 
nasal twang and sloven speech. Along with such 
training, breathing exercises and gymnastics are of 
the greatest practical value. 
Strange as it may seem, incorrect breathing is one 10 
HYGIENE OF THE VOICE 
of the most common errors in vocal students. A 
violent attempt is made to fill the lungs with air, 
the throat is “set,” and the pupil tries to force the 
entire effect, which is only too evident to the on- 
looker. 
There are few persons who cannot learn to sing. 
Some authorities say that every one can be taught, 
even if the element of song seems to be lacking from 
one’s mental and physical constituency. But how- 
ever widespread, however universal the function 
may be, the gift of song is indeed rare. It is this 
confustion of function and gift (for talent) which 
is responsible for so much mediocrity and disap- 
pointment. The boy or girl born and reared far from 
great centers of culture thrills with pride when told 
by admiring relatives or friends that he or she has 
a wonderful voice, “a voice that should be trained 
for the opera.” 
Nothing more cruel could be thrust into youthful 
rustic minds than the idea that to cast one’s lot in 
a great city means sure if not immediate success. 
Only the smallest fraction of those who come to 
New York ever amounts to anything. This sounds 
discouraging but is nevertheless true. Many hear 
the voice of victory, but few understand that it is 
not meant for them. 
Ordinaril> a few months of training will suffice to 
show the vocal possibilities actual or remote. One 
must then decide if singing is to be made a vocation 
in the true sense; that is, if it is to be made a mar- 
ketable commodity. So many fields stretch out be- 
fore the aspirant that it is well to choose one of 
them at the outset. The choice will probably lie 
between salon singing, concert, choir work, oratorio, THE BEGINNER 
11 
light opera, grand opera, vaudeville, etc. It is of 
great importance to know in which of these one is 
likely to find the greatest degree of satisfaction. By 
this time one should have a fairly definite idea of 
one’s capabilities. It will be known, for instance, 
whether the voice is a lyric or dramatic soprano, 
mezzo-soprano, alto or contralto. The quality will 
be quite evident and the range and carrying power 
also. The pupil should be able to read simple music 
“at sight” and should be spending some time at the 
piano each day. The art of accompanying one’s self 
while building the voice is well-nigh indispensable. 
It can be learned in a few months, and means to the 
pupil what shorthand notes mean to the college or 
professional student. 
Vocal ability, especially quality and timbre, seem 
very often to be inherited characteristics. 
Timbre is largely dependent on physical struc- 
ture, and to a certain extent is seemingly an ethno- 
ligical feature. Thus the aborigines (Maoris) of 
New Zealand, in whom the hollow spaces in the 
bones of the skull, technically called “sinuses,” are 
very ill developed, have voices remarkably deficient 
in resonance. The Italian ore rotundo utterance is 
almost a racial peculiarity; and, if one may say so, 
the voice as well as the speech of Americans is a 
racial characteristic. 
Tone work is of prime importance. For the first 
two years this should be studied intensively, so that 
the singing act becomes automatic. The tone 
should be free and easy, “sung on the breath,” 
without any strained effect—that is, there should be 
only a minimum of effort necessary to secure a maxi- 
mum effect. So-called “big tone” should be abso- 12 
HYGIENE OF THE VOICE 
lutely tabooed. The pupil who goes home after the 
first lesson and tries to sing an aria from grand 
opera need not blame the teacher if his voice does 
poorly; yet such persons are frequent visitors to the 
throat specialist as a result of their folly. 
The pupil is the clay with which we work. His 
impressions are easily moulded in the beginning and 
can be changed later on only with the greatest diffi- 
culty. His reliance upon the teacher and physician 
is, or ought to be, absolute. Good advice will make 
him;, bad advice will mar him and the career which 
is a part of him forever. He should not be told too 
much about anatomy and physiology, or of the 
movements of the jaw, tongue, lips, etc. We must 
beware of the idee fixe teachers and voice specialists 
alike. 
To sum up: Training of the voice should be be- 
gun as soon as the child can use language intelli- 
gently; that is, the child should hear good music and 
accurate speech, thus allowing imitation to play its 
very important part. He may be taught to sing 
little songs and recite simple rhymes. 
The voice should be strengthened by frequent ex- 
ercises not only indoors, but out-of-doors as well. 
Good teaching is always necessary, no matter how 
great the natural talent. 
Good singing is a help to good speaking, because 
it trains the ear to recognize pleasing sounds, and 
cultivates the sense of rhythm—training in song 
should, therefore, be a part of the curriculum of 
every school. CHAPTER II 
THE SINGER’S ENVIRONMENT 
No matter what the art may be, every one who 
seeks to tread its sacred pathway must secure for 
himself the best possible external conditions, must, 
in other words, provide an atmosphere in which this 
art can live and grow. It is not enough to have 
developed a satisfactory technic and a large public 
following. If the artist stops here the art itself will 
stagnate and instead of progression there will come 
a retrogression. So closely are life and art bound 
together that to command and maintain public 
favor requires great mental as well as physical 
strength, charm of manner—in short, personality. 
Singing is an esthetic calling dependent to a great 
degree upon mental attitude. Worry and fatigue 
show at once and create a depressing effect on an 
audience. A cruel, selfish, undisciplined nature can- 
not be expected in combination with beauty of tone 
and modulation of effect. The mind should be fed 
on the best there is in science, art, and literature. 
Only beautiful thoughts can be metamorphosed into 
beautiful expression; ugly, vindictive, ungenerous 
thoughts are sure to betray their possessor. In 
other words, vocal technic and a beautiful face and 
figure are not enough in themselves to carry an 
audience by storm. One has a duty to perform to 
the composer, to the public who comes to listen, to 
13 14 
HYGIENE OF THE VOICE 
the authorities behind the scenes, and to one’s self. 
It is a serious matter, this vocalization, and deserves 
every thoughtful consideration. 
Both the ear and the memory must be trained to 
analyze, to appreciate and to understand music as a 
Fig. 3.—Lateral view of the larynx, right thyroid cart, removed. 
1. Cricoid; 2. Thyroid cart.; 3. Epiglottis; 4. Thyroarytenoid; 5. 
Lateral crico-arytenoid; 6. Crico-aryt. posticus; 7. First tracheal ring. 
science and as an art. Therefore, no opportunity- 
should be neglected to hear great singers, not only 
to hear them, but to study out the secrets of their 
greatness, to reflect upon and to imitate all that is 
good in them. Then, when a high standard of ex- THE SINGER’S ENVIRONMENT 
15 
cellence is set before the imagination, it is a very 
illuminating experience to hear some of the worst 
singers that one can find. This end will quite satis- 
factorily be attained by attendance at a few recitals 
by amateurs where every fault and evidence of bad 
method can be strikingly studied. This should not 
be done in a spirit of carping criticism, but should 
be approached from the standpoint of analysis, just 
as a scientist takes up the work of another scientist 
and proves or disproves it regardless of the merely 
personal element. 
The question of foreign study is an open one. In 
the past much has been said and written both for 
and against it. There is no doubt that we have here 
in America just as good voices, and just as good 
teachers as exist in any European country. Never- 
theless, there is a certain spirit of enthusiasm, an 
atmosphere of achievement which is not always 
found here save in the great musical centres such as 
Boston, Cincinnati, Chicago and New York. There 
is, too, a rare opportunity abroad for the study of 
languages, a mastery of which is very desirable from 
every viewpoint. French, German and Italian are 
the three that one should know sufficiently well to 
make them intelligent instruments of artistic com- 
munication. With the acquisition of them goes a 
degree of accomplishment quite outside the sphere 
of one’s immediate work. 
Happily in these days good music can be effec- 
tively studied from the phonograph. Nearly all the 
great artists have given us a record of their achieve- 
ments, which will stand either to their credit or dis- 
credit until the end of time. The object of this 
study of “canned music” is not to supplant the 16 
HYGIENE OF THE VOICE 
teacher; that is impossible, but for purposes of com- 
parison, and to train the ear and sense of musical 
judgment. 
One should also take up in synoptic form a his- 
tory of music from the earliest times. It is profit- 
able to know how the art sprang up out of barbarism 
and ignorance, and how it has developed into great 
universal, vital force among the nations. 
The lives of the composers are also full of in- 
terest from a musical, biographical, and, not infre- 
quently, from a literary viewpoint. Knowledge of 
the personal and often exceedingly human side of 
the world’s great writers of music gives added charm 
to their compositions, aids the memory, and helps 
to an understanding of much that heretofore may 
have seemed quixotic and unintelligible. 
Travel, while not absolutely indispensable, is a 
great stimulant and an increasing delight, especially 
in retrospect. By its influence, the powers of ob- 
servation are widened and deepened, so that one 
comes ultimately to a wholesome perspective of 
national and individual likenesses and differences. 
It gives a feeling of assurance and a breadth of sym- 
pathetic understanding which are of great value. 
In Europe, the demand for musical talent of every 
sort seems to be greater than the supply. Just how 
this matter stands in the post-war period is some- 
what problematical; but in the past, Americans of 
talent and training have had little difficulty in get- 
ting “on the boards” when the time was ripe for it. 
Every European town of any size has numerous 
theatres, and, not uncommonly, an opera house as 
well, where stage experience can be acquired and a 
small honorarium besides. With this experience THE SINGER’S ENVIRONMENT 
17 
back of one, there is usually an opening somewhere 
in America for the artist who returns to his native 
heath. 
Just here it may be in order to say a word about 
the social demands made upon the singer’s time and 
energy. To possess a pleasing, well-trained voice 
is often an open sesame to soirees, card parties, 
dinners, musicales and other like functions. In gen- 
eral, one should not accept such invitations, except 
in case of a fast and firm friendship. First, the 
effort and time consumed are precious. Unless one 
is willing to sacrifice everything else for experience, 
there is no point in performing without remunera- 
tion, and nothing is accomplished for the singer save 
to satisfy the curiosity or whim of a crowd that 
wishes free entertainment. Finally, the singer who 
is often obliged to comply with urgent requests, does 
not appear at her best advantage; and, unkind as 
it is, she may be the target for hostile, unjust criti- 
cism. Late hours, overeating, and overdrinking 
which are nearly always a part of such “affairs,” 
work no good to the singer, and may lead her away 
from an industrious and serious pursuit of her art. CHAPTER III 
RANGE OF THE VOICE IN SPEAKING AND 
SINGING 
The range of the voice is from two to two and 
one-half octaves, although in exceptional persons it 
may have a compass of three octaves. As most 
music, however, is written for voices which span 
about two and one-half octaves, there is not very 
frequent occasion for a wider range. Two of my 
tenors have had three octaves. One had a large 
experience at La Scala in Milan and followed Caruso 
when that celebrated tenor signed a contract with 
the Metropolitan. Unfortunately, however, he was 
a failure as an actor. The other is a German tenor, 
short of stature and with a thick neck. His cords 
are short and thick and very difficult to see by 
laryngoscopic examination. 
Caruso had a compass of three octaves, but his 
method of production, from a strictly technical 
viewpoint, might be considered faulty. He was a 
law unto himself, and everyone who tried to imi- 
tate him, Invita Minerva, went “on the rocks.” 
This is a good example of what happens to most 
singers who try to develop from a crow into a 
canary—they cease having even a crow’s voice. 
And after all it is more creditable to be a good crow 
than a poor canary. 
Efforts have been made by authorities writing on 
18 THE VOICE OF SPEAKING AND SINGING 
19 
the singing problem to differentiate between song 
and speech. We all know that the voice can be used 
in two entirely different ways—one for the purpose 
of communication with our fellowmen in speech, 
and the other for expression of the emotions or to 
produce an artistic effect through song. In singing 
Fig. 4.—The larynx seen from above. A.—Anterior; P.—Posterior. 
1. Median epiglottic ligament; 2. Epiglottis; 3. Ventricular band or 
“false vocal cord”; 4. Ventricle of the larynx, between the true and false 
cords; 5. Vocal cord (left); 6. Cart, of Wrisberg; 7. Cart, of Santorini; 
8. Interarytenoid notch; 9. Posterior wall of pharynx; 10. Tracheal 
rings; 11. Pyriform sinus; 12. Ary-epiglottic fold; 13. Lateral epiglottic 
ligament; 14. Tubercle or eminence of the epiglottis. 
there is a succession of identical, quick vibrations of 
appreciable length, making up a note. Speech is 
similar in production but the vibrations are fewer 
in number and shorter. For example, nil sung is 
quite different from na spoken, the spoken sound 
being shorter and less pleasing to the ear than the 
sound when sung. 20 
HYGIENE OF THE VOICE 
Mackenzie says that speech is to song what walk- 
ing is to dancing. Herbert Spencer’s definition is 
widely quoted to the effect that “song is emotional 
speech.” This definition is, however, both inaccu- 
rate and untrue. Song is emotional, but it is not 
speech by any stretch of the imagination. One 
might assume that to carry a message from ear to 
ear is sufficient to be considered speech, but this is 
mere quibbling with words and amounts to nothing. 
The voice is developed by many teachers on the 
vowel sounds a, e, i, o and u. These are capable of 
more wonderful combinations in song than are the 
twenty-six letters in the alphabet in speech. The 
remarkable thing is that each vowel has its own 
pitch, which is produced by the changing shape of 
the mouth. Anyone can satisfy himself by pro- 
nouncing or singing the vowels before a mirror. The 
vowels o and oo resonate best in the lower register, 
while a (ah) and 2’(ee) resonate best in the upper 
register. 
There is no doubt that sex development influ- 
ences the range of the voice to a very remakable 
degree. In females it is not uncommon to find the 
low voice type contralto or alto showing many 
masculine characteristics. The body is often large, 
the features heavy. There is likely to be an ex- 
cessive amount of hair on the face, especially on 
the upper lip; and even the walk assumes a swing- 
ing stride which is not strictly feminine. Sopranos, 
on the other hand, are likely to reveal character- 
istics which are decidedly feminine, although, of 
course, the rule is very often broken. That is, it is 
impossible to say from external appearances just 
what either the quality or the range of a voice is THE VOICE OF SPEAKING AND SINGING 
21 
likely to be. It has been known for a long time 
that the voice of Eunuchs is always high and has a 
narrow compass. In fact, history states that in the 
early development of choirs, where soprano voices 
were in demand, castration was regularly practiced 
for the purpose of producing high voices. More 
will be said on this subject in another chapter. 
Most males are baritones, and their vocal compass 
lies between f and b flat. This explains why tenors 
of fine quality are so rare. The greatest effects in 
singing are in the upper and middle strata or regis- 
ters. This for sopranos and tenors. 
Singing increases one’s ability to articulate spoken 
sounds. It is a well-known fact that stutterers 
never have any impediment while singing. One 
reason is that breathing while singing is entirely 
different from breathing while speaking, and many 
stutterers hold the breath and seem unable to re- 
lease the spasm of the muscles in order that articu- 
lation may be effected. Speech usually occupies the 
middle of the vocal compass, because at that level 
the least strain is put upon the vocal apparatus and 
the voice carries better to most ears and is more dis- 
tinctly understood. In many persons there are 
“islands of hearing.” Some hear soprano voices 
best and some deep voices best. Every otologist 
will bear witness to this fact. 
The matter of vocal registers has been very much 
disputed in musical circles, some teachers even re- 
fusing to make use of the word “register.” But it 
is the idea, not the word, which is important. There 
is no denying that as one sings up the scale, he 
comes to a point where he must change his place- 
ment to produce the desired effect. This is the 22 
HYGIENE OF THE VOICE 
point of “break” in the voice, or better, the critical 
point. The singer finds a place where he must make 
a new adjustment of the vocal organs. He can 
continue for a few more notes at this level, when 
another step or critical point again requires some 
shifting of the placement. These points vary in 
different persons, and it requires long years of prac- 
tice before the voice is brought to such a state of 
perfection that no point of change is noticed by the 
vocalist. When building the range, it would seem 
logical to develop both ends of the voice from the 
middle, but in actual practice the range is increased 
from both limits. That is, a note is often added on 
the low voice about the time that a new high note 
is obtained; but sometimes, a new note develops on 
one end of the range corresponding to a loss of a 
note on the other end. The one great danger of 
developing the upper limit of the voice is “forcing,” 
and it is this which leads to so-called “relaxed” 
vocal cords, vocal nodules and phonasthenia. While 
development of one’s range to a maximum is very 
desirable, it is not an end in itself; for one may 
readily conclude, from what has been set down here, 
that excessive ambition to develop a high voice, for 
instance, may result in complete vocal shipwreck. 
There are many concert artists on the stage today 
who are able to earn a good living by the skillful 
use of a voice which is less than two and one-half 
octaves. By careful and intelligent direction other 
qualities will often make up for any lack of natural 
endowment. It is always well to bear this fact in 
mind. CHAPTER IV 
SOME VOCAL HABITS WHICH HANDICAP 
There is no denying that many of the singers’ 
ills are brought about by bad vocal habits which 
may be either the result of ignorance or bad train- 
ing, or a combination of the two. In America, fol- 
lowing out our usual haste for quick returns, singers 
do not do enough preparatory work before they un- 
dertake to make a living by their art. What would 
we say of a medical student who tried to depend 
upon his knowledge of medicine and surgery to gain 
a livelihood before graduation? Or what about a 
law student trying cases for pay before admission 
to the Bar? In both of these instances the law 
would intervene and prosecute the offenders for 
violation of the statutes. But the pupil who has 
had twenty or less singing lessons strikes out in 
vaudeville or cabaret work and boasts of making 
his expenses while learning. 
At first view this seems to be a very creditable 
and delightful thing to do, but it is only true on the 
surface. Many persons who try this short cut never 
get any farther than the hedgerow. They never 
learn to mount the stile and sally forth into the 
broad path of artistic success. Why? Because 
their time and effort are to a great extent used up 
in doing a good thing poorly. If two years were 
spent exclusively in thorough, conscientious tone- 
23 24 
HYGIENE OF THE VOICE 
work, the singing act would become automatic, and 
with this foundation there would be at least some 
hope, even for those who are bold enough to apply 
the acid test in public. It would be a great deal 
better if the necessary money were begged or bor- 
rowed or earned in some other way during the first 
two pupil years. The only singing that should be 
indulged in during this time is the actual work at 
lessons and the daily practice hour. Voice, like the 
muscles, requires daily exercise in a systematic, 
regular way. When technic is thoroughly estab- 
lished, there should be no uncertainty, no huskiness 
or hoarseness or cough after moderate vocalization. 
The attempt to do big “tone” work before the 
vocal organs are in any sense ready for it, is un- 
doubtedly responsible for a great deal of so-called 
“catarrh” and “throat trouble” and unkind remarks 
about the climate and weather in general. Voice 
fatigue is more often due to bad placement and in- 
correct breathing than to any other group of factors. 
It is, of course, positively useless to swallow all 
kinds of troches and lozenges for such a condition. 
The latter are of some use in infectious sore throats, 
bronchitis, “colds,” etc., but even then I, personally, 
do not recommend them. One cannot expect to 
treat a disease of the throat or lungs very effectively 
by putting medicine into the stomach. 
Tremolo, a fault of which many singers seem to 
be blissfully unconscious, consists of a waver or 
varying in the intensity of the tone. It is often 
due to ignorance of breath control, and sometimes 
is deliberately cultivated by the singer in the false 
notion that it is “artistic” or a “sympathetic vibra- 
tion” which will impress the listener favorably. It SOME VOCAL HABITS WHICH HANDICAP 
25 
is not a matter for the physician, but must be taken 
care of by the vocal teacher. 
It is hard for a beginner to understand that breath 
control, and not breath volume, is the important 
thing, that one must govern the breath so that none 
of it shall escape without giving an equivalent of 
sound. The lungs must be sufficiently filled with- 
out gasping, not filled to overflowing as if one were 
going to have his chest expansion measured; for too 
much air may be quite unmanageable, the exchange 
of gases in the lungs being a physiologic require- 
ment which must proceed with rhythm and regular- 
ity. One must be able to empty the lungs quickly 
or slowly, gently or violently as the exigencies of 
phrase and emotional interpretation demand. 
Everyone should know quite exactly his natural 
vocal limits, and not make himself ridiculous by 
attempting to do things quite out of his reach, not 
only for his own sake, but to spare pain and dis- 
comfort to his auditors. First, in this connection, 
is an instinctive knowledge of distance,—so to 
modulate the voice that a fine well-poised tone will 
go “spinning” to the topmost gallery with the same 
ease as a note or phrase sung forte. If a singer 
hears his own voice very loudly there is evidently 
much rebound, and he is not being heard by others 
nearly so well as he thinks. 
Falsetto is a faulty method of singing which has 
been frequently and widely discussed; but there is 
a distinction between falsetto and head voice which 
is not always clearly set forth or understood. These 
terms were used interchangeably by the old Italian 
writers; but “falsetto” is better used to describe an 
artificial method of delivery; that is, the limited 26 
HYGIENE OF THE VOICE 
“short-reed” register in men which is forced up- 
wards beyond its natural compass, or, as Rousseau 
defines it in his Dictionaire de Musique, “a kind 
of voice whereby a man going beyond the upper 
limit of his natural voice counterfeits that of a 
woman.” Not only do opinions of definitions differ 
decidedly, but also opinions of beauty,—some being 
enraptured of the flute-like quality of falsetto, 
others finding it the most disagreeable of all human 
sounds. It cannot be gainsaid, however, that fal- 
setto is really an artificial form of voice production, 
since young adults, who have naturally placed 
voices, never use it. There is a widespread feeling 
that falsetto is a trick, a kind of vocal quackery 
which is not to be indulged in by the genuine artist. 
Be that as it may, there is a form of head voice 
which is the natural successor of the chest voice 
in the vocal scale, and wThen it can be produced 
smoothly and without any break or flaw, so that 
a listener cannot tell when or how it is “carried 
over,” it is capable of making great effects if not 
used too frequently. 
Holmes maintains that falsetto is produced by 
the “rim of the larynx, which, instead of becoming 
dilated, suffers a progressive and marked constric- 
tion, until at last only the edges of the vocal bands 
can be seen through the narrowed orifice that re- 
mains.” This is a satisfying, even if highly theoret- 
ical, explanation, but does not at all describe the 
head voice which is resonated from the highest levels 
of the nasal sinuses, the uvula being almost entirely 
drawn up into the naso-pharynx, thus shutting off 
the post-nasal space. SOME VOCAL HABITS WHICH HANDICAP 
27 
The differences between head voice and chest 
voice are chiefly as follows: 
In chest voice, the vocal cords vibrate in their 
whole length, and the sounds are reinforced largely 
by the cavity of the chest, the walls of which can 
be felt to vibrate strongly when this register is 
Fig. 5.—Closure of post-nasal space by uvula in taking a high note. 
1. Uvula; 2. Vertebra of cervical part of spine; 3. Tongue; 4. Vocal 
cords. The arrow shows direction of vibrating tone and its reflection 
from the roof of the mouth. 
used. In head voice, only part of the cord vibrates, 
and the sound is reinforced by the upper resonators, 
mouth, bony cavities of the skull, etc. It is this 
which has given rise to the absurd statements of 
singers that they could feel their head notes coming 
from the back of the nose, the forehead, etc. In 
the ‘dong-reed’’ register (men chiefly) the pitch 
is raised by the increasing tension and lengthening 28 
HYGIENE OF THE VOICE 
of the vibrating element; in the “short-reed” reg- 
ister (women), by gradual shortening of it. 
Another common fault, which speedily becomes 
a habit, is the tendency to tighten or grip the throat 
muscles. This is a sure sign of bad training, or 
rather of no training at all; for no real teacher 
allows a pupil to sing “throaty” if he can possibly 
prevent it. Mackenzie says: 
“A feeling of tightness in the throat in singing is 
an almost certain sign of inartistic production; it 
is especially felt when the voice is being used in 
a wrong register. The sensation is probably due 
to excessive contraction or even slight cramp of 
the muscles which form the wall of the pharynx. 
This “tightening of the neck” may also exist as 
a vice of production throughout the entire compass 
of the voice. It spoils the beauty and fullness of 
the tone and even, to some extent, accuracy of 
pitch by altering the shape of the resonator. Con- 
stant practice on the middle notes and in piano 
singing, swelling the voice out by degrees, and in- 
stantly stopping when the tightness begins to be 
felt, are the best ways of overcoming the defect.”’ 
This vocal defect is of especial importance be- 
cause it lays the groundwork for phonasthenia which 
will follow as night follows day unless freedom of 
muscular action can be secured. 
Sound is produced in the larynx, but articulation, 
or the transformation of meaningless sound into 
voice, is performed in the mouth; in speaking, 
therefore, the two parts work together, the larynx 
sending out a stream of sound, and the mouth, by 
means of the tongue, cheeks, palate, teeth and lips, 
breaking it up into variously formed jets or words. SOME VOCAL HABITS WHICH HANDICAP 
29 
The infinitely complex muscular movements that 
go to the making up of tone must be guided by art, 
not by brute force; whether the laryngeal outlet 
be narrowed or widened, the voice should flow 
through it with the liquid smoothness of a stream 
of oil. 
Fig. 6.—Position of uvula in taking a low note. The vibrating air 
column is divided, part going through the nose, part through the mouth. 
1. Uvula; 2. Vertebra; 3. Tongue; 4. Vocal cords. 
Approximation of the cartilages stretches, whilst 
separation of them relaxes, the vocal cords. Ac- 
cordingly, we find that at the lowest part of the 
chest register the interval is at its widest, whereas 
in the upper, the gap entirely disappears, as can 
easily be verified by the singer’s own finger. 
Experiments on the living larynx have almost 30 
HYGIENE OF THE VOICE 
all been made on animals. It need hardly be 
pointed out that no conclusive evidence about the 
mode of production of the human voice can be 
drawn from that of brutes. 
“The first point in the training of the larynx/’ says 
Mackenzie, “is to insure the production of pure tone 
by accurate adjustment of the vocal cords. Each 
note must be ‘held’ without the slightest alteration 
of pitch or intensity, that is to say, with perfect 
steadiness and evenness. This may appear a simple 
enough thing, but like the goose-step of the recruit, 
it is the foundation of vocal discipline. When 
perfection has been obtained in this, the pupil’s 
control of his voice must be still further increased 
by constant practice of what the Italians call the 
messa di voce, i.e., the holding of a note in a vary- 
ing scale of intensity, beginning from the softest 
piano and swelling out by degrees to the loudest 
fortissimo and then back again in the same way to 
pianissimo in one breath. This is perhaps the most 
essential feature of artistic voice-production, and the 
utmost importance was rightly attached to it by 
the famous old teachers, who made their 
pupils constantly practise it, and considered the 
possession of the power as one of the surest marks 
of an accomplished singer. If, as is commonly the 
case, the singer employs more than one register, 
the matter must be carefully studied, the special 
pecularities of every voice being most diligently 
investigated.” ' 
“The proper use of the registers is a point of the 
greatest importance in teaching. Some tenors can 
attain a very high pitch with the long reed (chest SOME VOCAL HABITS WHICH HANDICAP 
31 
register), and Tamberlik, Duprez, Maas, and a few 
others have been able to hold it, whereas most 
tenors experience great fatigue of the tensor muscles 
of the vocal cords if they sing very high notes in 
the chest register; indeed, the attempt often brings 
on serious congestion of the windpipe. On the 
other hand, by using the short reed (falsetto) such 
singers can produce charming tones without any 
injury to the delicate muscular apparatus of the 
larynx. Many persons can produce two octaves and 
two or three notes with the long reed, and do not 
find it necessary to shorten the vibrating element, 
but a large number of mezzo-sopranos can only 
reach their higher notes with the head register 
(short reed), and contraltos also* usually employ 
this mechanism.” 
Interference is another vocal error which may 
become a habit, if persisted in for long. The chief 
kinds of interference are caused by improper use of 
the soft palate, tongue and false cords or ventric- 
ular bands. The pillars of the fauces, between 
which lie the tonsils, are frequently at the bottom 
of the difficulty and are often associated with tight- 
ness. 
The pillars are attached to the sides of the throat 
near the back of the tongue. Now these ridges or 
pillars are in reality bundles of muscular fibres, one 
of which (the anterior) is attached to the tongue, 
whilst the other is directly connected with the 
upper cartilage (thyroid) of the larynx. Eleva- 
tion of the soft palate must, therefore, ipso facto, 
tend to pull up the tongue and the larynx, an action 
which is assisted by the sympathetic contraction of 
the muscular pillars themselves. This explains 32 
HYGIENE OF THE VOICE 
why the larynx, as may be verified by anyone for 
himself, rises in the throat as the voice goes higher, 
a change of position which some writers have re- 
garded as an essential feature in the production of 
head tones. That it is not -so is proved by the fact 
that falsetto notes can be sounded without any 
accompanying elevation of the larnyx, provided 
that the tongue be fixed. The larynx certainly 
a little downward towards the chest in the 
utterance 'of deep notes; this, however, is a conse- 
Fig. 7.—Position of the vocal cords while singing. 
quence rather than a cause of low pitch, as the 
singer instinctively relaxes all the muscles support- 
ing the organ so that the cords may be in the posi- 
tion of least tension. The lowering of the chin 
towards the breastbone is part of the same natural 
adjustment. 
The inexperienced laryngologist may fall into 
error in examining the larynx, if he has had little or 
no experience with singers. It is of importance to 
know the normal, and then to know those slight 
variations which are only of importance if they 
lead one into the error of mistaking them for ab- SOME VOCAL HABITS WHICH HANDICAP 
33 
normal. Mere redness of the cords, for instance, 
is no indication of an inflammatory condition, or, of 
an improper use of the larynx. 
In some of the best singers, the vocal cords are 
never of normal color, i.e., pearly white, but always 
more or less red. Again, in determining the func- 
tional fitness of the cords, the manner ip which they 
perform their movements has to be taken into ac- 
count. As this depends much more on the efficiency 
of the nervous apparatus than on local conditions, 
it would not be wise for “the anatomico-physio- 
logico-laryngoscopical vocalist” to trust to his own 
observations. 
With respect to bad vocal habits, and the effort 
to acquire the opposite through thought and pains- 
taking practice, one is sometimes asked whether 
silence preceding a performance is not wise; that is, 
would it not be a good thing to give the voice 
absolute rest before “going”? 
Brouc lays it down as a rule that the most ab- 
solute silence must be observed during the whole 
day before using the voice in the evening. This 
counsel of perfection is, of course, for actors, but; 
if the rule is sound it must apply to speakers of all 
kinds. It is hard to believe that such an ultra- 
Trappistical code is beneficial, even supposing that 
any one could be found to adhere scrupulously to 
it. That the voice should not be exerted as in 
prolonged declamation or even much speaking in 
noisy streets, cabs or trains, every one will agree to, 
but absolute silence would probably be rather in- 
jurious than otherwise. 
As in all other matters of life, sound, practical 
common sense should govern the singer’s acts. 34 
HYGIENE OF THE VOICE 
Mackenzie cites the curious case of “a lady who 
was in the habit of drinking a glass of iced water 
immediately before going on the stage. To say 
nothing of the immediate shock to the nerves of 
the throat, the reaction that must inevitably follow 
such an application would be likely in less excep- 
tional organizations to induce a degree of congestion 
that would seriously interfere with clearness of 
delivery.” 
There is not much to hope for in a person with 
so little plain “horse sense” as that, either from 
an artistic standpoint or as regards the simplest 
requirements for everyday happiness. 
Defects of speech can sometimes be helped by a 
thorough mastery of the art of song, but many of 
these patients soon relapse into their old ways when 
away from the influence of the teacher. 
Stammerers and stutterers should carefully avoid 
each other’s company, and children of markedly 
nervous temperament should on no account be 
allowed to associate with persons who have any 
impediment or even singularity of speech. 
Defects of utterance can be cured only if the 
cause is recognized. For stammering nothing can 
be done unless the sufferer can learn to use his 
breath properly. The instructor’s efforts must be 
mainly directed to teaching his pupil to acquire 
some degree of control over his diaphragm and other 
respiratory muscles, so that the air or motive power 
shall not be allowed to leak away before the vocal 
apparatus can be got ready for it. 
“In one of the worst cases of stuttering that I 
have met,” says Mackenzie, “the utterance was al- 
ways improved by small doses of strychnia, whilst SOME VOCAL HABITS WHICH HANDICAP 
35 
the sufferer was almost deprived of the power of 
speech by tobacco.” 
Relief measures group themselves naturally into 
gymnastic and mechanical measures. The aim of 
the former is to make the pupil acquire a proper 
control over his organs of speech by means of 
regulated exercise of the breathing apparatus and 
of the tongue, whilst the latter seeks to help him 
by means of instruments which serve to hold up 
or keep down the tongue. 
The importance of securing a satisfactory teacher 
in these cases cannot be overestimated. To quote 
Mackenzie once more: 
“Patients have been brought to me who had lost 
all control over the voice, not from any disease or 
organic defect, but solely from nervous disturbance, 
caused by a blustering or unsympathetic master. 
It is as though one were violently to shake and pull 
about a watch whenever there is the least failure in 
the precision of its action.” 
Harmonious co-operation is the watchword of 
success in all difficult cases, no matter whether the 
mentor be teacher or physician. No matter how 
eminent the instructor, a pupil is not going to 
advance if she is half frightened to death, or if she 
develops any sort of antipathy to a personality or 
method. CHAPTER V 
THE IMPORTANCE OF GOOD HEARING 
In the chapter on “colds/’ mention is made of the 
fact that a common result is aural abscess with 
impaired hearing. As a matter of fact, we may 
safely say that fully 90 per cent of all difficulties 
with hearing arise primarily from some nose or 
throat infection. Very often the infection has been 
unrecognized or forgotten, but if the patient re- 
flects carefully, the sinister influence of some ante- 
cedent nasal disease makes itself manifest. 
Of the more severe types of disease causing ear 
trouble, scarlet fever is the commonest. In fact, it 
is rather unusual to examine a person who has had 
“scarlet” without finding some evidence of invasion 
of the ears by this dread malady. At the New York 
Institution for the Deaf and Dumb, where I served 
at one time as aural surgeon, a large percentage of 
the children had survived a severe scarlet fever in- 
fection successfully, only to be obliged to exist for 
the rest of their lives minus that special sense which, 
with the single exception of vision, is the most im- 
portant to human economy. That this should be so 
is exceedingly unfortunate; for, as yet, it is impos- 
sible to immunize or abort scarlet fever, chiefly 
because the germ or exciting agent is unknown. 
Complete isolation of infected children has done 
much to prevent its spread, but the interweaving 
36 THE IMPORTANCE OF GOOD HEARING 
37 
of human relations is such that absolute quarantine 
is well-nigh impossible. 
Cases of “hereditary deafness” are ordinarily de- 
scribed in the text-books, and are reported as such 
by writers in the medical journals. In the last 
analysis it is very doubtful whether deafness can be 
inherited. The predisposition is there, to be sure, 
just as it is in some cases of pulmonary tuberculosis, 
but the actual cause is probably not inherited—this 
portion of the body is merely less resistant than it 
should be, and cannot throw off the infection once 
it is encountered. In any event, we do know that 
“chronic catarrh” of the nose is very prejudicial to 
the hearing, particularly if it is of the post-nasal 
variety; that is, where there is a good deal of drop- 
ping from the back of the nose to the throat. Such 
cases must be studied and treated with diligence, 
and every effort must be made to build up the 
patient’s resistance against catching cold. The new 
vaccine therapy offers some prospect of help when 
used judiciously. 
There is no doubt that many singers have defec- 
tive ears. “The difference in most cases between 
singers and those who have ‘no voice’ is really a 
defect of ear on the part of the latter, who are 
naturally unable to imitate sound, that is, reproduce 
gradations of pitch, which, as a mater of fact, they 
either do not hear at all, or only imperfectly.” 
(Mackenzie.) It is not always simply a question 
of removing a little wax and letting it go at that. 
The idea of pitch may be quite different in the two 
ears, owing to middle ear diseases, or it may be of 
congenital (birth) origin. A thorough examination 
of the singer’s vocal powers must include hearing 38 
HYGIENE OF THE VOICE 
tests, and tone judgments. Some musically inclined 
people have no idea of sound as distinguished from 
noise. This is a misfortune akin to being born with 
one arm, but fortunately it is more amenable to 
treatment. The sense of musical sound can be 
cultivated to limits almost beyond the imagination, 
if sufficient pains be taken to secure accuracy. 
Standards of tone are furnished by the world’s 
greatest artists who have the gift of a “musical 
ear,” fortified by assiduous practice and cultivation. 
In this age we are particularly fortunate in having 
the phonograph as an aid in cultivating our hearing 
from the musical side; for in those who are not 
geniuses, the fountain spring of success in any art 
is conscious and laborious imitation. Only in this 
way can greatness be understood even in a moderate 
degree. Cultivation of a so-called musical ear is 
dependent on normal hearing, to begin with, rein- 
forced to the saturation point by the best that can 
be heard. It is the old question of having the 
physical and psychical elements fundamentally nor- 
mal, and then going ahead on a sound basis to 
cumulative development of the highest form of art 
which one can hope to reach in the short span of 
human existence. 
Relatively few cases of impaired hearing begin 
with violent symptoms. More often the process 
goes on insidiously, so insidiously that a great deal 
of acuity is lost before the afflicted one becomes 
aware of his handicap in the struggle for existence. 
Quite often it is discovered at table that some mem- 
ber of the family is always asking that sentences 
and phrases be repeated. When words uttered 
singly are misunderstood, the damage to hearing has THE IMPORTANCE OF GOOD HEARING 
39 
become extensive, and treatment may be of no avail. 
An intelligent person always fills in unconsciously 
from the context of what was said, if the sentence 
is of any length; but in the short sentences defini- 
tion of sound is more difficult, and mistakes are fre- 
quent. Rhyming words having a difference of only 
one letter are most frequently mistaken, and are 
sometimes the cause of much merriment at the ex- 
pense of the defective listener. Very often such 
mistakes are put down to inattention, or the unfor- 
tunate person is chided for having “wax in his ears.” 
All of us have in reality a gift of hearing which is 
much greater than our actual needs for the ordinary 
purposes of life; hence a very considerable amount 
of hearing may be lost without our becoming con- 
scious of the defect. Upon examination, such per- 
sons are surprised to note the difference of acuity 
in the two ears. 
In a quiet room, with the patient standing profile 
to the examiner, doors and windows closed, the eyes 
shut, one should hear an ordinary whisper at twenty 
feet. The watch should be heard at from six to 
fifteen feet, and all of the tuning forks should be 
detected at any reasonable distance. If this does 
not work out, then there is some defect in hearing 
which must be diligently studied and analyzed by 
the ear specialist (otologist or aurist). 
How does ear trouble begin? Does it come by 
way of the external ear channel? No, not often. A 
great many people think that stuffing cotton into 
the external canal before bathing is absolute pro- 
tection to the organ of hearing. This is a mistaken 
idea; for, if the drum is intact, it does no harm 
whatever for water to enter the canal,—in fact, no 40 
HYGIENE OF THE VOICE 
amount of water can stay in this canal, any more 
than it can stay in a bottle when turned upside 
down. It is all right to wear cotton for the relief 
of external pressure, if one is sensitive to that sort 
of thing, but it does no good as a preventative of 
hearing difficulties. The reason for this is as fol- 
lows: 
The middle ear is a small cavity in which the little 
bones—hammer, anvil and stirrup, as they are 
called, are located. These structures are separated 
from the external canal by the drum or tympanic 
membrane. Leading from the middle ear cavity to 
the throat is a channel called the Eustachian tube, 
after an Italian anatomist, Eustachius, who first de- 
scribed it. This arrangement aims to maintain a 
balance between the atmospheric pressure against 
the drum from the canal, and the pressure from 
within the tube, If now, the tube be closed by any 
swelling or disease process, then the air in the mid- 
dle ear is absorbed and the drum is driven inward 
by external pressure in the canal. However, in 
swimming, there is a great tendency for water to 
rush into the Eustachian tube as well as into the 
external canal. This water in the tube has great 
difficulty in finding its way out, owing to mechanical 
conditions present, and hence the peculiar feeling of 
fullness after swimming. If the water is relatively 
free from germs and irritating foreign particles, it is 
ultimately absorbed, or drains off slowly into the 
throat and no harm is done. On the other hand, if 
disease germs are at the back of the nose and are 
washed in wuth the water, they find a favorable soil 
for development and may form an abscess or set up 
a chronic, progressive inflammation. If an abscess THE IMPORTANCE OF GOOD HEARING 
41 
forms, the drum ultimately breaks unless opened 
with a knife, and the abscess contents escape. If 
no abscess forms, but only constant irritation goes 
on, then the delicate middle ear structures become 
thickened and finally the nerve of hearing becomes 
involved also. After this stage has been reached, 
treatment is of little or no avail, for there is no 
known method of restoring such a nerve to function. 
I have used water as a convenient aid to help the 
reader understand the process of infection, but in 
many cases the patient has not had his head under 
water for years. In such instances the infection is 
blown in while blowing the nose, or it may work its 
way along the structure of the mucous membrane 
from some nasal or throat focus (extension by con- 
tinuity). 
If there is any water or mucus at the back part 
of the nose (naso-pharynx), one should not blow 
the nose violently for there is great danger of in- 
flating the tubes and carrying the foreign substance 
directly into the middle ear. It is much better to 
pull the air back through the nose thus cleansing the 
naso-pharynx, or as it might be phrased, “it is safer 
to blow the nose backwards than forwards,” for by 
this method no extraneous matter can go where it 
may be harmful. 
A great many patients, not only singers, but those 
in other callings, come in with some vague pain or 
tenderness around an ear and ask whether by any 
chance they may not be getting up a mastoiditis. 
Of that disease there seems to be as much dread as 
of small pox, and, therefore, it may be in order to 
say a reassuring word. 
Mastoiditis always follows an infection in the 42 
HYGIENE OF THE VOICE 
nose or naso-pharynx; that is, there is a very bad 
cold in the head, usually with thick, yellow dis- 
charge (“matter”) which eventually gets up the 
Eustachian tube into the middle ear. One then ex- 
periences excruciating pain in the ear owing to a 
stretching of the drum by the fluid within the mid- 
dle ear cavity which is trying to find a way out but 
cannot get back into the nose because of the swollen 
condition of the tubal lining membrane. The fluid 
is, therefore, trapped; and, following the line of 
least resistance, breaks through the drum and dis- 
charges through the canal, staining one’s pillow or 
an applied piece of cotton. If an ear surgeon sees the 
condition early enough, that is just when the drum 
is swollen and bulging, he will make an opening in 
the drum with a very fine instrument and let the 
discharge out. Some people prefer that the abscess 
break spontaneously, but this is unwise as the con- 
dition seems more likely to become chronic owing to 
a persisting perforation of the drum. One is often 
asked if incision of the drum does not cause deaf- 
ness. The answer is positively No. There are a 
great many people going about their daily tasks who 
have been obliged to undergo what is called a radical 
mastoid operation for the cure of chronic discharge. 
In this operation, not only the drum, but the little 
bones in the middle ear called the hammer and an- 
vil, are entirely removed, and the bone cavity left 
behind becomes entirely covered with skin, but in 
spite of that a whisper can be heard at from six to 
ten feet. In other words, after a middle ear dis- 
charge dries up, the hole in the drum heals and the 
hearing is practically as good as it ever was. 
The ear surgeon sees a number of these cases dur- THE IMPORTANCE OF GOOD HEARING 
43 
ing the summer months, and they are usually the 
result of bathing, particularly diving. It is a com- 
mon sight to see a bather come out of the water and 
blow his nose violently instead of pulling air back 
through his nose as explained above. This is a prac- 
tice so dangerous to the ears, and, ultimately, even 
to the life of the patient, that wide publicity should 
be given to its possible pernicious results. Putting 
cotton in the ear canals does no good, of course, as 
water does not get in by the external route if the 
drum be intact. CHAPTER VI 
COLDS—THEIR CAUSE AND CURE 
I venture that if any one were to ask the au- 
thorities at the Metropolitan Opera House this ques- 
tion, “What is the usual reason for making a change 
of bill in your arrangement of performances?” the 
answer would be, “Because Mine. X is ill with a 
cold and cannot appear.” Of course, this is not 
always a valid reason; for “a cold” is a very con- 
venient excuse, and is ordinarily quite acceptable, 
but, as a matter of fact, it requires a very little cold 
to put a very big singer quite out of the running, 
so to speak. A cold is usually accepted as something 
inevitable, and the average person does little to 
alleviate it save to swallow a few “rhinitis tablets” 
and drink a hot toddy. These measures, while some- 
times effectual in other persons, often fail in singers 
because they do not relieve the local condition in the 
nose and throat in a way that permits satisfactory 
use of the voice. Camphor, quinine and belladonna 
are the drugs ordinarily used in the above men- 
tioned tablets, and, if taken in sufficient quantity 
to afford relief, they dry up the secretion too quickly 
and parch the mucous membrane. As every singer 
knows, a dry throat is fatal to good tone work. 
Every year there seems to be an increasing num- 
ber of singers who are suffering from vocal impair- 
ment as the result of an acute respiratory disease 
44 COLDS—THEIR CAUSES AND CURE 
45 
which has gone on through neglect or incompetent 
treatment to a chronic state. Many of these re- 
member having “sung through a cold” or grippy 
condition. A large number are suffering from 
chronic laryngitis or bronchitis and have a constant 
desire to clear the airways of secretion, which is 
always a persistent symptom. Vocal uncertainty 
is always an accompaniment of such a condition, the 
voice being good one day and bad the next. In 
spite of all the various singing methods which are 
Fig. 8.—Position of the vocal cords on deep inhalation showing the 
trachea divided into 1. Right bronchus; 2. Left bronchus. 
supposed to cure such an infection, it persists be- 
cause the bacterial cause is still present deep down 
beneath the mucous membrane and cannot be per- 
manently routed out. Anyone who understands 
the pathology of these conditions will readily see 
that no amount of vocalization or breathing exer- 
cises can ever hope to effect a cure. 
Grippe and colds, like the proverbial poor, “we 
have always with us/’ and, like the poor, too, grippe 
and colds are very often neglected. Therefore, a 
widespread campaign of enlightenment and elucida- 
tion is in order if the general public is to know how 46 
HYGIENE OF THE VOICE 
the ravages of these dread diseases are to be com- 
bated. Of the two, grippe is especially protean in its 
manifestations, attacking now the lungs, now the 
gastro-intestinal system, or again the nervous sys- 
tem without apparent rhyme or reason. During 
1916 there were many cases of abscess in the ears 
and complications in the nasal sinuses. In 1917 we 
had a return to the primary lung involvement type 
with fatal pneumonia as a frequent sequel. It is 
extremely important that a warning be sounded 
against temporizing with this stubborn malady. 
Prompt and effective local treatment is the only safe 
way to prevent a prolonged period of convalescence. 
Grippe, like colds in general, is an acute infectious 
disease which is contracted from some person pre- 
viously infected. It is not a visitation of Providence 
in retribution for sin, as some well-meaning persons 
who cling to the old theology seem to think, but a 
germ disease which can be definitely studied under 
the microscope. In the beginning it is purely a 
local condition as evidenced by sneezing, coughing, 
sense of tightness or fullness, watery eyes, discharg- 
ing nose, etc. These are all early symptoms, and it 
is at this stage that influenza can be cured or aborted 
by effective treatment. Later, when the system is 
reacting to the effect of the toxines absorbed from 
the site of the original infection, there are head- 
ache, rapid pulse, fever, pains in the muscles and 
joints, depression, and a whole train of other dis- 
tressing symptoms. 
A cold is something more than an annoyance. It 
is, in many cases, a real danger, because under the 
mask of a simple “acute catarrh” may be lurking 
the dread germs of pneumonia or tuberculosis. If COLDS—THEIR CAUSES AND CURE 
47 
the infectious nature of colds were better appre- 
ciated, they would have to be reported to boards of 
Health along with scarlet fever and diphtheria. To 
be sure, most people recover from a simple rhinitis 
or laryngitis in due season in spite of, or because of 
treatment as you wish, but who can say that colds 
do not furnish the soil and lay the stratum for many 
other diseases, both acute and chronic? A few 
months ago, the Commissioner of Health of New 
York City made strenuous efforts during an epi- 
demic of influenza to educate the public against 
spreading diseases by droplet infection. It was an 
impossible task, but it was worth trying. We ought 
to wage perpetual warfare against the ignorance and 
carelessness of those who cough and sneeze in public 
places without protecting the face with a handker- 
chief. It is, after all, such a little thing to do, to 
learn how and when to use the pocket handker- 
chief. Expectoration on the floor of a car, while 
disgusting, is much less dangerous to health than 
the sputtering of fresh, germ-laden spray into the 
air which must be breathed by defenseless passen- 
gers. The peculiar, pervading odor after a sneeze 
gives one a vivid idea of how great a number of 
persons can be infected from this one source alone. 
Sneezing and coughing are both cleansing acts. The 
mucous membrane of the nose and throat rebelling 
against the presence of some irritating, foreign 
agent, experiences a reflex nerve-impulse and en- 
deavors to shake off the intruder very much as a 
horse, by wriggling the skin, shakes off flies in sum- 
mer. The old idea that “a fit” of sneezing in an 
audience was simply due to unconscious imitation is 
no longer tenable. Particles cast off by some one 48 
HYGIENE OF THE VOICE 
having a cold are inhaled by susceptible persons, 
and eventually the whole audience may become in- 
fected. 
It is a momentous fact that practically all of the 
acute infectious diseases of childhood begin as nose 
and throat difficulties. In measles, there is the 
watery eye and running nose; in scarlet fever, there 
is the peculiar, red, strawberry tongue; in diph- 
theria, the whitish patches from which alone the 
expert diagnostician can make his diagnosis. Re- 
cently it has been determined that acute anterior 
poliomyelitis (infantile paralysis) begins as a nose 
and throat infection. These examples ought to be 
sufficient to convince any one of the ease with 
which all air-borne diseases can be carried from 
one person to another. With every breath, we are 
capable of drawing in the germs of some infectious 
disease. Why is it, then, that everybody is not 
constantly ill with one or another of these pesti- 
lences? Because the nasal secretion itself is capable 
of destroying a large number of the less virulent 
germs owing to its bactericidal power. Then, too, 
a very resistant person has a large supply of “anti- 
bodies” in the blood, capable of neutralizing toxins, 
which prevent active symptoms of disease from be- 
coming manifest. 
The acute respiratory infections lie no longer 
within the province of the general practitioner, but 
must be relegated entirely to the nose and throat 
specialist. No amount of drugs taken into the 
stomach can ever do much toward the cure of a 
condition which is not even remotely connected 
with that organ. When one has a “boil” on the 
neck, he wants the boil treated directly, and not COLDS—THEIR CAUSES AND CURE 
49 
some other part of his anatomy. The offending 
bacterium must be killed with antiseptics and routed 
out of its nest. A cold or a grippe attack is just 
as much an infection as a boil,—in fact, it may be 
caused by the same organisms. The mucous mem- 
brane of the nose, throat, larynx, trachea and lungs 
must be treated directly by application of antisep- 
tics. These antiseptics must enter every nook and 
cranny which can be reached. No other method 
has the same effect as direct application of a suf- 
ficient quantity. Fully fifty per cent of the cases 
of “chronic catarrh” and sinus disease one examines 
in daily practice, have never been treated by the 
direct method. Most of them have supported the 
corner druggist for some years in the mistaken 
notion that they were saving money, only to find 
eventually that they will be obliged for the rest of 
their lives to put up with the annoyances and 
distress incident to the activities of an incurable 
condition. Nearly every disease in its very begin- 
nings is curable; chronicity is simply another word 
for neglect, and neglect is the handmaid of ig- 
norance. 
The purpose of this chapter is to caution singers 
particularly against continuing their work after the 
acute symptoms of an infection have begun. Most 
vocalists think that an engagement outweighs every 
other consideration. The singer feels that he “sim- 
ply must appear,” and just as likely as not gets out 
of bed, braves wintry blasts and crowded convey- 
ances, exposes himself to the drafty back stage, 
and makes a poor showing which is not discounted 
in the least by public or critics who, of course, can 
know nothing of the laborious effort or inward 50 
HYGIENE OF THE VOICE 
anguish. Several medical consultants may be seen 
in the singer’s apartments on the day following, 
most of whom do little more than look serious. 
There is nothing that a physician dislikes more 
Fig. 9.—Enlargement oi the inferior turbinate, ending in strawberry- 
like posterior tip (T). Such a condition causes nasal obstruction similar 
to adenoids, and post-nasal dropping of mucus. 
than to be called in at the eleventh hour. It is 
usually very unsatisfactory to everybody concerned. 
The disease is then thoroughly established and dif- 
ficult or impossible to cure. COLDS—THEIR CAUSES AND CURE 
51 
When a cold is once under way, what can be done 
to check it? Many have been the articles written 
in medical books and journals concerning the treat- 
ment of colds. Some of these are helpful, more 
are worthless in so far as singers are concerned; for 
the requirements of the latter are special and 
peculiar. It demands very special observation and 
experience in treating singers to do good without 
doing harm. First of all, self-medication at home is 
not to be recommended, because nobody can see 
into his own nose and throat in a way to make self- 
medication effectual. Local appearances and con- 
ditions change from hour to hour, and it requires 
expert judgment to know just what to do and how 
to do it. Self-medication is often fostered by the 
tender ministrations of an obliging druggist, who 
feels in duty bound to placate a customer by hand- 
ing over the counter anything that the law allows 
him to sell without a prescription. It is unwise to 
ask the advice of a pharmacist in matters medical. 
He is in his place of business to sell drugs on the 
order of a physician, not to prescribe them. In 
fact he is not trained to prescribe, and when he 
becomes ill he must call in a medical adviser just 
like one who knows nothing of remedies. Drugs 
sold over the counter for the relief of colds are: 
phenacetin, salol, quinine, aspirin, troches, lozenges, 
etc. For a cough, some compound cough mixture 
is usually administered which upsets the stomach, 
and makes the last estate of the patient worse than 
the first. A cold in its beginning is a local not a 
constitutional disease, and should yield to local 
measures. Just so soon as the local symptoms are 52 
HYGIENE OF THE VOICE 
cleared up, the constitutional symptoms, if any, 
subside. 
At the very beginning of a “a cold” there are 
some don’ts which should prove of service: 
Don’t wait to see if the tight feeling in the nose 
and throat, the watery eyes, the altered vocal 
quality are “going to amount to anything.” 
Don’t consult your druggist or even the family 
physician unless he is thoroughly equipped to treat 
your condition locally. 
Don’t think you are showing your heroism by 
“fighting” against the infection and going about 
your daily work as if in the best of health. You 
are doing nothing of the sort,—in reality you are 
aiding an unseen enemy who will surely defeat you 
sooner or latter. 
Don’t swallow rhinitis tablets, aspirin, calomel, 
hot whiskey and patent medicines in the first stage 
of your malady. You are wasting valuable time. 
At this period your specialist can cure you in two 
or three visits. Later on he may not be able to do 
it at all. 
It would seem that the logical method of treating 
a cold is not to administer remedies by stomach, if 
no condition there requires attention, but to apply 
such remedies directly to the site where action is 
desired; that is, into the nose in acute rhinitis, or 
into the throat when active inflammation is located 
there. In dealing with these acute infections in 
singers, the two remedies most often used by the 
specialist are silver in some form or iodoform. The 
silver salts, while irritating and unpleasant, are effi- 
cacious in many cases. Iodoform has such a per- 
sisting, penetrating odor that it is very objectionable COLDS—THEIR CAUSES AND CURE 
53 
to many fastidious persons. It is most frequently 
suspended in oil or ether and sprayed on the in- 
flamed parts. 
During the past ten years I have been using with 
good effect, certain well-known antiseptic principles 
—not as a spray, but in drop form applied directly 
to the mucous surfaces. The results of these in- 
vestigations were published in the Boston Medical 
and Surgical Journal of November 4, 1915. This 
combination is mildly antiseptic, relieves conges- 
tion, cools and partially anesthetizes the inflamed 
areas, and gives the patient a pleasant sense of 
exhilaration for two or three hours. An ordinarily 
severe bronchitis will clear up in from forty-eight 
to seventy-two hours by this method. In acute 
laryngitis the relief is immediate. 
In acute bronchitis with severe coughing, it is 
astonishing how effective treatment may be. The 
oily vehicle which carries the aromatic drugs heals 
and lubricates the irritated mucous membrane, and 
in a few hours a marked change for the better is 
seen, the sufferer expressing himself as very highly 
gratified at the improvement. 
A certain patient is subject to sudden, severe 
attacks of laryngitis in the spring of each year. 
She loses her voice completely for weeks unless 
treated. In May, 1922, she appeared at my office 
absolutely voiceless, even whispering was difficult 
for her. Upon examination the entire larynx was 
found red and swollen, the vocal cords were thick- 
ened and covered with sticky mucus, and the whole 
picture was one of intense inflammation. Four 
treatments were given, one in the morning, and 
one in the evening for two days. On the third 54 
HYGIENE OF THE VOICE 
day the voice was entirely normal, and the patient 
was discharged. 
A word must be said in favor of the use of vac- 
cines in some cases, especially where there is a 
tendency to oft-repeated attacks either of rhinitis 
or bronchitis. A culture is taken from the nose 
or throat as the case may be, and an effort is made 
to identify the predominant germ. This done, a 
vaccine is made from the dead organisms which 
have been destroyed preferably by chemicals, and, 
when properly standardized, this vaccine is injected 
through a fine hypodermic needle beneath the skin 
of the patient. As a rule there is very little reac- 
tion, and the patient is entirely able to keep at his 
work. Several such injections may be required be- 
fore the susceptibility is reduced to a point where 
catching cold is rendered difficult. 
There are also several good stock vaccines fur- 
nished by pharmaceutical laboratories. These are 
all ready for use by the physician and save a great 
deal of time and trouble in preparing the cultures. 
In my hands, however, they have not always proven 
to be as effective as vaccines made from a patient’s 
own excretions. 
That a cold should never be neglected was well 
exemplified during the epidemic of influenza in the 
winter of 1915-16. Many neglected cases experi- 
enced complications in the nasal accessory sinuses 
necessitating operation; while others developed ab- 
scesses in the ears, and went through a painful siege 
for some weeks with ultimate diminution of hearing. CHAPTER VII 
VOICE FATIGUE (PHONASTHENIA) 
There seems to be a dearth of information con- 
cerning voice fatigue in singers and speakers in our 
American periodical literature, although it was 
recognized as a pathological entity as far back as 
1600, when Fabricius Ab Aquapendente expressed 
his views on the subject in a rather laborious essay. 
In England, the condition was long known as 
clergyman’s sore throat, while in France it was 
named more accurately by Mandl fatigue de la voix. 
In 1906, however, it was scientifically and accurately 
described in a little brochure entitled “Functional 
Weakness of the Voice in Singers, Speakers and 
Military Officers.” In that monograph, Flatau not 
only gave a clear exposition of the entire matter, 
but recommended and described a rational and suc- 
cessful therapy. 
Weakness of the voice, or phonasthenia, as it is 
now commonly known, is a disturbance in which a 
given voluntary impulse to the vocal bands is not 
followed by a normal tonal effect—that is to say, 
the produced tone is higher or lower than the in- 
tended tone, is unpleasant to the ear, and has no 
staying nor carrying power. 
The fundamental cause of this difficulty is in 
many cases faulty voice placement. Just as many 
people never learn to walk gracefully, many never 
55 56 
HYGIENE OF THE VOICE 
learn how to get the most out of their voices. In 
America we seem to be particularly unfortunate in 
our speech habits, so much so, that our so-called 
nasal twang and careless pronunciation make us a 
butt for ridicule in many foreign countries, where 
we go to exchange good American dollars for as 
much Old World culture as we can assimilate within 
a few short weeks. 
As an expressionist friend* has very tersely put 
it—‘‘Americans returning from Europe hear for the 
first time the raucous, sharp, high-pitched, nasal, 
unmusical voices of their countrymen. Their na- 
tional self-complacency has been punctured, and 
they set about correcting what to them has become 
an offense. The actor has always recognized the 
need for a pleasing expressive voice under perfect 
control. Ministers who deal with the greatest sub- 
ject that has ever engaged the mind of man—the 
destiny of the human soul—pay practically no at- 
tention to the method of delivery of their message. 
They rise upon their toes and fold their fingers, and 
scream till they are purple in the vain effort to be 
impressive.” 
To obtain the best effect, one must study the art 
of control over both body and voice. This demands 
laborious and painstaking effort. The time to begin 
is in childhood, at the “awkward age” when thought 
processes are still plastic and have not reached the 
stubborn and sometimes almost hopeless automatic 
stage,—a period of life in which it is difficult either 
to learn or unlearn. 
Voice is produced, not by the throat alone as is 
commonly inferred, but by every part of the body. 
*Miss Theodora Irvine of Carnegie Hail, N. Y. City. VOICE FATIGUE (PHONASTHENIA) 
57 
The nose, accessory sinuses of resonators, pharynx, 
buccal cavity, teeth, lips, tongue, larynx, lungs, bony 
thorax, diaphragm, thoracic and abdominal muscles, 
and, of course, above all the central nervous system 
take part in this complex vocal mechanism. The 
ears give one an idea of quality, timbre, pitch, loud- 
ness, etc. Touch enables one to “feel a tone,” as 
the expression is. The muscular sense is capable of 
telling whether individual muscle groups and an- 
tagonists are working properly. 
As for the throat itself, correct function of the 
vocal cords calls for the purest and best tone with 
the smallest output of effort consistent with artistic 
speaking and singing. This is a fundamental law 
and the one which is most frequently violated. The 
campaign speaker is always confounding big, burly 
voice with strong argument, and the ambitious 
singer is always mistaking a big, brawling tone for 
genuine art. Accuracy of method should be the 
first consideration. 
Phonasthenia is a condition which affects nearly 
all ages and both sexes. Voices of high pitch are 
especially susceptible, because not infrequently they 
have poor carrying power, and the user is always 
making an effort to be heard distinctly by all. 
Teachers, preachers, stump speakers, vendors, tele- 
phone operators, and singers are most frequently 
affected. 
Certain physical causes associated with diseased 
conditions engender disturbances which prevent the 
muscles concerned with voice production from re- 
acting properly to normal impulses. Thus anemia 
and chlorosis, through insufficient nourishment of 
the muscles and improper removal of waste, are not 58 
HYGIENE OF THE VOICE 
uncommon causes. In such cases, where voice gym- 
nastics and other therapy fail, arsenic, iron, and 
strychnine may work a cure. 
The edges of the vocal cords are extremely sensi- 
tive to slight influences. For example, pregnancy, 
a physiological condition, may change the quality 
and carrying power of the voice very markedly. 
Menstruation also affects some women in like man- 
ner. Convalescence from typhoid and influenza fre- 
quently show marked vocal change which are for 
the most part, however, merely temporary. Chronic 
diseases are a potent cause of voice fatigue; chronic 
tonsillitis with concrement formation is especially 
important. Nasal growths and deformities, puru- 
lent discharges, and chronic hypersecretion are also 
frequently responsible agencies. 
Beside the above mentioned, we have also to 
reckon with causative factors which demand a 
greater amount of strength for the production of a 
tone than should be employed. False teaching and 
improper vocal efforts are common factors. Im- 
hofer says that two-thirds of all cases of phonas- 
thenia in singers are due to bad schooling. Flatau 
believes that eighty per cent of young singers are 
affected with phonasthenia by the end of their third 
year of study. There seems to be no one error of 
method, but every rule which violates the law de- 
manding the use of the smallest amount of effort 
for the maximum of effect, tends to phonasthenia. 
The symptoms of phonasthenia are definite and 
certain. There is sudden and severe hoarseness or 
huskiness, tendency to clear the throat constantly, 
discomfort in the sides of the neck, and discomfort 
on swallowing. There is no sign of an active inflam- VOICE FATIGUE (PHONASTHENIA) 
59 
matory process, although redness is pronounced if 
the condition comes on acutely, as in public speak- 
ing. The voice is weak, unsteady, tends to break 
in certain spots, and to slide off the pitch into a 
lower key. 
In every case of phonasthenia, one should go care- 
fully into the history. Usually there have been 
from two to twenty singing teachers, each of whom 
has told the pupil that his (the pupil's) method was 
all wrong, and must be utterly changed. This pro- 
duces so much confusion and uncertainty that the 
pupil ultimately confesses to lack of knowledge of 
the very fundamentals of voice production. 
Many of these patients have gone through a 
process of having the voice “screwed up." A bari- 
tone has been changed into a tenor, or a contralto 
into a soprano. In some borderline cases it is almost 
impossible to say which type one is dealing with, 
whether, for instance, a voice should be trained as a 
baritone or a tenor. Moreover, certain peculiar 
changes take place quite unexpectedly at times. 
Thus Jean de Reszke began his career as a baritone, 
but his voice changed naturally to an exceedingly 
remarkable tenor. Singing out of one’s range has 
ruined many a good voice. Some music, as written, 
is specially difficult even for a well schooled voice. 
For example, the character, Ortrud in Lohengrin, 
makes very severe demands upon a contralto. 
Breathing, while essentially simple, is a great 
bugaboo to many singers. Instead of being an 
involuntary, automatic act, it is forced and vol- 
untary. The fault is chiefly in improper expira- 
tion. A singer will fill the lungs with air when 
about to take a high note and strive to force the 60 
HYGIENE OF THE VOICE 
entire volume through the narrow chink of the 
glottis. The column of air is too rapidly dis- 
charged. Graphically speaking, the abdominal re- 
spiratory curve is too sharp. It should be wide 
and show a gradual approach toward a straight line 
effect. 
The much-discussed coup de glotte, stroke of the 
glottis, is considered by some authorities to be a 
primal cause of phonasthenia. One must dis- 
tinguish between this method of attack and that 
used by coloraturas in doing agility exercises, for 
the latter is physiological, but the former demands 
that the vocal cords be pressed tightly together in 
making the attack. 
Tongue interference is also a common cause of 
voice fatigue. Here the tongue is arched upward 
and backward, pressing against the epiglottis, and 
dampening the desired effect to a marked degree. 
Usually, the more one draws a pupil’s attention to 
this matter, the more unruly does the tongue be- 
come. Holding the tongue down with a pencil or 
spatula does no good. The condition is of cerebral 
origin and must be corrected from that standpoint. 
Now and then some teacher boasts of a special 
trick or device for overcoming all the singer’s diffi- 
culties, which he has elaborated into a “method” 
and promulgated as a law. As already emphasized, 
there is only one way to sing and that is the cor- 
rect way, viz., by using a minimum amount of 
effort to produce a maximum artistic vocal effect. 
Singing is a great art which does not readily yield 
to a series of rules and regulations. Because it is 
such a simple natural process, excessive thinking 
about how it is done has made it one of the most VOICE FATIGUE (PHONASTHENIA) 
61 
difficult arts to acquire. It is first of all a gift—a 
gift which is not widely distributed among man- 
kind in spite of the fact that nearly every one can 
sing a little. A high artistic standard has been set 
by the world’s great singers which is impossible 
of attainment by the great mass of mankind. It 
is a gift which manifests itself in infancy, and hard 
work is only a very subordinate qualification in 
attaining great place in the world of song. 
For years the battle has been waged between the 
so-called open technic of the Italian school and the 
closed technic which is more distinctly French. 
This debate is of some importance to physicians, 
because it has a direct bearing on phonasthenia. 
Singing with wide open mouth, enormous lung 
volume, and violent movements of the body, lays 
the foundation for an early onset of phonasthenia. 
It is especially bad for contralto, baritone, and bass 
voices where “big tone” is considered of prime im- 
portance. On the other hand, the excessively 
“covered” type of production, projecting lips, 
cramped smile, and a too frequent use of pianis- 
simo wearies the listener and robs the voice of that 
dash and brilliancy so essential to certain type of 
song. 
Anything which disturbs the automatic singing 
act, every adventitious element in the tone-produc- 
ing and tone-resonating apparatus, violates the 
fundamental principle that the least exertion should 
secure the greatest effect, and tends to phonasthenia. 
The voice must be handled as an individual problem. 
The psychic element, mental poise and suggestion 
are all important. It is very necessary for every- 
one who essays to deal with singers to cultivate 62 
HYGIENE OF THE VOICE 
an attentive ear, refined taste, and a habit of re- 
flection. Only in this way can critical judgment 
be educated to interpret what is wrong with the 
voice. Imhofer has put the matter tersely and cor- 
rectly: “Whoever busies himself with the treat- 
ment of voice defects must be a laryngologist, a 
musician, and a diplomat all in one.” 
The treatment of voice fatigue, both in speakers 
and singers, is fraught with difficulty, chiefly be- 
cause the thing mostly to be desired, viz., rest, is 
felt to be impossible. The patient wishes to know 
how he can go on with his work and make a fair 
showing in spite of his disability. But it is of no 
use for a physician to treat such a case while the 
causative agents persist. The physician must recog- 
nize all causes for the vocal breakdown, both direct 
and contributory, and deal with them accordingly. 
With singers a system of prevention should be 
worked out. This will astonish most persons, for 
such a thing as hygiene of the voice is practically 
unknown. The teacher must be invited to send 
his pupils for early examination not only of the 
nose and throat, but of the general physical condi- 
tion as well. This should be done after the first 
interview between teacher and pupil before lessons 
are begun. If in the general examination there are 
extreme nervousness and irritability, poorly nour- 
ished body, chlorosis, anemia or debilitating dis- 
ease, the pupil should be advised not to undertake 
so difficult and prolonged a task as voice culture. 
If he does, disappointment and even worse are 
inevitable. 
The “feeling” and significance of early voice 
fatigue should be explained. The first lessons VOICE FATIGUE (PHONASTHENIA) 
63 
should last not longer than twenty minutes, con- 
sisting of vocalization for five minutes, followed by 
a rest for five minutes. The pupil should not go 
home at the end of the first lesson to strain his 
voice by attempting arias from grand opera. He 
must be taught how delicate the vocal mechanism 
is, and that a long, bright career is rather to be de- 
sired than a short brilliant one. On his own behalf, 
the physician should realize the utter futility of 
spraying, painting, burning, the use of pastilles, 
etc., save when called for in acute infections and 
chronic productive processes. 
When treatment is decided upon, the full and 
earnest co-operation of the patient must be insisted 
upon. Discipline must be rigid, even to the min- 
ute of the hour for appointment. First of all a 
voice analysis with piano should be made with 
notations of all defects. Then the “silence treat- 
ment” must be carried out rigorously, remembering, 
however, that this will not cure voice fatigue, for 
the symptoms will disappear only to return when 
the voice is used. 
The patient is better off away from people who 
make social demands upon him. In certain cases 
vocal gymnastics can be begun right away, but the 
general body condition must be good, especially the 
condition of the nervous system. 
Local causes such as growths, etc., should be re- 
moved when analysis shows that they are of great 
importance, but one must remember that these 
patients are often suffering from local over-treat- 
ment, or rather misdirected treatment. A specific 
case of this came to my attention in which a 64 
HYGIENE OF THE VOICE 
phonasthenic had been so much operated upon and 
cauterized that he became neurasthenic as well, so 
that he could not even take vocal gymnastics. 
Nasal insufficiency, if marked, leads to forcing 
and should be corrected, but preferably by a con- 
servative method. The nasal fossae must be 
equalized in size and function. 
Tonsils in singers must be studied before removal 
is advised. It may be wisest to do a tonsillotomy, 
partial removal, rather than a tonsillectomy, total 
removal, or even to treat the crypts conservatively. 
Caustic agencies are to be avoided in phonasthenia 
—they do little good unless there is much hyper- 
secretion. Warm applications are useful for pains 
in the throat. Menthol may be applied to the 
mucous membrane for cooling, analgesic effect. 
Flatau advised cupping each side of the larynx 
for from fifteen to forty-five minutes. After a few 
hours, this is followed by moderate swelling of the 
vocal cords. In a few days the cords became paler, 
less swollen, and of greater mobility. This method 
often does well with speakers. A spray of ice 
water is a welcome measure with some persons. 
Voice fatigue in speakers is often due to the fact 
that the voice is pitched too high, i.e., above its 
normal range. According to Spiess, the most favor- 
able tone register for speakers is about three tones 
below the middle of the voice range. As soon as 
possible the patient should be taught, by a teacher 
of expression, how to secure and maintain a proper 
relationship between the natural voice and the 
height necessary to declamatory demands. 
The speech must be slow, fairly light, with good VOICE FATIGUE (PHONASTHENIA) 
65 
lip and tongue action. The voice should be directed 
forward against the upper teeth and hard palate, 
and increased and diminished in a monotone. Cer- 
tain syllabic exercises such as the no, na, nu, ni, na, 
and co, ro, mo varieties, sung with moderate 
strength in middle voice, are helpful. During these 
exercises special attention must be paid to the 
breathing. It is, of course, undesirable that the 
physician undertake this work personally, but he 
should insist that it be carried out with a good 
teacher. 
Imhofer and others have worked out a helpful 
but rather complicated system of electrical tests 
of phonasthenia, which need not be taken up here. 
Such tests are of value chiefly in the resistant and 
long standing types of the affection. 
When can we safely say that we have cured a 
phonasthenia? This is sometimes a difficult matter 
to determine, but if there are no subjective dis- 
turbances, if the voice is of good clear quality and 
keeps to the pitch—in short, if there are no dis- 
turbances of intonation, we may safely dismiss the 
case. A useful test is made by applying an elec- 
trical current to the larynx during vocalization on 
a single note. If the larynx is normal, the tone 
should be elevated because of increased muscular 
action. 
Quite marked phonasthenic symptoms may dis- 
appear under proper attack, correct breathing, and 
accurate tone placing. 
The entire problem of voice fatigue is worthy 
of intensive study at the hands of every laryn- 
gologist. A physician’s advice and help are badly 66 
HYGIENE OF THE VOICE 
needed by the singing teacher in treating this con- 
dition, but the doctor in his turn can learn very 
much of interest and practical value from the 
vocalist. In the meantime, the singer-patient is 
benefited by this joint effort of his mentors. CHAPTER VIII 
VOICE TEACHER AND VOICE PHYSICIAN 
Next to thorough analysis of one’s qualifications, 
physical, mental and vocal, comes the problem 
of securing the services of a satisfactory singing 
teacher. All singers will, I think, accede to the 
statement that this is one of the most difficult ques- 
tions to settle. Very few great artists have started 
with one teacher and continued with him through- 
out the long years of preparation. There are many 
reasons for this, chief of which is that one may go 
a long way with her teacher, only to find that the 
personality or the “method” is unsuited to her 
special needs. 
When I first began to pay attention to the vocal 
problem and came into closer contact with teachers 
of singing, I was at a loss to understand the basis 
of antagonism which apparently exists in some 
quarters between teacher and laryngologist. In- 
stead of a spirit of friendly co-operation, there 
seemed to be a watchful and jealous eye under 
which the pupil was obliged to exist. Teachers were 
blaming nose and throat specialists for performing 
unnecessary operations, ruining voices, giving sing- 
ing lessons, undermining the influence of the teacher 
over his pupil and raising havoc generally. The 
laryngologist on his side indulged in disparaging 
remarks and showed other evidence of disregard for 
67 68 
HYGIENE OF THE VOICE 
the members of a profession closely allied to rhino- 
laryngology. In each and every case I found that 
the accusers had no intimate knowledge of each 
other’s work, of the problems they were trying to 
solve, or of the difficulties to be overcome. It was 
manifest that few physicians had ever visited a 
vocal studio to watch the actual work of instruction, 
and that the teacher was equally uninformed of the 
specialist’s viewpoint in the management of throat 
and nose conditions. 
One thing, however, is certain; namely, that both 
have at heart one common aim, one definite purpose, 
the welfare of the pupil. Many a singing teacher 
devotes hours and hours in an attempt to build up 
a voice which to the casual observer seems to offer 
little hope of promise, and this without one cent 
of reward. Unfortunately, too, such effort some- 
times brings forth no sense of gratitude in the pupil. 
On the contrary, one may see such utter lack of 
appreciation as to shake his faith in human nature. 
But the teacher, like the physician, takes it all as 
“part of the game” and plods along doing his stint 
of work as best he can from day to day. When we 
think of the long apprenticeship, the hard struggle 
for recognition, the relatively short career, and the 
rapid vocal decline, we must in all justice condone 
much in singers that would be quite inexcusable in 
others. 
The burning question is, after all: How long is 
the voice going to last? And again: How can we 
help to lengthen the span of vocal life? To begin 
with we must consider each individual separately; 
for his problem may be quite different from that of 
his associate or friend. Any voice which is going VOICE TEACHER AND VOICE PHYSICIAN 
69 
to amount to anything must be built up on a solid 
mental and physical basis. A beautiful tone quality 
is of little ultimate value if there are no brains to 
top it off with. Or, given both of these in good 
measure, one can expect little if the physical organ- 
ism, the general health, is vitally deficient. Mens 
sana in corpore sano is just as important to the 
singer as to any other person; in many respects it 
is of the utmost significance. To excel in song prob- 
ably requires more natural talent, more careful 
Fig. 10.—View of the post-nasal space (naso-pharynx) showing a 
strawberry-like enlargement of the posterior tip of the inferior turbinate 
which completely obstructs the left nostril. 
adjustment of essentials than any other art. Seri- 
ousness of purpose and hard work, while important, 
are less so than talent or intelligence and physical 
fitness. We cannot create talent or intelligence, but 
we can correct many physical defects and can mold 
thought-processes. First of all, the body as a whole 
must be made an efficient instrument of the will. 
The physical organism must be put right. It is dis- 
appointing in the extreme to see the pupil struggle 
along for two or three years under the burden of 70 
HYGIENE OF THE VOICE 
nasal insufficiency, obstructive adenoids, or chronic 
disease of the tonsils, then suddenly become aware 
of the reason for lack of progress. All this for want 
of a thorough and careful physical examination at 
the outset. 
Every teacher and physician should know a great 
deal more than he is obliged to make use of in his 
daily work. His fountain of knowledge should be 
so inexhaustible that no pupil or patient can pump 
him dry. This applies, of course, to those things 
which are known of a certainty, not to the merely 
speculative or quixotic. There must be an increas- 
ing desire to explore the unknown, and to push back 
the veil of ignorance a little further, so that the 
physical horizon of the chosen field shall become a 
vanishing point. It is true that all roads lead to 
Rome, but there is certainly one which is wider, 
smoother, shorter and shadier than all the others. 
It is this which vocalists as a whole are seeking in 
the efforts now making for “standardization.” 
Whether it can be done or not is an undecided 
question, but there is no harm in striving for it. 
Nothing but good can come out of discussions of 
the subject, even if the discussions are sometimes 
attended with more heat than light. The light is 
needed, to be sure, but the heat is a purifier and a 
refiner of ideas. There must be, after all, certain 
guiding principles, which are the basis of all success- 
ful results—the differences are those of degree only 
and not of fundamental fact. 
Thousands of young men and women begin vocal 
work in the fall of each year simply to have some- 
thing to do, or because some friend is taking lessons, 
or to appease the family pride. Under such condi- VOICE TEACHER AND VOICE PHYSICIAN 
71 
tions it does not seem to make much difference who 
undertakes this training task. Very often a pupil 
is influenced to go to a certain teacher because of 
reasons which should carry no weight whatever. 
One of these is to help some individual who has 
been unfortunate, to earn a living. That is, perhaps, 
the poorest reason of all, and is almost sure to bring 
about both regret and repentance. Time, money 
and effort may thus be wasted, and in the end the 
pupil gives up in disgust. 
There are many honest, conscientious, hard- 
working, competent teachers who give excellent 
instruction. Unfortunately, there are a few in every 
walk of life who have no end or aim in view save 
the almighty dollar. These are sometimes the 
highest in price,—they are surely the most expen- 
sive in the long run. But, all in all, there is just 
as much loyalty to a definite ethical standard, just 
as much self-sacrifice and nobility of purpose among 
singing teachers as among any other class of profes- 
sional men. I have known teachers to spend months 
and years in training a naturally beautiful voice, 
only to have the entire effort wasted through some 
foolish whim or caprice or lack of stamina in the 
pupil,—and all this without hope of reward. 
Some people have the idea that a successful in- 
strumentalist, especially a pianist, knows a great 
deal about training the voice. This is not neces- 
sarily true at all; in fact, vocal teachers and instru- 
mentalists are seldom found in happy combination 
in the same person. If one must take an instru- 
mentalist, let it be rather a violinist; for the latter 
comes nearer to an understanding of what is meant 
by fine modulations in tone work than any other 72 
HYGIENE OF THE VOICE 
performer. Of all instruments, as has often been 
said, the violin comes nearer to approximating voice 
in its effect on the ear than any other instrument. 
It is important to determine whether the teacher 
has been a singer who has failed in his work. There 
are some broken-down singers who have come to 
their unhappy state through bad vocal technic. 
Needless to say, it is little short of tragic to entrust 
a fresh young voice to such guidance, however 
honest and conscientious the master may be. Of 
course, he may have failed because of ill health 
or some like misfortune, which reasons certainly 
should not militate against him. Every teacher 
should be able to illustrate his points in a manner 
which it would be no crime to imitate; for imitation 
plays no small part in voice cultivation. 
If the master insists on the forte use of the voice 
during the entire lesson, if at the end of the session 
there is always a strained, tired feeling in the throat, 
weakness or huskiness or tickling, and cough, then, 
whoever your teacher is, whatever his standing in 
the community, he is not for you. As Mackenzie 
so well says: “The most skillful and experienced 
teacher may err, but Nature is never wrong, and 
her laws have the sanction of an unfailing Nemesis.” 
Madam Seiler lays great stress on the importance 
of female voices being trained by women and male 
by men. As vocal art is so highly imitative, there 
may be some truth in this view. According to her, 
F. Wieck always instructed women with the help of 
trained female voices. “The suggestion may seem 
puerile to those who teach solely by the light of the 
laryngoscopic lamp, and who, like the fencing- 
master in the comedy, think more of the way in VOICE TEACHER AND VOICE PHYSICIAN 
73 
which a thing is done than of the result, but if the 
teacher uses his own voice as an example, it seems 
just as likely that a woman trained entirely by a 
male teacher will sing like a man, i. e., with pre- 
dominance of the chest register, as that if taught 
writing by a man she will write like one.” 
It is insufficient evidence of teaching ability if a 
master has produced only one successful pupil who 
is making a fine showing in vocal art. This may be 
simply an accident, some voices being naturally so 
well placed as to defy destruction by incompetent 
meddling. The only practical test is to visit the 
teacher’s studio, watch his method, hear him sing, 
and study his pupils. A knowledge of his past 
musical career is often of some additional value. 
The Italian masters spared no pains to “unite the 
registers,” dovetailing the one into the other, and, 
as it were, planing the surface of sound till the voice 
was smooth and uniform throughout the entire com- 
pass, and no “break” or difference of timbre could 
be detected. 
“In the proper management of the registers lies 
the whole secret of fine singing,” says Dr. Macken- 
zie, “and in nothing is the skill of the master more 
clearly seen than in the success with which he im- 
parts this accomplishment to his pupils. It is on 
this point, too, that vocal training most requires to 
be controlled by the physician, not, of course, that 
a medical man should presume to dictate to the 
singing master what should be done. All I claim 
for science is a right to veto against methods which 
are physically hurtful. If in the attempt to develop 
the voice, a register—i. e., a particular mode of pro- 
duction—is forced beyond its natural limits in a 74 
HYGIENE OF THE VOICE 
given individual, the result is likely to be serious 
injury to the vocal organs, in precisely the same way 
as when the strength of any other part of the body 
is overstrained. It is in order to guard against evil 
of this kind that I have laid such stress on the neces- 
sity of dealing with every voice according to its 
idiosyncrasy. If a teacher mistakes his own ideas 
as to the registers for ultimate facts of nature, and 
insists on making every larynx rigidly adapt itself 
to his a priori conceptions, he cannot fail to work 
much mischief. He may have some brilliant suc- 
cesses, but his record of failures will certainly be a 
heavy one.” 
Far be it from me to belittle the praiseworthy 
efforts of vocal teachers. As a class, they are of an 
exceedingly high order of intelligence, and intensely 
in earnest. Unfortunately, however, their work is 
not standardized and they are severe critics of each 
other. It is to be hoped that in time it will be 
compulsory for every teacher to have a license from 
the State Board of Regents, just as the doctor and 
lawyer must now have. Then the incompetents will 
be reduced to a minimum, and the truly worthy will 
be more highly thought of than at present, when 
there is such confusion and internal dissension. 
Recently in New York City an effort was made by 
M. Philip Berolzheimer and other friends of music 
to have an ordinance passed with would call for the 
licensing of all vocal teachers. A hearing was held 
in the office of Mayor Hylan, to which the best- 
known and most influential teachers in the city 
came in large numbers, and, almost to a man, 
brought forth arguments against any such pro- 
cedure, so that in the end nothing was done about VOICE TEACHER AND VOICE PHYSICIAN 
75 
it. If any reform is to come at all, it should be from 
within; that is, the right-mincled teachers must in 
some way drive out the quacks. It is for the teach- 
ers who have earned a respected place among their 
confreres to band together for the common good and 
try, if they can, to frame such legislation as will 
put vocal teaching on a plane with other great and 
worthy professions. 
In June, 1915, at the Convention of the New York 
State Music Teachers’ Association, held in New 
York City, an honest and praiseworthy attempt to 
begin standardization was set down in a series of 
eighteen postulates formulated by “the Committee 
on Standards” and discussed at length by the entire 
assembly. These statements of fact for the guid- 
ance and instruction of all interested in the singing 
voice were entitled, “Fundamental Principles of 
Breathing,” and are to be found in Appendix I of 
this book. Another set of “Fundamental Principles 
of Voice Production” were submitted for discussion 
by the National Association of Teachers of Singing 
at the same meeting and approved, but apparently 
nothing has come of either of these efforts, and yet 
they are almost axiomatic, and should serve as a 
basis for standardization. The reader will find this 
second set of Principles in Appendix II. 
Although the legitimate fields of laryngologist and 
vocal teacher are distinct and separate, they have 
so much in common that co-operation should prove 
of great advantage in the training of singers. 
The physician may be, and usually is, incompe- 
tent to decide how a given note is to be delivered, 
or a particular vocal effect produced, but he alone 
can determine whether the vocal cords are strained 76 
HYGIENE OF THE VOICE 
or otherwise damaged thereby. The laryngologist 
can see, with the mirror, any congestion induced by 
vocal strain and can testify to the prompt return 
to normal, which occurs when the method of pro- 
duction is changed. 
According to most authorities, training should 
always begin on the middle notes, and until the 
messa di voce has been perfected on these, no effort 
should be made to extend the range. Many teachers 
train the voice upwards from the middle; but there 
is some logic in favor of training from the middle 
both upwards and downwards. 
Together with the messa di voce, the pupil should 
practise portamento; that is to say, the carrying of 
the voice from one note to another instead of 
jumping. 
But at this point I must again hark back to my 
old theme, even at the expense of wearying the 
reader, namely: Before a pupil begins actual work, 
he should be thoroughly tried out and examined by 
a laryngologist who knows something of the singing 
problem. The nose, throat and ears should be tested 
by every known method, and a definite idea should 
be obtained also of the general bodily health. It is 
helpful to know the range and compass of the voice, 
and to determine any serious faults of tone produc- 
tion which are not due to purely physical causes. 
For this, one may try out a voice at the piano and 
make careful notes of what is found; then, at a 
later date, this can be done again for purpose of 
comparison. Any recommendation as to vocal exer- 
cises should be communicated to the teacher direct 
and not to the pupil, since it is the teacher who is 
immediately responsible for vocal growth and prog- VOICE TEACHER AND VOICE PHYSICIAN 
77 
ress. The laryngologist should avoid falling into the 
error of always finding some physical cause for every 
disturbance of which the singer complains. Very 
often such symptoms are the result of something 
the singer does in practice at home which is not 
found out at once by the teacher. There are, too, 
some voices which do not develop satisfactorily, 
where neither the teacher nor the physician can find 
any discoverable cause for the defect. Secretory 
changes in the mucous membrane are of especial 
importance and are frequently overlooked. There 
may be an abundant, sticky secretion which dries 
and forms crusts in the nose, or the mucous mem- 
brane may be very dry from glandular inactivity,— 
a condition which interferes greatly with the singer’s 
finer work, especially the soft tones. 
It is not my purpose to go into these matters 
exhaustively, but merely to point out a common 
ground upon which the rhinologist and vocal teach- 
ers can think, act and work together for the further- 
ance of perfection in the science and art of song. CHAPTER IX 
VOCAL HYGIENE 
Hygiene of the voice is, of course, indissolubly 
associated with general bodily hygiene, but there 
are some special considerations which the singer, 
above all other persons, ought to have constantly 
in mind. 
First of all, it is of especial importance that the 
upper airways be kept in the best possible condi- 
tion. In a previous paragraph the importance of 
an examination by a competent nose and throat spe- 
cialist early in the pupil period has been emphasized. 
It is hopeless to expect much from a nose in which 
the partition is so deviated as to obstruct one side, 
or where there is a chronic discharge. In such a 
case resonance is of poor quality, mouth breath- 
ing, especially at night, is always present, and there 
is a constant series of colds and sore throats. 
One is often asked about nasal douching. There 
is still a divergence of opinion among specialists 
in this matter, but the majority do not look upon 
it with favor owing chiefly to the danger of infect- 
ing the ears. The nose is always filled with for- 
eign matter, dust, germs, etc.: therefore, while 
douching, fluid may carry this foreign matter, espe- 
cially bacteria and muco-pus so often seen in the 
nose, right up into the Eustachian tube and the 
middle ear. 
78 VOCAL HYGIENE 
79 
After douching, there is a great tendency to blow 
the nose in order to clear out the excess of fluid, 
but when the nose is blown at all forcibly, there 
is great danger of propelling this foreign matter 
into the middle ear and producing an abscess which 
may go on even to so serious an affair as mas- 
toiditis. 
A nasal douche should not be used as a routine 
procedure. This is definite. However, if there is 
much free discharge or dry discharge (crusts), one 
may use any of the good alkaline preparations now 
on the market, taking especial care not to blow the 
nose forcibly afterwards. So-called normal saline, 
or physiologic salt solution is, perhaps, as helpful 
as anything which is sold over the counter. This 
is made by putting a level teaspoonful of ordinary 
table salt (not shaker salt) into a pint of water at 
body temperature, roughly about 100° F. Where 
there is much discharge one should make up a quart, 
using two teaspoonfuls of salt. The ordinary house- 
hold douche bag is excellent for this purpose. It 
can be fitted with a glass tip—a medicine dropper 
of fairly large calibre is excellent for the purpose— 
and hung about a foot and a half above the head. 
If there is much discharge as in acute sinus infec- 
tion, suction and irrigation by means of the Nichols 
nasal syphon will cleanse the nose better than any 
other method, but it should never be used save 
upon the advice of a physician. 
Following douching, only very slight snuffing 
should be allowed, placing one finger against a 
nostril so that only one side of the nose at a time 
will be submitted to air pressure. It is always 
safer to use an atomizer to open the nose, but where 80 
HYGIENE OF THE VOICE 
the discharge is of a sticky character, this is not 
very effective. 
In salt water douching, it is important that not 
too much salt be used. Professor Imhofer, of 
Prague, reports a case of total loss of smell (an- 
osmia) from frequent use of too salty a solution. 
In any case the water should be at body tempera- 
ture. If too hot it will congest the interior of the 
nose, producing a reactionary swelling, or even 
destroy the surface of the mucous membrane lining 
the nose. If too cold, it may cause much irritation 
and aggravate the symptoms already present. 
Gargling is a good way to cleanse the back part 
of the mouth and throat, but there are many per- 
sons who never learn to do it well. The teeth and 
mouth should be cared for after each meal. 
Although breathing is the one great unconscious 
act in the human economy, rivalled only by the 
activity of the heart and circulatory apparatus, it 
is surprising how few people get the most out of 
their lung capacity. Most of us use about one- 
fourth or one-half the amount of lung tissue with 
which kind Nature provided us. This has been 
abundantly proven over and over again. The 
breath must be taken noiselessly. Nothing can be 
more distressing to an audience than the gasps 
which often break a flood of vocal melody like the 
creaking of the bellows of an organ. The air should 
be drawn in through the nose; the mouth being 
used only as a subsidiary passage, when absolutely 
necessary. Lamperti used to say that the vocalist 
should take his breath and retain it like the swim- 
mer, and there is no doubt that those who excel in VOCAL HYGIENE 
81 
this art adopt very similar methods as regards res- 
piration. 
It is a curious fact that men breathe differently 
from women, the former using the abdominal meth- 
od—that is, pushing down the diaphragm—and the 
latter doing most of the work with their upper ribs. 
Every physician finds patients with great areas 
of lung into which very little air enters. Knowing 
this, one does not need to wonder at flat chests and 
poor general physical development. The elasticity 
of fully expanded lungs gives a sense of grace and 
poise which is truly remarkable. The writer re- 
cently saw an excellent new system of dramatic 
interpretation based entirely upon a correct breath- 
ing outline. It is surprising how few teachers make 
a systematic effort to train pupils how to breathe— 
that is, to teach breathing as an art without vocal- 
ization. This matter is worthy of intensive study. 
There must be good development of the abdominal 
and chest muscles. This can be taught by any 
physical educationist in a short time, and needs 
then only to be practiced at home. Various forms 
of exercisers, such as the Whitely apparatus, can 
be used with great advantage in one’s room before 
an open window. The breathing capacity must be 
increased by properly directed exercises. I strongly 
recommend all those who wish to excel as singers to 
undergo a regular course of gymnastics if possible, 
in a gymnasium where suitable apparatus exists. 
It must not be forgotten that exercise of the whole 
body brings the respiratory muscles into play, and 
if systematically pursued, greatly strengthens them. 
Most of the text-books on the training of the voice 
contain rules for respiratory gymnastics, and an ex- 82 
HYGIENE OF THE VOICE 
cellent series of exercises is contained in Guttmann’s 
Gymnastics of the Voice (Edgar S. Werner: New 
York). Walking, fencing, swimming, dumb-bell 
practice, are excellent means of improving the 
“wind” provided they are not pushed to the point 
of actual fatigue. 
The lungs must be emptied thoroughly, but with- 
out straining, and the pupil must strive to gain 
such control over the breath that he can mould the 
issuing stream of air to any shape, and regulate its 
volume and force so that no part of it is allowed 
to escape uselessly. 
For the past year I have been sending patients 
to physical instructors of repute for this work and 
the results have been surprising. A contralto with 
a truly remarkable range and great versatility used 
to be so fatigued after the opera that she felt quite 
ill during the entire day following. She was small 
and thin, and exhibited very inadequate muscular 
power, especially of the abdominal region. A 
woman gymnast of well-deserved recognition took 
her in hand and in about eight months produced a 
truly excellent development which gave the patient 
grace, poise and an invaluable sense of assurance. 
Proper clothing for the body is an efficient means 
of protecting the nose and throat against the many 
ills to which these organs are subject. Too much 
clothing is as bad as too little. The body surface 
should be protected, not coddled. Cotton is not as 
good as either silk or wool for undergarments, and 
none of these in my experience is so thoroughly 
satisfactory as linen mesh. This latter readily ad- 
mits ingress of air and egrees of body vapors so 
that a kind of “skin breathing” can go on continu- VOCAL HYGIENE 
83 
ally. The waste from the eliminating glands in 
the skin is readily taken up by linen mesh and the 
body surface does not chill so readily. 
Tight collars and tighter corsets are an abomina- 
tion. How they constrict the blood vessels and 
hinder muscular action need scarcely be mentioned. 
Public singers require no instruction on this point. 
They soon learn to adjust these articles of apparel 
so that they cease to cause inconvenience and inter- 
ference. 
Open neck waists may be worn, if, upon going 
out, the neck is not swathed in furs. If close- 
fitting furs are worn the change is too great and 
the skin is made sensitive to sudden variations. A 
cold sponge bath for the neck and chest upon rising 
is a good protective against cold. It is also good 
practise to hold the cold sponge against the nape 
of the neck, squeeze it out and thus enjoy a kind of 
spinal douche. All this should, of course, be fol- 
lowed by brisk rubbing to encourage “gymnastics 
of the skin vessels.’’ 
The condition of stomach and bowels is of espe- 
cial importance. Indigestion is a foe to good vocal- 
ization, especially if there is an excess of stomach 
acid (hyperacidity). Free daily evacuations must 
be maintained. The food should not be too spicy 
or too hot when served. Much harm is likely to 
follow over-eating. 
In the matter of food, every sensible person is 
the best counsellor for himself. As Bacon most 
wisely says: “A man’s own observation what he 
finds good of, and what he finds hurt of, is the best 
physic to preserve health.” It would be easy to 
frame elaborate schemes of diet in which the exact 84 
HYGIENE OF THE VOICE 
weight of meat and the precise quantity of veg- 
etables allowable should be laid down with the ac- 
curacy of a physician’s prescription, but such solemn 
trifling can only interest the professed valetudinar- 
ian. Let a man eat to the satisfaction of his natural 
appetite what his palate craves and his stomach 
does not kick against; an adult has, as a rule, been 
taught what his ailment should be by that most 
practical physician, experience. Let him take his 
meals at regular intervals and chew his food prop- 
erly and he may laugh at the highly rarefied menus 
dictated by the framers of dietetic decalogues. 
A good meal should follow any prolonged vocal 
effort, but hot or pungent things, which as already 
said, are always hurtful, must be particularly 
avoided under such circumstances for the reason 
just given. In fact, all the precautions which I 
have enjoined in various parts of this work against 
atmospheric or other irritants (close rooms, tobacco 
smoke, etc.) are doubly necessary when the throat 
is congested and fatigued after a great effort. 
Wine may be used in moderation if no catarrh is 
present and if the stomach bears it well. In spite 
of popular opinion most dark beers, especially those 
of foreign brew, contain less alcohol than the lighter 
variety. No benefit is to be derived from cognac, 
punch, high balls, etc. In fact, the less indulgence 
in all spirituous liquors the better. 
Certain social or environmental considerations 
are responsible for many voice troubles. Traveling 
in railway trains in badly ventilated cars, the air 
laden with black soot, cinders and dust, is a poor 
preparation for a stage performance. Many, if not 
most, theatres have no provision for ventilation, VOCAL HYGIENE 
85 
save doors and windows. The stage is often drafty 
and the thinly clad artist is exposed to the blasts 
of air which chill the body surface and provide 
conditions conducive to “colds.” Dry sweeping in 
some houses is indulged in an hour or so before the 
curtain rises. The windows and doors are then shut 
and the steam heat (if it is winter) does the rest. 
Is it any wonder that singers complain of dry throat 
and coughs? Add to this, the powder that is shaken 
about in a stuffy dressing room and you will produce 
clinical material in short order. 
The importance of rest at certain physiologic 
periods cannot be overestimated. One veteran 
teacher of my acquaintance, residing in Chicago, 
who has given his finest efforts to the successful 
furtherance of the art of song, makes it a point 
not to allow his girl patients to sing at all at cer- 
tain intervals. Speaking, of course, need not be 
interdicted; nevertheless, care should be taken not 
to try to drown out a noise or to strain the throat 
in heated debate. It is a curious fact that the voice 
in anger is always elevated. 
Vacation time should be spent in a fairly high dry 
climate, where the social demands are not too great. 
The pine woods are in many respects ideal, other 
things being equal, but the singer must exercise the 
while a judicious control over his activities. Ocean 
air while excellent for some persons, causes catarrhal 
symptoms and stuffiness in others which do not com- 
pensate for the “delights” of the seashore. 
Of outdoor sports, the best for the singer is golf- 
ing or tennis. Swimming is a menace to the ears, 
nose and throat. Bicycling is fatiguing and de- 
velops only the lower extremities, while the chest 86 
HYGIENE OF THE VOICE 
and trunk muscles are largely neglected. Automo- 
biling is not “exercise” by any stretch of the imag- 
ination. Great currents of air laden with dust are 
swept into the vocal airways and the result is a dry 
throat, huskiness and hoarseness. 
It should be remembered that the final test of 
voice efficiency—the result so to speak—is in reality 
an answer to the question, “How long should a 
voice endure?” The life of a voice is much more 
important than the plaudits of the crowd. Incor- 
rect method, faulty voice placement, in a word, poor 
technic may not prevent the singer from winning 
praise from the uninitiated and unthinking for a 
time, but finally there will come a break, a loss of 
efficiency, a refusal of the delicate mechanism to 
obey the mandates of the master. This marks, 
in many cases, the beginning of the end. The voice 
is prematurely old, and one’s active career is ended. 
If a singer has lived carefully and has had no un- 
fortunate accident or illness, the voice should last 
up to the period of well-defined senile changes. 
This life span is somewhat shortened in the average 
individual who is careless about vocal hygiene. In 
women, fifty to fifty-five years of age marks the 
limit of public singing efficiency; while in men, 
this limit is reached at about sixty. Anyone who 
has been able to earn a living in a public career for 
such a length of years may well have reason to be 
proud of his achievement, for it means that he has 
made the most of his gift and has not subjected it 
to wanton abuse. Youth is prone to overestimate 
its abilities and to force an issue where a more 
rational method of procedure would be in order. 
Advisers who are older and presumably wiser should VOCAL HYGIENE 
87 
endeavor to keep a check on too prodigal usage of 
the voice in those consigned to their care, and by 
precept and example should show that moderation 
in all things is the first essential to a long and 
happy life. PART II 
CHAPTER X 
EXAMINATION AND DIAGNOSIS 
This chapter is written especially for physicians 
and will have little appeal to the patient. In fact, 
the patient may be much better off for not reading 
it at all. The physician is the mentor. He is the 
one responsible for diagnosis and relief of the symp- 
toms which he is called upon to treat; and, there- 
fore, his work is peculiarly his own, and his point 
of view cannot be, or at least seldom is, understood 
by the one consulting him. 
It may seem unconventional to “lecture” profes- 
sional brethren on the art of managing patients, but 
this is a subject which is seldom or never touched 
upon in medical school, and has to be found out by 
experience, which is long and sometimes costly. In 
fact, there are plenty of us, no doubt, who never 
profit by experience at all; therefore it may be said 
that we never have learned our art. 
Singers are different in many ways from the ordi- 
nary patients who visit a doctor’s office. They have 
a psychology which is all their own. They are 
usually frank, intelligent, inclined to be emotional, 
quite easily “upset,” and unduly influenced by mat- 
ters which may seem trivial to others. If they are 
for you, they will be the kind of friends who would 
89 90 
HYGIENE OF THE VOICE 
die for you at a moment’s notice; and if they are 
not for you, the quicker you part company with 
them the better. All in all, they are delightful 
people to know and to work with, and are extremely 
appreciative of any good you may do them. It will 
do no harm to humor them a little, and it will do 
you no harm if they sometimes embarrass you with 
well-meant but rather exaggerated compliments or 
even terms of endearment. As a famous philosopher 
once said: “Everything goes.” With singers, every- 
thing goes well, or it does not go at all. 
Let me assume that you, a physician, who essays 
to diagnose and treat vocal difficulties in singers, 
are sitting at your desk with the patient before you. 
This is a great moment in the life of the patient, 
although it may mean little or nothing to you. All 
her future hope is perhaps centered in you because 
someone has been good enough to say that you are 
the one Moses who can deliver the people of Israel 
from their difficulties and dangers. That is proba- 
bly not strictly true, but you must endeavor to live 
up to your reputation. It is quite likely that you 
are not the first physician who has been consulted 
with respect to the present disability, and it is also 
likely that you will not be the last, although it 
should be your effort to see to it that you are the last 
and never the least. This singer has tried many 
sources of relief, including osteopathy, chiropracty 
and Christian Science. When she tells you that any 
one of these was “simply wonderful” and gave her 
a “world of relief,” do not be offended or take it 
too seriously; for she knows and you know in your 
heart of hearts that were this strictly true the pres- 
ent interview would not be held. The chances are EXAMINATION AND DIAGNOSIS 
91 
she is not saying this to annoy you, but because 
she may think that had she persisted in that other 
kind of treatment she would have been cured, and 
has a half-hearted regret deep seated in her soul. 
Of course, the patient may be cynical, even doubt- 
ful, of your ability. She may have come reluctantly 
at the request of some old patient of yours, or some 
“friend” has made her life so miserable that she has 
some to you in self-defense. 
After you have talked with her for a time, you 
may decide that conclusions she has drawn with 
respect to her efforts to get well are not entirely 
unjustified. Every human being has a certain meas- 
ure of faith and also a certain measure of doubt. 
The transition from one to the other may be quick, 
and, unfortunately, it may also be permanent. It 
is your job to dispel the doubt and increase the faith 
and that may be the hardest thing you have to do. 
Personally, I always feel that the patient’s fear of 
visiting me, or of having something done, or of 
undergoing an examination, is the hardest thing 
that I have had to combat. I sometimes tell myself 
that I am the worst fear specialist in the world, 
because I sometimes despair of ever overcoming the 
peculiar objections which some people feel against 
any kind of interference on the part of those who 
would willingly help them. But one must disregard 
all sham and hypocrisy and encourage a happy 
spirit of co-operation. If a patient cannot be in- 
spired with faith in you, and if you cannot become 
deeply and thoroughly interested in the problem 
before you, then neither of you can help the other, 
and the probable outcome of your acquaintance will 
scarcely amount to friendship. Relief or cure of 92 
HYGIENE OF THE VOICE 
a condition or disability, whether functional or 
organic, will depend on mutual understanding and 
co-operation. We should aim at all times to put 
the patient at ease, to cultivate a kind, sympathetic 
manner and avoid brusqueness; especially should 
we not assume an air of superiority, of cocksureness 
and smartness. It is difficult to see in the nature 
of things how anyone can hold such an attitude for 
any length of time, considering the pitfalls and 
errors into which every one of us is prone to fall. 
One should always knock at the door of humility 
and seek admission into its sacred portals. 
If you are unfortunate enough to frighten the 
patient, she will never give you her confidence or 
tell you important symptoms and facts in her his- 
tory, and this alone may lead to misinterpretation 
and failure. One should never try “to make a hit” 
with the patient, but should resolve earnestly and 
thoroughly to diagnose and heal the disease or dis- 
ability so that everyone concerned will be pleased 
with the result. Remember, everything must be 
subjugated to result, to a successful issue. If you 
undertake to handle a case at all, your time con- 
sumed, your inconvenience, your own distressing 
aches and pains (for sometimes a doctor is suffering 
physically or mentally while treating a patient 
much more than the patient himself), your fee, and 
all else, are secondary. 
It is a nice courtesy to have a pleasing attendant 
on service in the waiting room. She should be a 
bright, attractive, young girl of good personality, 
who knows how to ingratiate herself with the pa- 
tients and find out from them anything that it is 
desirable for the doctor to know, without allowing EXAMINATION AND DIAGNOSIS 
93 
them to find out anything about herself or the 
doctor, which patients usually have no business to 
find out. It is in human nature to pump the office 
nurse or attendant regarding the doctor’s peculiari- 
ties, his habits, his family, the number of patients 
he sees, the number of operations he does, and the 
kind of automobile he drives. All of these gossipy 
details are of interest to hundreds of people, but 
they do not make for a sound, stable relationship 
in the office. The doctor is extremely fortunate if 
he can find an attendant of such great tact and 
intelligence that she can parry one question by ask- 
ing another, and thus obtain information where 
information is sought. The patient should be 
courteously received, offered a seat, asked if she 
would like to read; and, if so, a magazine may be 
offered, and thus a seeming obligation to converse 
may be avoided. In general, coats and wraps should 
be brought in with the patient when entering the 
office from the waiting-room. Almost nine out of 
ten people will leave their coats, wraps, hats, hand- 
bags and packages on the chair which they occupied 
while waiting for the doctor to open his office door, 
not realizing that thirty seconds after they have 
been ushered in, someone else is quite likely to come 
in from the street and find no place to sit. More- 
over, it is good practise to have the patient leave by 
a rear door and not pass through the waiting-room. 
But now that the patient and you both sit at or 
near the desk, the first and important point is to 
obtain a good history. This history should be taken 
by the doctor who is to examine the patient, and not 
by an office attendant or even an office associate, 
although he be a doctor of medicine. The patient 94 
HYGIENE OF THE VOICE 
will appreciate this personal interview ofttimes even 
more than the examination, for it puts her into per- 
sonal touch with her advisor, and may change her 
whole mental attitude toward her condition. More- 
over, this little tete-a-tete may afford, not infre- 
quently, a fair guess at a diagnosis. Some physicians 
prefer to examine the patient first and then take 
the history. Personally, I always do the opposite. 
A filing system should be adopted which is uniform, 
brief, but sufficiently exhaustive. It should be 
capable of amplification to any desired size. For 
instance, a card system can be increased by the addi- 
tion of other cards for further notes and annota- 
tions. There are many good cards now in use upon 
which stamped outlines of various organs can be 
filled in with pen or pencil, showing the exact loca- 
tion and relative size of any growth or other 
abnormality. There is no printed form, however, 
which is uniformly satisfactory, and one must have 
in mind some sketch or outline or system which will 
help him to remember to ask all necessary questions 
in order that no salient points be missed. One 
should be careful to get the exact and full name, 
the address—both home and business—name of firm 
or employer, telephone number, date, place and time 
of interview, referred by whom, and a note as to 
whether anyone else was present when the history 
or examination was made. It is surprising how 
helpful such notes may sometimes become at a later 
time. One should always remember that any case 
with which he has come into contact may become 
a court case at some future time, and therefore you 
will be very glad if your notes are not only complete 
but exhaustive. EXAMINATION AND DIAGNOSIS 
95 
This much information having been obtained, 
your next step is to find out the patient’s chief com- 
plaint,—you must know at this stage what brought 
the patient to you. Following this, you may go 
back into the history for all necessary information 
regarding the general as well as the special diseases 
with which the patient has been afflicted. It is 
always well, too, to know what previous operations 
have been performed. No record is complete unless 
one knows the condition of the appetite, the bowels, 
manner of living, habits such as smoking or drink- 
ing, etc. While all this is going on, you must sub- 
consciously study the patient out of the angle of 
your eye. Her manner of speaking, her physique, 
her position in the chair, all of these apparently 
insignificant matters count for something. Let her 
tell her story, even if it be a little long-winded, but 
make her stick as closely as possible to germane 
facts. 
Supposing, for instance, you have a rather stout 
individual before you with rosy cheeks, rather thin, 
dry-looking hair, with apparently very little hair 
on the general body surface, who sits lazily and 
apathetically before you,—here is a suggestion that 
there is some endocrine disturbance or mental in- 
stability. Something may also hint to you that you 
are not hearing the truth, the whole truth and 
nothing but the truth. 
After a satisfactory history has been obtained, 
one is ready for the examination. The watchword 
during an examination is: “Guard your tongue.” 
You will often be asked for a final opinion before 
you have had time to do more than give a cursory 
glance. In fact, several sittings may be required 96 
HYGIENE OF THE VOICE 
in order to render an opinion that is worth anything. 
Suppose that the patient is suffering with an acute 
rhinitis. This may make the septum appear crooked 
or the turbinates hypertrophied. Be careful in such 
a case about advising an operation. A septum oper- 
ation may already have been performed, and when 
the rhinitis is well the nose may look entirely differ- 
ent to you. Above all, do not criticize the operative 
work of your predecessor. You do not know any- 
thing about the extraordinary conditions he may 
have met, or the struggle he may have had to over- 
come the peculiar whims or objections or nervous 
reactions of the patient. There may have been 
unlooked-for and uncontrollable bleeding, for in- 
stance, or the patient may have fainted several 
times during the procedure, or many unforeseen 
things may have happened, all of which were not 
preventable, but they had their influence in deter- 
mining the final result. 
In my student days a good story used to go the 
rounds of a certain famous nose and throat specialist 
who had an enormous clientele; in fact, he had so 
many patients that it was impossible for him to do 
any of them full justice, and his diagnosis and treat- 
ment were limited to the least time-consuming 
process. On one of his busiest days an excessively 
modest young woman came in for examination. 
She was of the type known as the “Yes, sir” and 
“No, sir” variety, which must have been pleasing 
to the busy practitioner, who had no time for con- 
versation. He sat her down in his examining chair, 
hastily pried open her mouth with a tongue depres- 
sor, and said: EXAMINATION AND DIAGNOSIS 
97 
“So you have had your tonsils operated on, have 
you?” 
“Yes, doctor.” 
“Well, no one would know it. Of all the rotten 
operations I have ever seen, this is about the worst!” 
“Yes, doctor.” 
“Who did this operation?” 
“Excuse me, but you did, doctor.” 
This story serves as a reminder that one should 
always go slowly in his criticisms. 
When proceeding with the examination, if one 
examines the ears it is a good point to look into the 
good one first. In all cases, one should use warm, 
clean instruments, preferably just out of the steril- 
izer, within the view of the patient. It is very 
reassuring to know that everything is clean and 
comfortably warm, and to this end it is not a bad 
plan to wash one’s hands where the patient can 
know what is going on, as she may not fancy being 
handled by the same hands which examined her 
predecessor. Avoid offering a used towel as you 
would the plague, and protect the patient’s clothing 
with a clean towel or apron in order that no drop of 
staining or soiling drug may give annoyance. In- 
quire if she has a handkerchief, or, better yet, pro- 
vide one and do not inquire. Never jerk or pull 
or act as if you are in such a hurry that you cannot 
be thorough. Use as much time as you need, but 
do not waste a second. Charge for your time or do 
not take the case. You cannot afford to be slipshod 
or sloven no matter what happens. 
In examining the nose, proceed cautiously, as you 
may hurt the patient promptly if she happens to 
have a furuncle in the vestibule. It is also easy to 98 
HYGIENE OF THE VOICE 
catch one of the little hairs in the speculum and 
bring tears to the patient’s eyes. This blunder is 
sometimes not only uncomfortable but momentarily 
painful. Study thoroughly the turbinates, meati 
and septum. Be sure to look down along the floor 
of the nose. Spray in or mop in a little cocaine 
solution so that you can palpate with a probe. 
Examination by this method should be the rule, as 
touch will convey a very different idea from sight. 
Even more important than a deviated septum is an 
enlarged inferior turbinate which extends backward 
into the pharynx and ends in a posterior tip. Such 
patients complain of an alternating stuffiness of the 
nose, and usually post-nasal dropping as well. Ex- 
amine carefully for discharge coming from beneath 
the middle turbinate. This may give the first hint 
of an active or latent sinus trouble. Then ask the 
patient to hum on one note continuously, closing 
the nostrils alternately with your fingers. In this 
way, you will be able to tell whether the sound 
comes through more clearly on one side than on the 
other, which will give some idea of the head reso- 
nance. Whenever possible, the post-nasal space 
should be studied by the small mirror or naso- 
pharyngoscope. 
In examining the throat, do not neglect the 
tongue, teeth and gums, from all of which one may 
derive considerable information. If the tonsils can 
scarcely be seen, one should hook back the anterior 
pillar with a blunt hook and explore the crypts with 
a probe or applicator. Cheesy particles may be 
obtained by pressure or by applying a suction glass. 
In this connection, always examine for glands at the 
angles of the lower jaw. When using the laryngeal EXAMINATION AND DIAGNOSIS 
99 
mirror, first be sure to study the lingual tonsil. 
There is sometimes a good deal of difficulty in seeing 
the cords, and it may require several examinations 
before this can be thoroughly done. You must de- 
termine the color, size, shape, length and presence 
or absence of nodules, etc., at a glance. Also, 
whether the cords are too dry or too wet, both of 
which facts are significant. It is also important to 
know the condition of the sub-glottic region, as there 
may be a tracheitis. If the patient complains of a 
tickling sensation in the episternal notch, and if 
there is redness of the tracheal mucosa with irri- 
tating, non-productive cough, the diagnosis of infec- 
tion of the trachea is certain. It is possible that 
the cords and larynx in general might look quite 
normal in such a case, but the singing voice may be 
entirely out of focus. Most laryngologists say that 
it is impossible to tell from examination of the cords 
what the quality and pitch of the voice is; that is, 
one is not supposed to be able to tell a baritone 
from a tenor, or a soprano from a contralto, by 
mere laryngeal examination. In many cases, how- 
ever, it is not difficult to make a shrewd guess from 
the general contour of the nose and pharynx, com- 
bined with a view of the larynx. The tenor’s cords 
are usually short and thicker than those of a bari- 
tone or basso, which are longer and flatter. A 
similar relationship holds good for the difference 
between soprano and contralto or alto. It some- 
times is a matter of some importance for the 
laryngologist to be able to determine in just what 
classification a voice belongs, for it is not uncommon 
to find pupils being trained out of their proper 
sphere, particularly if a voice is naturally low and 100 
HYGIENE OF THE VOICE 
they want it to be high. Great, and sometimes 
permanent, damage may be done to the vocal 
mechanism by this mistaken idea that the voice 
can be screwed up out of its proper range. After 
the examination has been thoroughly conducted and 
notes have been made on the findings, it is proper 
that one should report to the singing teacher or 
physician, especially if any thought of operation 
comes into question. Where the pupil is a minor, 
no treatment or operative procedure of any kind 
should be undertaken without the written consent 
of one or both parents if they are living. The con- 
sent of a sister or an aunt or next of kin is not 
sufficient for any one of several reasons. In the 
first place, the physician may be unable to collect 
a fee for his services, because the guardian or parent 
may say that consent to the operation was not 
given, or they may refuse to pay the bill, or they 
may sue for damages in case any unforeseen thing 
happens, such as hemorrhage or other undesirable 
eventuality. Therefore one should constantly be on 
his guard, both to protect himself and the patient. 
The advice set down here is not a matter of per- 
sonal opinion, but is the result of reading records of 
many court cases where physicians have been sued 
for malpractice. CHAPTER XI 
PHYSICAL DEFECTS 
In a rather large group of pupil singers who 
come to New York each year from all parts of this 
broad land, it is extremely rare to find even one 
who has undergone anything approaching a physical 
examination for the purpose of finding out whether 
the body as a whole is capable of undertaking a 
career. Those who have had gymnasium training 
in college in recent years are, of course, examined 
and recommended to take this or that form of exer- 
cise to benefit certain groups of muscles or to ex- 
pand certain organs which are backward in growth 
and strength; but such recommendations are seldom 
carried out with any degree of thoroughness, and so 
far as any influence on a vocal career is concerned, 
such influence is practically nil. 
A very large percentage of vocal patients who 
come to the voice physician do so because they have 
an important engagement which they fear to un- 
dertake because “something has gone wrong with 
the voice.” They seldom come to find out whether 
the vocal apparatus is in good condition or how 
they may keep it so. In the presence of acute in- 
fections, pain is the only symptom that brings them 
for consultation and relief. Very often this infec- 
tion has progressed for weeks, until all mucous 
membrane areas are affected. It is then extremely 
101 102 
HYGIENE OF THE VOICE 
difficult in some cases to avoid operation. If the 
patient were seen in the first twenty-four-hour 
period, prompt relief and prevention of further 
trouble could be afforded in one or two treatments. 
Such a disease as mastoiditis, for instance, would 
become practically unknown if the nose and naso- 
pharynx were promptly and effectively sterilized by 
antiseptic medication at the very beginning of a so- 
called “cold.” Fear and neglect are the fiercest 
enemies that the physician has to fight, whatever 
his specialty may be. 
It is not too much to say that if the great singer 
holding a leading place in an opera company were 
to consult his or her voice physician twice a week 
during the season and receive prophylactic care, 
there would be no such thing as postponement or 
substitution of performances because of vocal ill 
health. The economic loss to managers, and the 
untold disappointment and inconvenience to the 
public are enormous during every musical season. 
This could be almost entirely avoided if we were 
all a little more intelligent and resourceful in pre- 
venting disease than we are in curing it. 
The Government, as we know, demands a thor- 
ough examination before it accepts a student of 
military tactics, and insists that any imperfections 
be corrected. In this it sets a most excellent ex- 
ample for those in civil life; but did any one ever 
hear of a vocal teacher demanding that a pupil be 
sound in mental and bodily vigor before undertak- 
ing the exacting, strenuous and prolonged cultiva- 
tion of the voice? 
Loving parents spend thousands of dollars an- 
nually on vocal lessons and maintenance while PHYSICAL DEFECTS 
103 
studying, but did any one ever tell them that it 
was unwise for Mary or Jane to attempt to do any- 
thing with her voice because of a bad heart or poor 
muscular development or some other chronic ail- 
ment? In these matters the family doctor is an 
unsafe guide, because he does not often know much 
about the singing problem, and may be honest in 
his belief that certain irregularities can be greatly 
improved by deep breathing and studio life in gen- 
eral. This is true only in a very limited sense; for 
studio life, especially of the strenuous, exacting 
type, is more of a health taker than a health giver, 
and many pupils find themselves unable to keep 
the pace because they are neither physically nor 
mentally capable of enduring excessive stress of any 
kind. 
General ignorance of health matters and the hu- 
man tendency to neglect are factors which must be 
held largely responsible for the poor showing of 
many young men and women after the student 
period is finished. There is an old-time and seem- 
ingly deep-rooted prejudice against calling in a 
physician until the wyorst has happened. Just so 
long as the body machine can be kept going at a 
fair rate of speed, the engine is never overhauled. 
Fuel and water in some form are supplied at more 
or less regular intervals, but there is no slowing 
down to see if each nut and bolt is properly ad- 
justed. The machine frequently is run at top speed 
for years together, and is horribly abused as to the 
quantity and quality of what is put into it, and as 
to what is expected to come out of it in the form 
of energy. 
Defective nasal resonance puts undue stress upon 104 
HYGIENE OF THE VOICE 
the cords and vocal muscles, giving rise to fatigue 
and other annoying symptoms. Such defection is 
often due to some physical obstruction or anomaly 
in the upper airways such as adenoid enlargements 
or bony irregularities. 
The causes of defective nasal resonance are usu- 
ally physical. That is, there is some overgrowth 
of bone or soft tissue which obstructs the nasal 
chambers and deadens the tone. One of the com- 
monest of these conditions is so-called “deviation of 
Fig. 11.—Deviation of the nasal septum (partition) causing complete 
obstruction of the lett nostril. 
the nasal septum,” which is the partition that 
should divide the nose into two equal right and left 
chambers, but often so out of plumb that one side, 
or even both sides are obstructed to the ready inflow 
and outflow of air. Often there is a history of some 
injury such as a fall or blow on the nose which has 
produced a fracture unknown to the victim, but 
which causes more and more difficulty in breathing 
as time goes on; or it may happen that normal 
growth of the nasal bones is in some way perverted, 
bringing about obstruction as early as the fifth 
year. One can test the patency and resonance of PHYSICAL DEFECTS 
105 
the nasal chambers by holding a finger on one side 
of the nose and humming continuously on a single 
note. If one side is freer than the other, a marked 
difference in resonance will be noted as well as in 
air volume. If this changes from hour to hour or 
day to day, that is, if one side is now closed, now 
open, alternating with the other side, then the 
obstruction is probably due to “turbinate” enlarge- 
ment. The turbinates are scroll-like bones, three 
in number, situated one above the other in each 
nostril, their purpose being to warm and moisten 
the incoming air. Any increase in their size for 
whatever reason will diminish resonance and inter- 
fere with breathing. (See Fig. 9.) 
There are many other types of nasal insufficiency 
such as polypi, chronic discharge, etc., which need 
not be described here, suffice it to say that all of 
these various conditions are amenable to operation 
and treatment with good results both locally and 
in improvement of the general health; but with 
such causes of “interference” constantly at work, 
one dare not hope that any amount of mere vocal 
“training” can ever bring a voice to full flower. 
Certain physical defects which are not strictly 
vocal may also hinder the singer from making the 
success that is his due—for instance an ugly, mis- 
shapen nose. Fortunately, in the present excel- 
lence of plastic surgery, the human countenance 
can be “moulded nearer to the heart’s desire.” If 
the nose has been broken, it can be quite easily 
straightened; if too long it can be shortened; if too 
flat it can be elevated by transplantation of bone 
so that its contour is quite normal. If it is 
“humped,” a simple operation, not unlike what a 106 
HYGIENE OF THE VOICE 
carpenter might be expected to do when working 
on wood, will make it perfectly straight. As a mat- 
ter of interest let me recite briefly the report of a 
case which was highly satisfactory to all concerned. 
It is simply one of many, and is typical of the so- 
called “hump nose” deformity. 
Some of my patients have been women who have 
been obliged to go out into the world and earn a 
living under conditions which made them unusu- 
ally sensitive to this imperfection and prevented 
them in many instances from advancing in posi- 
tion and salary. This is particularly true of stage 
folk, who depend as often upon “looks” as upon 
histrionic talent for success in their work. 
Miss B. was referred by her physician for my 
opinion as to the possibility of improving her ap- 
pearance by the reduction of a bad nasal hump. 
She had already visited an advertising “nose fac- 
tory” where she was promised a cure if she could 
raise $1,000, but, this being impossible, her hopes 
were dashed to earth for the time being at least. 
There was a history of injury suffered some ten 
years ago with resultant nasal insufficiency, due 
probably to a deflected septum. In any case, she 
had undergone an operation on the nasal partition 
which was so thoroughly done that there was left 
a considerable depression below the hump. Our 
problem, therefore, was to remove the hump and 
build up the depression. This was carried out in 
her case as an office procedure, although my prefer- 
ence was that she take a bed in the hospital. Ether 
was administered until the patient was well anes- 
thetized, then instruments were used to bare the 
bone, care being taken, of course, not to “button- PHYSICAL DEFECTS 
107 
hole” the skin. No cut was made in the skin, all 
work being done from within the nose. The hump 
was thoroughly freed of all overlying tissue until 
bare bone could be felt in every direction. With 
an ordinary nasal saw the projection was slowly 
sawn off. The piece of bone was removed with 
ordinary grasping forceps, and the base smoothed 
down. A small piece of the bone which had been 
removed was pushed down into the depression un- 
til one was sure that the middle line was perfectly 
straight. Blood clots and debris were curetted and 
massaged out of the wound so that there might be 
nothing left behind which could spoil our result. 
Nothing further was done. The patient was ad- 
vised, after lying around for an hour, to go home 
to bed and apply cold compresses to the entire ex- 
ternal nose. She said that she had no post-opera- 
tive pain nor headache, in fact, no uncomfortable 
reaction of any kind, which is quite the rule in the 
majority of cases. 
I wish merely to emphasize that this is an ex- 
tremely simple operation with practically no risk, 
and can be done under local anesthesia in a tolerant 
patient. There seems to be no need to undergo 
the expense of hospital care if one has an office 
operating room where minor surgical work can be 
carried out aseptically. This is a desideratum not 
to be overlooked. 
About one week is usually required before such 
a patient is able to take up her vocation once 
more. 
Warts, moles and other like disfiguring marks on 
the skin of the face and neck can be removed with- 
out pain or other objectionable experience. ... A 108 
HYGIENE OF THE VOICE 
singer had writhed for years under the affliction of 
two seed warts about the size of a pea situated just 
at the hollow of the neck. She had been told not 
to have them removed or she would die of a hem- 
orrhage. It required several months so to gain her 
confidence that she would allow me to operate. 
After her decision was made, it look less than five 
minutes to do the work, and in about ten days it 
was fairly difficult to locate the tiny scars. She 
has worn low neck dress since that time with great 
satisfaction. There was no trick about it—any 
physician could have done it years ago. 
An important feature which is, I think, more 
neglected abroad than in America is the possession 
of good sound teeth. Toothache is very common 
in Europe because hygiene of the mouth is so little 
understood among the masses; while in the United 
States we have such widespread educational efforts 
as “the toothbrush drill” in the schools, and hence 
there is less suffering from aching jaws, and greater 
conservation of teeth. American dentistry is very 
highly thought of on the Continent, and the in- 
fluence of our oral hygienists is just beginning to 
make itself felt. It has become customary here in 
this country among the better educated to visit a 
dentist once in six months in order that he may find 
and fill any carious spots, and clean off the enamel- 
destroying “tartar” from the teeth. 
In spite of all this, teeth do decay as age ad- 
vances, and it then becomes necessary to extract 
them in order to prevent pain and such disorders 
as “chronic focal infection” which affects the gen- 
eral health. Nevertheless, the pendulum has swung 
too far, and I am sure that teeth are sometimes ex- PHYSICAL DEFECTS 
109 
tracted unnecessarily in the hope of relieving facial 
neuralgia or rheumatism—in some instances the 
whole jaw is “exodontized,” the patient is minus 
his grinding apparatus, and has the same symptoms 
as before the extraction. A physician or dentist 
should, therefore, be very sure of his diagnosis be- 
fore undertaking such drastic measures. 
But if teeth must be removed, every effort should 
be made to secure a well-fitting artificial denture— 
first, because the food needs to be thoroughly mas- 
ticated, second to improve the appearance and 
fortify the “personality,” and, finally, to insure 
perfection in vocalization—both speech and song. 
A missing tooth is an abomination to the tongue, 
and often causes a disagreeable hissing or lisping 
which greatly detracts from one’s impressiveness. 
Both the vowels and consonants are likely to be 
imperfectly pronounced, and the sibilants are too 
much in evidence, so that an audience, whether 
single or multiple, may become more interested in 
such peculiarities than in the subject matter of 
speech or song. It is a curious fact that a spot 
on a piece of cloth no matter how elegant the 
material, impresses the eye and mind much more 
than the whole fabric. 
Just a word of caution—all artificial dentures 
should be removed before retiring, to give the gums 
and sound teeth, if present, a rest, and to prevent 
inhaling or swallowing them during sleep. It is 
surprising how often this happens, and the services 
of a highly skilled specialist are then required to 
recover the teeth and save a life. CHAPTER XII 
VOCAL NODULES 
Every throat specialist, in the course of his daily 
work, is at times consulted by singers who com- 
plain that they “simply cannot keep from catching 
cold/’ There is an inordinate tendency to hoarse- 
ness, especially at certain levels of the voice. This 
hoarseness comes on suddenly without apparent 
cause, does not seem to be related to exposure, and 
often subsides almost as suddenly as it came. 
There is constant fear that an attack will come on 
at some inopportune moment. An aria is dreaded 
because hoarseness may develop, and a “break” 
will reveal the singer’s imperfection. Not a few 
singers with the above symptoms are treated by 
general practitioners of medicine, and also occasion- 
ally, one fears, by an unwatchful specialist, for 
“recurring laryngitis.” This mistake can easily be 
made if one is unfortunate enough to be unable to 
examine the cords thoroughly. It occasionally hap- 
pens that one cannot bring the glottis within the 
purview of the laryngeal mirror owing to volun- 
tary or involuntary muscular contractions—that is, 
the patient cannot or will not relax his throat. The 
epiglottis is far backward and acts almost like a 
lid in covering the cords. There is also in some 
patients such an active pharyngeal reflex that noth- 
110 VOCAL NODULES 
111 
ing can touch the pharynx without producing 
violent gagging. This precludes all possibility of 
examination until the pharynx is sufficiently anes- 
thetized to tolerate touching. Of course, much time 
is thus consumed and several sittings may be re- 
quired, but the importance of taking plenty of time 
for diagnosis, and of studying the larynx thoroughly, 
needs to be emphasized again and again in working 
with singers. Even the most expert among men is 
not infallible, but it is the highest prerogative of 
the man of science to reduce errors to a minimum. 
Errors due to carelessness ought to be capable of 
reduction to the zero point. 
The actual cause of such symptoms is a growth 
on the margin of one or both vocal cords and is 
spoken of as a nodule or node. It acts like a wedge 
between the cords, thus keeping the edges from ap- 
proximating during vocalization. 
Nodes have been dubbed inelegantly and inac- 
curately, perhaps, but at least graphically, “corns 
on the cords.” In origin they are not unlike the 
proverbial much-to-be-regretted and complained-of 
corn in that they are produced by what may be 
termed “a mechanical insult.” The foot restricted 
in its movements by a tight shoe, the toe cramped 
and confined by firm, unyielding leather, rebels 
against the insult, and, to protect itself, the skin 
heaps up millions of microscopic cells in certain 
little spots. This locus dolori constitutes a corn if 
on a toe, and a “callous” if located elsewhere on the 
foot. So much for the corn. 
Now, a vocal nodule is always the result of a like 
mechanical insult—that is, there is a disharmony 
between the vocal cord and its externals. One 112 
HYGIENE OF THE VOICE 
might as well face the fact in plain language, viz., 
every vocal nodule is the result of faulty technic. 
This is a hard pill for many vocalists to swallow, 
for after years of untiring effort and at great cost 
to the individual and all those near to him, it is 
cruel to find that one’s career is likely to be wrecked 
on the shoals of an improper conception of produc- 
tion of tone. However, the sooner this fact is dis- 
covered and acted upon, the greater the possibility 
that all is not yet lost and that vocal reconstruction 
is still possible. Some one is sure to say: “That 
cannot be true, for So and So is a great singer, and 
he has had these nodules removed several times 
with wonderful results after each operation.” The 
great singer, yes; but the great artist, no. The 
great artist is one who has perfected himself in the 
knowledge of tone production, and has not sacrificed 
himself to the galleries. He will, in all human 
probability, never be annoyed by nodes on the cords. 
The process by which a node is produced may be 
explained as follows: 
Along the knifelike edges of the cords, there are 
a few microscopic glands which secrete a small 
amount of mucus and pour it out of their tiny 
mouths as a lubricant. Now, if the cords are very 
tightly squeezed together, obstruction of the 
mouths of the ducts leading from the gland cells 
to the surface takes place. This usually follows 
an acute respiratory infection during which the 
larynx has been abused. Secretion keeps on piling 
up within this closed cell region, and we then have 
a tiny bulge or excrescence projecting beyond the 
free border of the cord. When the pressure within 
becomes great enough, the tiny gland empties itself VOCAL NODULES 
113 
if the obstruction at the mouth is not absolute. 
One then sees upon examination a thread of viscid, 
mucoid material stretching across the space between 
the cords during quiet breathing. 
Certain vocal exercises, vocal rest, etc., may di- 
minish the little retention sac to a point where it 
cannot be seen. Silver nitrate applied by the laryn- 
gologist is also often of great benefit. The case is 
then “cured,” and teacher, pupil, and perhaps doc- 
tor, too, feel very proud of this victory. However, 
just so soon as the singer returns to his old habits 
Fig. 12.—Vocal Nodules. “Soft,” small variety. Often overlooked 
but causing symptoms of chronic hoarseness and deficient vocal power. 
of straining and pressing and squeezing, just so 
surely will the troublesome “node come back.” In 
fact, it was never entirely gone, but was reduced to 
the point where it could give no more trouble so 
long as the cause of its origin became inactive. All 
this applies to the soft node, which, from a medical 
standpoint, is a simple, incomplete retention cyst. 
Let us suppose, however, that the tiny mouth of 
the tiny gland remains totally obstructed, and the 
singer’s squeezing and pressing continue; we then 
have what is known as “organization” of the con- 
tents of the cyst into a firm, smooth, consistent, 
solid tissue. This is the true node, hard, firm and 114 
HYGIENE OF THE VOICE 
fibrous. No amount of vocal exercises can ever 
cause this kind of node to disappear entirely. 
Change of method of breathing, attack, etc., may 
render it of no great annoyance to the singer, who 
may “sing over” his difficulty, but in most cases 
the node must be removed by an extremely delicate 
surgical operation. Nevertheless, it is entirely use- 
less for a throat surgeon to operate in such a case 
if the faulty technic continues; for the same cause 
that produced the first node will likewise produce 
the second, third or fourth. After removal of such 
Fig. 13.—Vocal Nodules. Large, fibrous type. Not all of the 
growths can be shown as they are attached to the edge and under sur- 
face of the cords. 
a growth, the singer should commit himself into 
the hands of a scientific, conscientious, skilled 
teacher who understands the condition as here out- 
lined, and who knows how to readjust the vocal 
mechanism. Removal is an extremely difficult pro- 
cedure from the surgeon’s viewpoint, and is not un- 
attended by risk, but “to sing or not to sing, that 
is the question,” and there are many who willingly 
take the one chance that Fate proffers them. 
While a vocal nodule is always an annoyance and 
sometimes is capable of destroying a career, this is 
not invariably so. One of my patients, a basso- VOCAL NODULES 
115 
cantante of fine parts and an excellent artist, has 
had a very small nodule on the edge of his right 
vocal cord for at least ten years. Yet, during all 
this time, he has always had a position with one or 
other of the various opera companies, and has made 
a very good living. This may be accounted for, 
however, at least in part, by the fact that he is 
almost immune to respiratory infection. During 
two years in London he sang quite constantly with- 
out a “cold” or other vocal disability, and was never 
examined or treated by a physician during that 
time. Only the well-trained ear can detect any 
harshness or huskiness in any part of his voice, and 
he still sings one of the finest performances of 
Ramfis in Aida that I have ever heard. CHAPTER XIII 
ON CERTAIN NOSE AND THROAT DISORDERS 
IN SINGERS AND SPEAKERS 
At the very bottom of most ills from which 
artistic people suffer, there is a subtle psychological 
element which must not be overlooked, and which 
must be weighed in the balance with all other find- 
ings, no matter of what nature they are. This is, 
I think, so well understood by most rhino-laryngolo- 
gists that it is, perhaps, unnecessary to do more 
than mention it here, since the successful physician 
is always a good student of human nature, and from 
his experience is usually able to outline in his own 
mind just how to manage his patient; that is, he 
must know what to say, or what not to say, even 
more than what to do. But putting aside the un- 
stable, fickle, unreliable and often strongly neurotic 
characteristics, one must go back into the history of 
every case far enough to determine just how any 
given disorder began. This may have had its origin 
in the thoughtless remark of some medical adviser 
who did not comprehend the psychological elements 
in the situation, or in some actual physical condition 
which has been, for the most part, long since for- 
gotten. Of one thing we may be quite sure in prac- 
tically any case that comes to us for advice; namely, 
that the singer has never been exactly measured 
in all those essentials which are indispensable to 
116 THROAT DISORDERS IN SINGERS 
117 
uninterrupted and progressive success. The voice 
physician has, therefore, to constitute himself a sort 
of physico-psycho-analyst; that is, he must study 
and investigate a great many details which have to 
do both with the mental and physical, as well as the 
artistic life of his patient. 
Laryngologists, especially those who are inter- 
ested in voice, must aim to encourage teachers of 
singing to do something more than simply to “try 
out the voice” when a pupil presents herself to begin 
study. This is a matter upon which I have harped 
rather continuously in various addresses and articles 
for some years past, and it has been mentioned in 
another chapter in this book as well; but the idea 
seems unlikely to take root in the general public 
mind unless we as physicians can show that it is for 
the future well-being and happiness of the pupil, 
and not to put money into our pockets, which cer- 
tain ill-minded folk may insinuate. As a matter of 
fact, from the mercenary viewpoint, we would do 
better to say nothing about prevention and “patch 
up” the singer from time to time; but this is not the 
way of modern medicine, as every intelligent person 
knows. 
The intoning of a few bars at the piano, or the 
hearing of some simple song, is ordinarily all that 
the maestro requires before voice lessons are started. 
Nothing is known of the physical condition of the 
candidate, and it is usually considered sufficient to 
possess a beautiful, or even just merely a good voice, 
and that hard work will do the rest. No greater 
fallacy exists; for the factors which go to make a 
successful artist are so numerous that one can 
hardly undertake to write them all down, much less 118 
HYGIENE OF THE VOICE 
to study them at first hand. Many a singer with 
good natural gifts, fails miserably because of some 
unconsidered fault of personality or mentality which 
could have been adjudged by the practiced eye to be 
irremediable at the outset. Or again, failure may 
result from utter disregard of simple, easily control- 
lable elements. It would be of everlasting benefit to 
all concerned if the teacher, at his first interview 
with a pupil, should ask for the co-operation of the 
laryngologist who has paid some attention to the 
voice problem, and secure from him a written report 
of his findings, including his opinion as to the pos- 
sible development of the voice under certain natural 
physical handicaps which so often are joined with 
good talent. To illustrate just what is meant: 
suppose that way back in childhood an attack of 
laryngeal diphtheria has left certain muscles im- 
paired; that an intubation has been necessary, for 
instance, or that a certain amount of paresis in 
contradistinction to paralysis has persisted. Or, 
assume that scarlet fever at some forgotten period 
has invaded the ears and has left its deadly menace 
behind in the form of chronic middle ear suppura- 
tion which lights up sharply with every acute 
respiratory infection, or that the lesser evil, deafness 
of moderate degree, determinable by modern exact 
tests, makes accurate pitch judgment impossible. Is 
it not fair to say that one can scarcely recommend 
the vast expenditure of time, energy and money in 
the pursuit of an ignis fatuus which may end in 
dreadful disappointment or even tragedy? 
It is a common experience for the doctor who for 
want of a better name has been called a “voice 
physician” to have a patient come in with the fol- THROAT DISORDERS IN SINGERS 
119 
lowing story: This girl is 26 years of age. Ever since 
childhood she has been told that she has a beautiful, 
even marvelous, voice. Down in her little home 
town, let us say somewhere in Tennessee, there is 
a village parson who is thought to be something of 
a connoisseur in music. Soon after taking up his 
pastorate he hears Dorothy sing, she impresses 
him greatly with the purity and sweetness of her 
“naturally” produced voice, and he accordingly 
drafts her for the village choir. The postmaster, a 
pillar of the church, wishing to encourage the girl, 
tells her that she ought to go to New York and “take 
up vocal,” as they say in the hinterland. This opin- 
ion is reinforced by the local doctor and by all of 
the aunts and uncles, who are likely to be both 
numerous and unanimous in their praise. Not much 
urging is needed in any case, so it is decided that 
Dorothy must go to the city called Gotham, where 
such talent may be reasonably expected to be recog- 
nized by stalwart headlines in the great dailies. 
Well, the girl and her mother arrive and are sur- 
prised to find just what they had expected to be 
surprised about, namely, that there are a great 
number of singing teachers who are more than 
anxious to “work out” Dorothy’s musical salvation. 
The girl’s ambition has now been kindled to a 
frenzy, and to make the Metropolitan Opera in 
about a month seems so easy that the secret is 
confided in numerous letters to waiting worthies 
back home. Two years go by and Dorothy now 
finds herself in the hands of her sixth singing 
teacher who has torn down all of the work done by 
his previous five confreres, and, starting all over 
again, soon finds that his pupil has come to an 120 
HYGIENE OF THE VOICE 
impasse. She is not making the desired progress 
and in desperation a laryngologist’s advice is sought. 
The doctor gets to work and tries to measure the 
physical and vocal capabilities of his patient. He 
finds that the chest muscles are undeveloped and 
that Dorothy stands and walks with a crooked 
Fig. 14.—Interior of the nose. 1. Ethmoid cells; 2. Sphenoid sinus; 
3. Body of sphenoid bone; 4. Very large adenoid; 5. Uvula; 6. Right 
tonsil; 7. Hard palate; 8. Entrance to nose through nostril; 9. Nasal 
septem (partition). 
spine. There is in consequence a good deal of lung 
tissue that is only partially filled with air. The girl 
is awkward in every movement. She knows nothing 
about diet or exercise. Her voice is shrill, badly 
produced, uneven throughout the musical scale, and 
strangely unresonant. There is a deviated septum, THROAT DISORDERS IN SINGERS 
121 
hypertrophied turbinates, and an adenoid which, 
seen by posterior rhinoscopy, looks like the back 
drop at the Hippodrome. The tonsils are “cheesy,” 
and there are several small glands at the angle of 
the jaw on each side. He recommends several oper- 
ations, but his suggestions are not kindly received 
by the teacher, who says that a month of interrup- 
tion in lessons cannot be tolerated. He has to make 
his living, too, as well as the rest of mankind, and, 
to be frank, would have sent the girl in before, but 
felt sure that the inevitable would happen, and that 
the doctor would hold it his bounden duty to find 
something to operate on. The opinions of the 
teacher and doctor go back home, and so does the 
girl, without having anything done; for she is dis- 
couraged beyond measure and probably wants to 
die. 
Now this recital, although humorous in its es- 
sence, is of the truth. It is a daily affair and is 
destined to continue unless in some way laryngolo- 
gists can secure the co-operation both of teachers 
and parents. The difficulties of compromise are 
indeed great, but the patient’s interests come first 
and it is certainly our duty as medical men to do 
what we can to spread the gospel of early and 
thorough examination of all would-be candidates for 
vocal honors. 
In the prevention of ills common to singers and 
speakers (actors), the physician must inform him- 
self, as already mentioned, about the influence of 
common diseases of childhood, especially concerning 
the ills which lie in the wake of the exanthemata. 
These are in the last analysis respiratory infections 
for the most part, the first symptoms of which ap- HYGIENE OF THE VOICE 
122 
pear as exanthemata,—witness Koplik’s spots in 
measles, the strawberry tongue and red sore throat 
of scarlet fever, and the sticky exudate in diphtheria 
which we call “membrane.” Fortunately, most of 
these diseases clear up without persistent sequelae, 
but they have a bearing on the health of the nose, 
throat and ears which ought always to be kept in 
mind. 
Tonsils and adenoids must be removed, if diseased, 
or if they cause symptoms through obstruction. As 
time goes on we shall have to consider them less 
and less in adult singers, since they are being so 
generally removed in childhood. But the end re- 
sults of unsuccessful or faulty operations will always 
confront us and will afford knotty problems at 
times; for instance, where the uvula has been 
removed or the naso-pharynx greatly narrowed 
through atresia. 
Sinus involvement in children, which is being 
intensively studied by many of our best rhinologists 
at this time, is an important theme, because, if 
unhealed, it may lead to many chronic conditions, 
such as atrophy, chronic post-nasal discharge, 
chronic hoarseness, etc. Where the diagnosis is 
readily manifest in adults, one cannot expect to 
overcome the condition or to relieve it so that a 
vocal career can be hoped for. Permanent patho- 
logical changes in the respiratory tract must always 
be looked upon as having grave importance for the 
singer, and this is almost equally true of the audi- 
tory tract as well. A deviated septum in childhood, 
the result of trauma or as an expression of familial 
divergence from the normal, is always of importance 
to the growth and health of the individual, so that THROAT DISORDERS IN SINGERS 
123 
it often becomes a serious question when we take 
all factors into account, whether we ought not to 
attempt submucous resection on a child regardless 
of the resultant deficient growth or deformity of the 
external nose. I am inclined to believe that as time 
goes on we will become more radical in this regard, 
expressly so in cases of extreme deviation which 
produce occlusion of one nostril; for the end result 
to the patient may be just as unfortunate as per- 
sistent enlarged or diseased tonsils and adenoids. 
Life and health must, of course, always come first 
and looks must follow in their train. 
In order to understand the disorders common to 
singers, one should have some conception of the 
mechanism of voice production. Although this has 
been touched upon in an earlier chapter, it may not 
be out of place to take it up here in a little more 
systematic fashion. Reduced to its lowest terms, 
production is composed of three elements or factors: 
1. The motive-power element. By this is meant the 
muscular force which so acts upon the air tract as 
to control both the volume and power, making it 
possible to increase or diminish the emitted sounds 
to any desired degree. One commonly hears teach- 
ers and singers speak of the diaphragm in this con- 
nection as if it alone were the only motor muscle 
to be considered, but it is only one of many; for 
the well-trained singer uses nearly all of the muscles 
of the body in securing his effects, especially those 
which make up the torso—the thoracic and abdom- 
inal groups. 2. The laryngeal element. The voice 
is, of course, produced at the cords through vibra- 
tions which are set in motion by air waves coming 
up from the lungs, the vocal bands being under the 124 
HYGIENE OF THE VOICE 
control of the intrinsic and extrinsic laryngeal mus- 
cles. 3. The resonating element. Resonance is 
commonly thought to take place in the chest, in the 
ventricles of the larynx, in the naso-pharynx, the 
nasal fossae, beneath the turbinates, and in the 
accessory sinuses. 
Now a variation from the normal function in any 
one of these can set up a series of permutations and 
combinations which alter the pitch, power, intensity, 
volumq, timbre, quality—in fact, all of those pecu- 
liar fundamental factors which we group together 
and call “the voice.” For example, if one holds the 
Fig. 15.—Fibroma growing from the left vocal cord, causing chronic 
hoarseness. 
nose he immediately changes the relationship of 
these three elements, and the voice is described as 
having a nasal quality. If he should inject some 
substance such as paraffin into the cords so as to 
change their size or shape, the ear would detect a 
change in quality and power. Finally, if the chest 
were strapped or otherwise held in a vise-like grip 
limiting all muscular movements, there would be 
loss of power, volume and probably a change in 
voice quality. 
Let us apply these simple principles to disturb- 
ance of function which we see every day through THROAT DISORDERS IN SINGERS 
125 
malformation or deformity of the nose. A patient 
with a badly deviated septum always has a peculiar 
vocal quality. The voice is high pitched, has poor 
carrying power, and is deficient in resonance. The 
column of air as it comes into the naso-pharynx 
divides into two streams, part going to each side of 
the posterior edge of the septum. If the fossae are 
equally free, the length of the air column is the 
same on both sides, and the resonance on both sides 
is about equal. But if the air column is shortened 
in one fossa through obstruction, the tone is damp- 
ened and sub-resonant. This is very well seen by 
humming into the nose on a single note and 
pressing the nostrils alternately, when a marked 
difference can be noted by the examiner which may 
be scarcely perceptible to the patient. The differ- 
ence is, perhaps, more noticeable in the presence of 
hypertrophied turbinates, or polypi, or in the pres- 
ence of a generalized swelling within the nose due 
to an infection (acute rhinitis), or after various 
nasal operations until the so-called reaction has 
disappeared. In such a case the voice is not rein- 
forced and most of the vocal effort lies across the 
level of the vocal bands. If prolonged or strenuous 
vocal exercise is indulged in under such conditions 
the voice becomes husky or hoarse or even aphonic. 
That is why we ought not to allow our patients to 
sing or make public speeches in the presence of a 
“cold,” for, in doing so, they jeopardize the larynx 
and may bring about a vocal strain which is perma- 
nent insofar as great vocal effects are concerned. 
The voice may never be quite the same again. 
Careful examination of the larynx will show a sticky 
secretion on the edges of the cords and even a slight 126 
HYGIENE OF THE VOICE 
bowing, so that a very great muscular effort is 
required to bring the bands together in full align- 
ment, and soft-voice work, such as pianissimo, is 
rendered impossible. As already mentioned, this 
disability may lay the foundation for the develop- 
ment of vocal nodules. 
In advising as to the possibility of taking up a 
vocal career, one should make sure that the candi- 
date possesses an anatomical configuration which is 
naturally good or which can be surgically moulded 
to the required degree. The essentials are: a free 
nose, properly warmed and moistened air (good 
turbinal function), a roomy naso-pharynx, normal 
action of all palatal muscles, no adenoid, normal 
faucial and lingual tonsils, vocal bands free and 
quickly responding to the will, arytenoids normal 
(uncrossed), chest volume and expansion good, 
breath control good. Asymmetry in the larynx, 
especially the crossing of arytenoids, is regarded as 
unfavorable by practically all authorities. E. Barth 
makes the point that “in spite of careful schooling 
and great zeal for work the voice in its upper range 
and when used forte remains tremulous and uncer- 
tain” in practically every such case which he has 
studied. This is, of course, a condition which is not 
amenable to any known treatment, surgical or other. 
But with all the essential factors quite normal— 
anatomical configuration, good general health, a 
strong athletic body, et cetera—one must remember 
that bad use of a good voice will most certainly ruin 
it eventually. The singing teacher is too often 
blamed for conditions over which he has no control; 
for example, a pupil after a few lessons takes a posi- 
tion as “cabaret artist,” whatever that may mean, THROAT DISORDERS IN SINGERS 
127 
and attempts arias from grand opera roles under 
the most adverse conditions, such as noise, smoke 
and bad air, and failing to make good charges the 
teacher with having ruined her voice. So that in 
the absence of any inflammatory signs or symptoms, 
the laryngologist may be somewhat puzzled as to the 
cause of vocal disability unless he keeps in mind 
the mode of life and the wilful ignorance of many 
young singers. 
The upper airways are even more subject to local 
infections than the lower, although many persons 
never have a “cold in the head” which does not ex- 
tend downward into the larynx, trachea and bronchi; 
and, as already mentioned, it is the attempt to “sing 
over” this disability which lays the foundation for 
much future trouble. The end result is a secretory 
disturbance of some sort, post-nasal dropping of 
mucus or muco-pus which later on often changes 
into a dry condition; and, as every singer knows, a 
dry throat is more difficult to manage than a wet 
throat. Sometimes “the cold” seems to have cleared 
up and is almost forgotten by the patient, but still 
the voice gets husky and does not respond to the 
urgent efforts of the will. This is a type which I 
have ventured to call “Latent,” because to the ex- 
aminer there is very little which can be seen, and I 
am inclined to believe, too, that it is this type which 
leads most often to mistaken advice as to the neces- 
sity for some operation. The sub-glottic region just 
beneath the vocal bands seems to be the locus 
minoris, and if one studies this carefully and asks 
the singer to phonate, he will often be rewarded by 
seeing some tiny droplets of mucus work their way 
up over the surface of the cords. When the patient 128 
HYGIENE OF THE VOICE 
feels this obstruction to the use of his cords, he often 
clears his throat and produces a sound described as 
“A-hem,” which is nothing more nor less than a 
shaking of the vocal bands to free them of secretion. 
The throat then remains free and the voice clear 
until this secretion recurs. In the presence of such 
secretion the voice is husky and breaks easily; that 
is, the tone is unsteady, inclines to slide off pitch, 
and the singer is very much afraid to take a note 
pianissimo or legato because of the utter spoliation 
of the vocal effect in case the tone breaks. This 
clearing of the throat begins as a real necessity and 
ultimately may become a habit long after the hyper- 
secretion has disappeared. Sub-glottic hypersecre- 
tion is in all probability one of the causes of phonas- 
thenia or voice weakness because it leads inevitably 
to forcing, chronic hoarseness, and so-called relaxed 
larynx, dissipating the vocal power and encourag- 
ing the formation of vocal nodules. Garcia in his 
“Hints on Singing” says that phonasthenia or voice 
weakness causes “hoarseness, relaxed throat, languor 
of the organ which refuses to execute passages gen- 
erally possible, dryness or heat in the throat, diffi- 
culty in swallowing, and fatigue after a few minutes’ 
exercise.” 
A few illustrations from actual case histories may 
serve to impress on the mind certain points which I 
have tried to elucidate in this chapter. Certain 
changes have been made in the actual case histories 
in order that identification be rendered impossible. 
A young woman of unusual vigor and possessed of 
apparently all the essentials necessary to a good 
career as a vocal artist came in with her singing 
teacher for examination. For some months she had THROAT DISORDERS IN SINGERS 
129 
been troubled with sneezing without any other signs 
of so-called hay-fever or pollinosis, or whatever one 
chooses to call that peculiar syndrome or symptom 
complex which has baffled rhinologists for many 
years. There was slight thickening of the septum, 
but no deviation. Resonance was good and the air 
stream from both nostrils satisfactory. No contact 
points could be found nor any hypersensitive areas 
on the mucosa of septum or turbinates. In other 
words, a satisfactory diagnosis could not be made 
without going into the protein sensitization tests. 
An alkaline spray containing a tiny amount of ad- 
renalin was prescribed, also blennotasin tablets, 
which have a certain vogue in these conditions be- 
cause they are said to dry up excessive nasal secre- 
tion. Not satisfied with this, the patient went on a 
journey to a relative who is a rhino-laryngologist. 
This gentleman did an extensive submucous resec- 
tion, removed both middle turbinates and cauterized 
both inferior turbinates. The result was brilliant in 
that sneezing stopped at once. But the nose is now 
so wide open that the airways are constantly dry 
and scaly, and the voice has that peculiar quality 
which has been described as rhinolalia. The larynx, 
too, is becoming dry and the vocal work unsatisfac- 
tory. One must conclude that this patient is the 
victim of too much radical surgery; for nothing 
taken out can ever be replaced, and what may seem 
to be the shortest road to a brilliant result may 
prove in the long run to be the least desirable. 
At a well-known vaudeville house a singer with- 
out any special qualifications and with practically 
no training, while striving for a high note, sud- 
denly became hoarse. Examination about an hour 130 
HYGIENE OF THE VOICE 
and a half after the accident disclosed a hemorrhage 
into the substance of the left vocal cord. The con- 
dition was explained as well as one could, and the 
prophecy ventured that it would respond to treat- 
ment in about two or three weeks. Looking further 
for a cause, there was a bad deviation of the nasal 
septum on the side of the lesion, hypertrophied in- 
ferior turbinates, and post-nasal secretion which 
dripped into the pharynx and probably on the cords 
as well. The advice was given to have the nose op- 
erated upon at once, then, during the post-operative 
period, the larynx could be treated and no time 
would be lost, but it was also emphasized that a 
change of vocal method would have to be made lest 
the condition recur again. Instead of considering 
this advice the patient went to a neighboring city 
and was assured by a laryngologist that the hemor- 
rhage into the cord was a myth, and that submerged, 
diseased tonsils were the sole cause of the hoarse- 
ness. Accordingly, a tonsillectomy was done, but 
the patient bled so profusely that he was rushed to 
a hospital, where a ligation of the external carotid 
was done by a general surgeon and the patient’s life 
was saved. He has never done any public singing 
since and I am unable to say what happened to the 
cordal hemorrhage, but it was undoubtedly absorbed. 
A lyric soprano doing her turn in comic opera was 
much distressed because of sudden attacks of hoarse- 
ness associated with a good deal of laryngeal secre- 
tion. Small vocal nodules were to be seen on each 
cord, but by treating the larynx the patient was en- 
abled to continue at work in the hope of tiding her 
over into the dull summer season. It was planned 
to remove the nodes, as they were not of the type THROAT DISORDERS IN SINGERS 
131 
that can be “sung off,” as the expression goes. 
Meanwhile the services of an experienced teacher 
were to be enlisted with the idea of changing the 
method of production and “re-set” the voice, so to 
speak. Through some misunderstanding there was 
an error about an appointment and the singer left 
my care in anger and went to another specialist, who 
told her that the real difficulty was not nodes at all, 
but a film of uric acid that had spread over the 
entire cordal surfaces. He put her on a diet and 
advised an elastic abdominal belt for some real or 
imaginary visceroptosis. At the next performance 
the restriction of the abdominal muscles and dia- 
phragm showed in the voice, which was thin, weak, 
of poor carrying power, and could not be re-enforced 
through resonance from the chest and head. A few 
days later this singer was virtually carried from the 
stage and was obliged to spend some weeks in a sani- 
tarium. A period of inaction followed, covering 
about two years, and the lady is now singing very 
well. What happened I do not know, but one can 
hardly assume that the uric acid theory is respon- 
sible for a cure in this case. 
The following vocal disability was assumed to be 
due to a post-influenza condition: A tenor had made 
a good record at La Scala by singing Caruso roles 
after that justly famous and greatly lamented artist 
had signed up with Metropolitan. Having finished 
his European season, this man, who was of very 
unstable nervous temperament, crossed the ocean to 
seek further laurels in America. En voyage he con- 
tracted a cold and landed in New York quite ill. 
After two or three weeks in bed with a condition 
which his general practitioner called influenza, he 132 
HYGIENE OF THE VOICE 
was sent to Lakewood to recuperate, but found to 
his great alarm that his voice was notably deficient 
in power, intensity and range. Whereas, he had for- 
merly possessed the remarkable range of three 
octaves, he could use only about two at this time. 
The voice was “foggy,” broke easily at F sharp and 
G natural, could not be sustained and was produced 
only by a great muscular effort, in other words, by 
“squeezing” the cords together which fatigued him 
greatly. He was subsequently treated by several 
laryngologists, one of whom applied pure tincture 
of iodin to the larynx, followed by oil sprays! This 
was continued daily for some two weeks, and he was 
advised when visiting the doctor to walk around 
Central Park preceding each visit. Finally he came 
under my care through a patient whom he met in 
Lakewood. Examination showed nasal insufficiency, 
some bogginess of the turbinates and post-nasal 
discharge of pus-stained mucus. There was much 
secretion on the cords which did not completely ap- 
proximate throughout their entire length, but left 
a bowed, elliptical space about the middle of the 
glottis chink. Only by forcing could high notes be 
produced, and soft voice work—pianissimo—was 
impossible. Cleansing and astringent antiseptic 
treatment, silence, followed in about three weeks by 
vocalisees to strengthen the strained laryngeal mus- 
cles, was carried out. In about two months he had 
completely recovered and finally returned to Europe, 
where at last reports he was doing well. 
The most aggravated conditions are seen in vaude- 
ville singers, who are usually people of talent with 
little or no training in the proper use and care of the 
voice. Their work is constant and fatiguing to the THROAT DISORDERS IN SINGERS 
133 
last degree, and they never feel that they have time 
enough either to learn the fundamentals of voice 
production or to be treated when most in need of it; 
and, hence, are likely to consult the laryngologist 
only when in extremis. Most of them do from two to 
four turns a day under conditions which would wear 
down the most accomplished and highly trained 
vocal artist, “go on” after excesses of various kinds, 
work straight through an acute infection of the air- 
ways, and violate all of the rules of voice hygiene 
generally. The necessity of keeping them at work 
offers a difficult and disturbing problem and is quite 
generally unsatisfactory. Very often the anatomical 
configuration is anything but good,—the nose is 
stuffy from turbinal enlargement, the septum is 
deviated, latent or manifest sinuitis exists, especially 
of the hyperplastic variety with chronic post-nasal 
discharge, and, likely as not, chronic tonsilitis as well. 
In fact, the entire list of common disorders of the 
airways may be found in a single case. 
A good example is that of X. Z., who has had 
many years’ experience on the vaudeville stage. He 
is a large man, weighing 225 pounds, possessed of a 
powerful tenor voice, harsh at times but not with- 
out a pleasing quality which brings him a “good 
hand” from his audiences. He has never taken any 
care of his vocal apparatus but has indulged in all 
of the joys common to a profession always en route. 
Nevertheless, he has earned a good living for his 
family for 20 years. At the time of his first visit he 
had, to use his own phrase, “joined the down-and- 
outers.” Examination showed a marked deviation 
of the septum, hypertrophy of all turbinates, and a 
sticky post-nasal discharge which he could remove 134 
HYGIENE OF THE VOICE 
only with great difficulty and by making a disgust- 
ing noise. The pharynx seemed dry and slightly 
puckered (pharyngitis sicca of mild degree). The 
tonsils were quite large, deeply buried and contained 
“cheesy” material which was expressed from the 
crypts. Laryngeal examination disclosed thick, 
rather beefy cords which did not approximate well 
because of a thickened posterior wall and inter- 
arytenoid hyperplasia,—apparently the result of a 
chronic productive inflammation of the mucosa. 
There was some thickening of the tracheal mucous 
membrane and the rings could not be readily 
counted. Mobility of both cords was unimpaired 
save for the inter-arytenoid condition just noted. 
He had taken cough medicines and inhalations on 
the advice of physicians in the various cities he had 
visited without any marked relief, and he persisted 
in using the voice in spite of all caution as to the 
value of silence treatment. However, in the sum- 
mer of 1919 he accepted my advice and underwent a 
submucous resection of the septum plus a reduction 
of the turbinal hypertrophy. At a later sitting the 
tonsils were removed under local anesthesia, and 
still later on I exsected the inter-arytenoid and pos- 
terior wall thickening. The final result was a nose 
normal both for breathing and resonance, a satisfac- 
tory fauces, the pillars being intact, although fused 
together partially, and a smooth laryngeal posterior 
wall and commissure with normal function of all 
laryngeal muscles. He then went on tour in the fall 
of 1919 and sang songs which he had not dared to 
put in his repertoire for many years. There is still, 
of course, a woeful lack of savoir faire, but he got 
“full time,” as the routinieres say, and regarded THROAT DISORDERS IN SINGERS 
135 
himself as absolutely rejuvenated. Only recently, 
however, he returned to New York from a town in 
Texas where he was playing and underwent treat- 
ment for an acute infection of the entire air tract, 
through which he sang until forced to quit by dint 
of circumstances, but at this time is all right and at 
it again. Curiously enough there seems to have 
been no tendency to chorditis nodosa at any time, 
a condition which ought to have appeared by all 
known rules, but perhaps the thickening in the 
laryngeal posterior commissure may have been the 
expression of what in another case would have been 
an avowed nodal growth. CHAPTER XIV 
THE TONSIL QUESTION 
This is a matter of such importance to the singer 
that one must go into it quite fully. When a 
physician speaks of tonsils he usually has in mind 
that they are not two but four in number,—the 
adenoid situated in the vault of the pharynx be- 
hind the nose, the lingual tonsil at the very base 
of the tongue, and the lateral or faucial tonsils sit- 
uated, one on each side of the tongue, just below 
the free border of the soft palate. It is with the 
latter that we are especially concerned, since they 
are so frequently subject to acute infection with 
the onset of violent symptoms. 
From observation one rather definite conclusion 
may be drawn; namely, that the tonsils are a sort 
of sieve or first line of defense, and screen out from 
the blood and lymph streams, disease germs which 
either are circulating in these fluids, or are intro- 
duced into the mouth with food or close contact 
with people who are carriers of infection. ' 
Not infrequently the physician observes cases of 
acute nasal infection with or without discharge of 
pus which are followed by an attack of acute ton- 
sillitis. After nasal operations, for instance, sore 
throat is not infrequent, and when we examine the 
tonsils we find redness, swelling, and pain on swal- 
136 THE TONSIL QUESTIONS 
137 
lowing with possibly fever and general malaise. 
Evidently, therefore, tonsils which are functioning 
normally are useful organs, but when they become 
diseased they are a menace to bodily health. 
In recent years we have learned that rheumatism 
is not infrequently caused by tonsil infections, and 
every case of rheumatism should be studied by the 
physician with this possibility in mind. There are, 
of course, many other foci of infection from which 
rheumatism can take origin, but once the tonsil is 
convicted, we can easily eliminate it as a source of 
further trouble. 
The construction of the tonsil is very favorable 
to infection. It is a small round or flattened mass 
of gland tissue studded with small holes called 
follicles. These follicles stand ready to catch par- 
ticles of food and drink, germs which are ever pres- 
ent in the mouth, and, in fact, any debris cast off 
from the mucous membrane lining of the buccal 
(mouth) cavity. When putrefactive germs find a 
place in one or more of these crypts, there is just 
sufficient heat and moisture to cause them to mul- 
tiply, and in a few hours we have the well-known 
sore throat, redness, internal swelling, pain on 
swallowing, glandular swelling in the neck, general 
malaise and rise of temperature to 102 or 103 de- 
grees Fahrenheit. Pain in the back and bones, and 
general depression are due to the absorption of 
poisonous (toxic) material into the blood stream, 
and the subsequent effect on the nerve centers. 
About this time Nature tries to come to the res- 
cue, and the body begins to manufacture a toxin of 
its own which is intended to neutralize the effect of 138 
HYGIENE OF THE VOICE 
the germ toxin. But in many cases the germ toxin 
has a great handicap over the body antitoxin, and 
Fig. 16.—Enlarged and diseased tonsils. 
several days pass by before the invading enemy is 
conquered and eliminated. 
During this period of infection the patient suffers THE TONSIL QUESTIONS 
139 
considerably, and is thoroughly determined to have 
the tonsils removed as soon as he recovers. Time 
is a great healer of trouble, however, and once the 
body condition returns to normal, the patient usu- 
ally decides that another attack is unlikely and 
confesses himself willing to “take a chance.” 
Whatever may be said for or against tonsillectomy 
in other persons, in singers it is a matter of vital 
importance. The laryngologist is confronted daily 
by the eternal question: “Doctor, if I have my 
tonsils removed, do you think there is any danger 
of my losing my singing voice?” The patient who 
frames this interrogation usually has a long story 
to tell of someone who has had the tonsils removed 
and was never able to sing thereafter. It is nearly 
always a hearsay story. Seldom do we find anyone 
who has seen a “before and after” demonstration 
of this disability. Many singers, when questioned, 
acknowledge that they can recall no specific in- 
stance of lost singing voice following tonsil re- 
moval. Nevertheless, feeling that this subject is 
worth sifting out, and in order to get first-hand in- 
formation, a questionnaire was sent out to 500 
physicians, and to 500 singing teachers. A sur- 
prisingly large number of answers were received, 
and it was gratifying to note the interest that the 
matter seemed to inspire. Many of the busiest and 
best known men not only answered the questions 
but took the trouble to write a personal note as 
well. This personal element has added greatly to 
the interest of compiling and classifying the neces- 
sarily varying opinions. I shall present the evi- 
dence adduced covering 5,000 operations. 140 
HYGIENE OF THE VOICE 
To physicians. 
Question 1. How many singers approximately 
have you tonsillectomized? One hundred and eight 
men reported 3,427 tonsillectomies. Of these, some 
could not spare the time to look up records; others 
kept no records, and five were against operating on 
singers at all. 
Question 2. Did cicatrical (scar) contractions of 
the pillars and soft palate result in any casef Out 
of 341 cases, only 46 showed cicatrical contractions, 
which is truly an excellent operative record. On 
the other hand, one gentleman said he had “ob- 
served” two hundred cases operated on by other 
surgeons, “many” of which showed such contrac- 
tions. Another surgeon had “treated” 100 post- 
operative cases in 22 of which (22 per cent) he 
found cicatrical contractions in the fauces. It is 
fairly impossible to form any accurate judgment 
of this matter owing to the guesswork with which 
many physicians seem to be laboring. The word 
“many,” “few,” “several dozen,” “great number,” 
etc., shows the mental haziness which descends on 
our horizon when we try to collate facts for scien- 
tific purposes. However, in order to strike an 
average we may say that cicatrical contractions 
seem to be present in about one-sixth of the total 
number of cases reported. 
Question 3. What were the effect of tonsil opera- 
tion on the singing voice? A, good; B, bad; C. no 
change. This is the salient question in the inquiry, 
and yet it was frequently answered in slipshod 
fashion or overlooked entirely. One hundred men 
reported good results in approximately 2,849 cases; THE TONSIL QUESTIONS 
141 
while 29 men reported no change. Four physicians 
declared absolutely bad effects, but did not go into 
particulars as they were especially requested to do; 
therefore, we are in the dark as to what these bad 
effects were. Two of these men had never operated 
and the other two had done “very few” operations. 
Both declared their observation to be based on a 
“large” number of post-operative cases sent to them 
for inspection. 
Question .4. Were these effects temporary or per- 
manent after one yearf In all cases the good effects 
ivere permanent. In cases where untoward or bad 
effects were noted, they disappeared within from 
one to three months after operation. No bad effects 
seem to have persisted after the third month. A 
great many men expressed dissatisfaction in not 
being able to follow up their cases in a proper 
manner, since pupil singers migrate to larger towns 
and to Europe. In general, singers as a class, are 
fond of consulting many different specialists in the 
cities where they visit. 
Questions 5 and 6. What had effect, if any, was 
complained of, and what do you think was the cause 
of this bad effect f Ninety-five men reported no bad 
effects in a total of 2,904 cases. One holds the proud 
record of 300 tonsillectomies without a single bad 
effect of any kind. Thirty-eight men reported bad 
results in 172 cases. These were in outline about 
as follows:— 
Vocal stiffness for a few weeks. Decreased vol- 
ume and impaired quality. 
Difficulty with the flexibility of the top voice. 
Voice lowered and range limited. 
Difficulty in placement or loss of placement. 142 
HYGIENE OF THE VOICE 
Loss of purity and sweetness of tone. 
Metallic quality. 
“Catch” in the voice. 
Dryness of the throat and a sensation of a feather 
tickling the throat. 
Vocal fatigue after vocalization. 
The causes of these untoward symptoms as 
viewed by the specialist were: Faulty operative 
technic whereby the pillars and soft palate were 
injured; changes in the faucial contour due to 
cicatrical contractions; involvement of fibres of the 
glossopharyngeal (9th cranial) nerve; temporary 
inco-ordination of vocal musculature; lost lubricat- 
ing function of the tonsils; relaxed pillars neces- 
sitating a re-arrangement of the resonating influence 
of the pharynx and nasopharynx; and, finally, using 
the voice too soon after operation. 
One surgeon reports 3,500 tonsillectomies. Of 
the subjects, about fifty were singers, and in none 
was there any difficulty except “stiffness of the 
throat” for a few weeks. 
Question 7. What type of tonsil (buried, small, 
hypertrophied, pedunculated, etc.) in your opinion 
gives the best chance of voice improvement after 
removal f All are practically agreed that the hyper- 
trophic (enlarged) tonsil offers the best hope of im- 
provement. The best answer probably is that any 
diseased tonsil, whether large or small, should be 
removed if such disease and resultant symptoms 
have been established beyond peradventure. Some 
years ago, Prof. O. Chiari of Vienna, showed that 
greatly hypertrophied tonsils may be removed with 
impunity only if we calculate beforehand how to 
prevent relaxation of the palatoglossus and pala- THE TONSIL QUESTIONS 
143 
topharyngeus muscles. Removal of such a mass of 
lymphoid tissue leaves a large fossa which must be 
filled in by granulation tissue and subsequent scar. 
He always felt it wiser in such a case to do a ton- 
sillotomy (partial removal) and to treat the cryptic 
stumps with chromic acid or the electrocautery after 
healing is fairly established. 
This brings us to the crucial question. 
Question 8. Do you know of any case in which 
the singing voice was apparently destroyed by a 
tonsil operation? Only fifteen men out of 133 con- 
fessed a knowledge of any case in which the singing- 
voice had been destroyed by operation. The in- 
quiry was intended to apply to patients who had 
been obliged to give up all effort to sing after ton- 
sillectomy. One man replied: “Lots of them, as a 
result of injuring the pillars during radical extirpa- 
tion. I consider enucleation with the capsule in- 
jurious to the voice because of resulting prolapse 
of the pillars and I apply the old rule, to remove 
only diseased or hypertrophied tissue.” In one case 
“harm was done by a bungling operation.” Doctor 
X. reports two patients “who stated that they were 
never able to sing after tonsillectomy,” but adds 
naively that he doubts whether they could sing 
before the operation either. 
Sifting down the “evidence” of these 15 laryn- 
gologists who align themselves against tonsil opera- 
tions in singers, such evidence is intensely vague, 
uncertain, and, seems, after all, to be based mainly 
on hearsay. 
Question 9. To what circumstance or technical 
fault do you attribute this destruction? There 
seems to be a unanimity of opinion that faulty 144 
HYGIENE OF THE VOICE 
technic is at the bottom of any post-operative diffi- 
culty. The phrase “faulty technic,” occurs again 
and again, while injury to the pillars, laceration 
of the uvula and soft palate, too extensive cutting 
or tearing of parts adjacent to the tonsil, and 
ignorance of anatomy and function of the tonsil 
are other ways the reports have of describing the 
causes of vocal impairment as they view it. A cer- 
tain physician complains of those “who operate 
without anesthetics in sensitive throats which 
patients cannot control during operation.” Surely, 
anyone who attempts, without anesthesia, any kind 
of operation on a highly strung supersensitive singer 
is guilty of a serious offense. 
To Singing Teachers. 
Thus far we have considered only the reports 
coming out of the experience of the laryngologist. 
Let us now take up the replies to the questionnaire 
set for singing teachers only. There was a great 
deal of difficulty in reaching the teachers, because 
their national organization has few members and 
no complete list of names and addresses. A large 
number of those addressed replied, but the writer 
regrets that he was unable to secure a longer list. 
Question 1. How do diseased or enlarged tonsils 
affect the singing voicef The general opinion 
among singing teachers is that the tonsils muffle 
or deaden the voice, take up space needed for per- 
fect vocalization, interfere decidedly with amplifica- 
tion of tone, make the voice thick and throaty and 
limit its compass, diminish the pharyngeal and naso- 
pharyngeal (head) resonance, affect the general THE TONSIL QUESTIONS 
145 
health, cause liability to colds and weak throat, and 
prevent the expansion of the throat necessary for 
high voice. 
Question 2. How many of your pupils approxi- 
mately have had their tonsils removed ? About ten 
to twenty per cent of vocal students sometime in 
their career undergo tonsil operations. One teacher 
says that a large percentage of so-called throat trou- 
ble is caused by diseased tonsils, and recommends 
all such people to undergo the operation before be- 
ginning vocal work. 
Question 3. Was the removal total or partial? 
The consensus is that total removal is preferable; 
for, after partial removal “the tonsils grew agayi” 
and the pupil went through the same series of “sore 
throats every few days” as before. One teacher 
says that the question of total or partial removal 
depended, in his experience, on the skill of the 
operator. 
Question 1+. Was there any kind of bad effect on 
the singing voice? If so, how manifested? Nearly 
all of the reporters say that no bad effect was noted. 
One teacher found it “hard to bring into the voice 
any softness of color.” Another thinks the opera- 
tion does not benefit “since it makes the focusing 
of tone impossible.” “Natural conditions are 
changed,” says one, and fine adjustment of the 
pharynx is interfered with. In some cases the voice 
was lowered; in others, heightened from a half to 
a full tone. In at least one case lack of resonance 
was complained of, and in another the voice was 
weak and there was difficulty in focusing and hold- 
ing the pitch. 
Question 5. Do you know of ayy case in which 146 
HYGIENE OF THE VOICE 
the singing voice was apparently destroyed by tonsil 
operation? (If so, a detailed report would be most 
acceptable.) The majority of reporters answered 
“No,” emphatically. One voice was damaged (not 
lost) “by cutting a pillar of the fauces.” Another 
teacher complains of the “careless cutting of liga- 
ments” but does not say what was the result to the 
voice. Still another teacher finds that “in all cases 
emptiness of tone was the result, and in many cases 
the tonsils grew again, causing more operations.” 
One reporter calls attention to the alleged fact that 
Campanini never sang after the removal of his ton- 
sils. 
Question 6. What percentage of good results have 
you found? Fourteen teachers have seen 100 per 
cent of good results; a few, only 50 per cent. Some 
found no effect, good or bad, and one thinks the 
operation “helpful in some cases, harmful in others.” 
At least one is enthusiastic about results, and would 
have every pupil operated upon regardless of the 
indications. 
Everywhere throughout the long list of answers 
there is evidence of an ignorance which ought not 
to exist. The vocal teacher is often out of sym- 
pathy with the laryngologist, and the laryngologist 
quite as surely fails to understand what the teacher 
is driving at. 
For example: “In all my work as a teacher I have 
never had to send a pupil to a throat specialist. The 
tonsils, if there has been any difficulty, have, through 
correct use of the throat, voice and breathing with 
the aid of proper systemic remedies, gone back to 
natural, normal size, etc.” 
By contrast, a Chicago teacher writes: “If more THE TONSIL QUESTIONS 
147 
singers would consult a skilled throat specialist, we 
should have more real singers. No matter how per- 
fect the method, it does not count unless throat and 
nose conditions are normal.” Another thinks that 
“bad tonsils can be corrected by proper habits as 
applied to food, air, breathing exercises and sleep. 
They are indications of a poisoned system. Re- 
moval does not touch the cause.” In a personal 
letter, a physician wrrites his opinion that “much 
tonsil trouble is caused by bad teaching.” 
In my own experience twenty-five singers have 
been tonsillectomized with uniformly good results. 
That is, the range has been improved a half to a 
full tone, and there has been no difficulty in adjust- 
ing voice placement to new conditions. Vocal power 
and resonance have both been increased. In one 
case, that of a large man, hemorrhage occurred four 
hours after operation. This was controlled by grasp- 
ing the bleeding point with a special kind of artery 
clamp, and recovery was uneventful. There was no 
contraction of the fauces in this case, and his teacher 
declared that the improvement in vocal work was 
very noticeable. However, in one baritone whose 
course of healing was complicated by an infection 
of unknown origin, there seemed to be a greater 
tendency to attacks of acute bronchitis. Whether 
this was really so I cannot say as it was necessary 
to rely on the testimony of an extremely introspec- 
tive patient who magnified his ills whenever pos- 
sible. Nevertheless, in spite of this apparently un- 
toward result, he was glad he had gone through the 
operation, and his vocal range and power were un- 
doubtedly increased thereby. 
In certain selected cases it is probably better to 148 
HYGIENE OF THE VOICE 
temporize than to operate. Every specialist of ex- 
perience will know and recognize the considerations 
which afford a basis for this judgment. Occasion- 
ally, it is better to do a tonsillotomy (partial re- 
moval) previously as mentioned. This statement 
will be a shock to certain confreres I know, but I 
think it is true in certain selected patients, neverthe- 
less. As a rule, complete enucleation should be 
done. Undoubtedly, the small, “cheesy” tonsils 
should be removed en masse, as nothing is to be 
gained by simply puttering with them. The sooner 
they are out the better. 
The late Dr. G. Hudson Makuen, of Philadelphia, 
whose work on voice and speech defects is known 
the world over, wrote me “it is safe to say that no 
tonsillectomy has ever injured the voice when the 
operation was really indicated and properly per- 
formed, but that many cases have been injured by 
ill-advised and careless operations I have no doubt 
whatsoever.” 
Dr. Solis Cohen of Philadelphia, thinks that 
“where hypertrophied tonsils impair the voice, im- 
provement should follow operation. Where the 
contour of the tonsil is essential to the timbre of 
the voice, interference will impair it. 
Finally, Dr. Justus Matthews, formerly of the 
Mayo Clinic, Rochester, Minnesota, who has per- 
formed an enormous number of tonsil operations, 
answered the questionnaire and added the following 
opinion: “I believe that most of the cases of loss 
of singing voice following tonsil operation are purely 
imaginary and are due to some other cause. How- 
ever, I have seen several cases and feel certain that 
the cause is to be found in the cutting of the nerves.” THE TONSIL QUESTIONS 
149 
Summary and Conclusions: 
An analysis of 5,000 tonsil operations in singers 
show that in the hands of skilled operators there 
need be no fear of bad results. 
It is the consensus of opinion that bad results are 
most often due to cicatrical contractions occurring 
from careless dissection or from neglected after 
treatment. 
Pain in the tonsillar region, neck, and larynx 
after operation is probably due to division of some 
of the larger branches of the glossophyngeal nerve 
(9th cranial) (Justus Matthews). 
Loss of singing voice after tonsillectomy might 
be due to nerve lesion, but is probably due to ad- 
hesions and scar formations in the fauces. 
Loss of singing voice occurs very rarely after 
tonsillectomy. Impaired voice is possible, but most 
cases show an increased range of from one-half to 
a full tone. 
The singer’s problem is a very special one, and 
no laryngologist should undertake to operate on 
these patients unless he has some knowledge of the 
art of singing. 
At operation the greatest care and skill must be 
exercised in securing a clean, free dissection. In- 
jury to the tissues surrounding the tonsil may prove 
disastrous. 
Post-operative care is of special importance. The 
patient should be seen daily until full healing occurs. 
To sum up: Not every tonsil should be removed. 
The normal organ should be let alone. The diseased 
tonsil, or the abnormally large tonsil, should be re- 
moved, not by slicing off a piece but by thorough 150 
HYGIENE OF THE VOICE 
dissection, shelling it out of its bed. In skilled 
hands there is practically no danger, and the good 
results which are likely to follow far outweigh any 
other consideration. 
There are in the last analysis only two chief 
reasons for removing the tonsils: first, when they 
are so enlarged that they interfere with speaking 
or swallowing; second, when they are diseased, re- 
gardless of size. The greatly enlarged tonsil is not 
in most cases dangerous,—it is merely a nuisance, 
a mechanical obstruction in the throat; but the 
diseased tonsil, on the other hand, is a menace to 
good health, and may be the remote cause of un- 
timely death. CHAPTER XV 
HAY FEVER OR POLLINOSIS 
For many years hay fever has been one of the 
mysteries of medicine. The causes ascribed have 
been so many and varied that its true nature has 
been unnecessarily obscured. Recently, however, 
the American Hay Fever Association, an organiza- 
tion composed chiefly of sufferers from this malady, 
has done much to clear up this obscurity, and has 
very definitely determined that the condition is to 
a very great extent preventable. 
The phrase “hay fever” is a misnomer; for hay is 
in reality seldom responsible for the well-known 
symptoms, and fever, when present, is usually due 
to some complication caused by bacteria. A much 
better name is provided by the word “pollinosis,” 
which identifies pollen as the active agent. Prac- 
tically all of the plants responsible are pollinated 
weeds, such as the cockle burr, Johnson grass, yellow 
dock, ragweed and goldenrod. Dr. W. Scheppegrell, 
of New Orleans, does not think that goldenrod 
should be classed with the hay-fever producing 
plants. 
It must be remembered, though, that pollen is not 
the only cause; for in some people it has been deter- 
mined, by testing the skin, that such substances as 
dog hair, horse dandruff, parrot feathers, etc., cause 
a reaction in the respiratory mucous membrane so 
151 152 
HYGIENE OF THE VOICE 
severe as to bring on an attack simulating hay fever, 
or an actual paroxysm of asthma. Certain foods, 
such as meat and eggs, are capable of producing 
such reactions in susceptible persons, and, there- 
fore, the treatment of a given case must be preceded 
by exhaustive study in order to make an accurate 
diagnosis. 
Not infrequently, asthma is associated with hay 
fever. An acquaintance related to me a most un- 
usual case of the combined condition, occurring in 
his practice, where all efforts to find a cause had 
failed. The woman in question had been tested 
not only for all the most likely pollens, but for 
corn, wheat, beef, etc., on the supposition that 
something in the dietary might be uncovered as the 
causative agent, but all to no purpose. Finally, 
some astute person thought of the pet parrot in 
this connection; accordingly, a protein test of the 
feathers was made and applied to the skin of the 
patient, when, to the surprise of everyone, an enor- 
mous reaction took place, thereby proving the 
etiology. Much to the lady’s regret the parrot was 
disposed of, but the end justified the means—she 
was promptly cured. 
Numerous investigators have observed that there 
is an apparent relationship between the flowering 
of certain plants and the periodic annual coughing 
and sneezing which, in certain persons, occurs regu- 
larly at the same season of each year. Since that 
time it has been definitely proven that the pollen 
of certain weeds and flowers may produce symptoms 
in susceptible people. Dr. J. S. Goodale, of Boston, 
and others began to make emulsions and solutions 
of pollens of various plants, and to test the sensi- HAY FEVER OR POLLINOSIS 
153 
tiveness of hay fever subjects to each variety. Dr. 
Goodale made several scratches in different areas 
of the skin of the forearm, and into each of them 
he put a drop of the extract of various pollens. It 
was surprising to see that some persons were suscep- 
tible to ragweed only, others to goldenrod only, still 
others to yellow dock, etc. When the skin reacted 
to the pollen, a welt or wheal would rise around the 
inoculated area, while other areas would be negative 
by comparison. 
In this there is a curious resemblance to the action 
of poison ivy, which causes a most distressing itch- 
ing and burning in some persons, even if they 
merely walk where the wind can carry the pollen 
in their direction; while other persons can pull it 
up by the roots and even smear it over the face 
with impunity. Some persons are, therefore, very 
definitely immune to these agencies; others ex- 
tremely susceptible. 
When pollen lodges on the mucous membrane of 
the nose, it sets up a local irritation, as evidenced 
by sneezing, watery nose and coughing. The 
poisonous (toxic) principles—foreign proteins, as 
they are called—are absorbed through the mucous 
membrane into the blood. If now the patient has 
a resisting substance in his blood, or if his blood 
can manufacture such a resisting substance, the 
pollen toxin will be neutralized and no constitu- 
tional symptoms will result. Again, if the absorbed 
toxins cannot be thus neutralized, then they are 
carried through the entire system and are probably 
excreted and reabsorbed from the nasal mucous 
membrane, thus repeating a vicious cycle. In the 
administration of pollen vaccine, an attempt is made 154 
HYGIENE OF THE VOICE 
to introduce a resisting substance into the blood of 
the sufferer, so that the foreign proteins absorbed 
into the blood from the air tract will be neutralized. 
When there is an abundance of pollen in the air, 
all persons breathing this air inhale about an equal 
amount, but only those have symptoms of pollinosis 
who are unable to neutralize the amount present 
on the nasal mucous membrane, and such quantity 
as penetrates through this membrane to the blood 
stream. 
I recall an instance at a summer hotel, where 
I chanced to be house physician a few years ago, 
which is rather interesting. One of the lady guests 
came to me complaining of watery nose and eyes, 
itching and burning, sneezing and stuffiness,—that 
is, she had all the well-known and distressing symp- 
toms of a violent hay fever reaction. In earlier life 
she had been disturbed annually by this peculiar 
syndrome, but for some fifteen years had been quite 
free of the malady and regarded herself as cured. 
We all were naturally at a loss to account for the 
phenomenon, when it suddenly came into my mind 
that the young people had decorated the hotel 
public room with flowers, twigs, leaves, etc., to make 
a holiday celebration. Fortunately, the affair was 
soon over, the decorations were promptly taken 
down, and the lady’s symptoms disappeared almost 
immediately. 
The effect of pollinosis on the singer incapacitates 
him completely for a number of weeks. The au- 
tumnal type of the disease is especially pernicious, 
since the symptoms are most distressing just at the 
opening of the musical season. Stuffiness of the 
nose decreases head resonance, and the dripping of HAY FEVER OR POLLINOSIS 
155 
the secretion from above affects the larynx ad- 
versely. When absorption of pollen toxins into the 
blood is very considerable, depression and lassitude 
make any kind of effort extremely irksome. 
As to treatment by a specialist, it is important 
that the nose be freed of all growths and redun- 
dancies, and that nasal breathing be effectively 
secured by operation if necessary. 
Recently a surgeon in Fresno, California, whose 
name just escapes me, wrote a very readable and 
interesting report of his experience in the use of 
95 per cent alcohol. The nose is slightly anesthe- 
tized and the alcohol injected into both inferior 
turbinates. The procedure is extremely simple, and 
its sponsor claims about 90 per cent of cures with it. 
No explanation of the modus operandi by which 
such brilliant results are obtained is forthcoming, 
and the treatment is, thus far, purely empirical. 
Along with the stuffiness, sneezing, etc., there is 
not infrequently an associated difficulty in the res- 
onating cavities, or nasal sinuses, causing an out- 
flow of yellow discharge, and, as a rule, there is 
also enlargement of the so-called turbinate or scroll- 
like bodies, the primary purpose of which is to warm 
and moisten the entering air. A crooked nasal par- 
tition, or diseased tonsils or adenoids, must be cor- 
rected in order that the entire upper respiratory 
tract be put in the best possible physiological con- 
dition to make subsequent treatment effective. 
One must aim to keep the patient in an atmos- 
phere as free as possible from pollen, dust, and all 
other air-borne irritants. This measure, of course, 
will not relieve those suffering from a food-protein 
type of the condition, which is, after all, probably 156 
HYGIENE OF THE VOICE 
not so common as the flowering pollinating variety. 
A prolonged sea voyage, or a protracted residence in 
the mountains during the pollinating season, are 
very helpful in attaining this end. The first pre- 
scription is to cut all weeds and pollinating plants, 
or, better still, pull them up by the roots. 
New Orleans has succeeded in passing an ordi- 
nance against flowering weeds and plants which is 
strictly enforced. The results, thus far, have sur- 
passed all expectations. In the eradication of pol- 
len-bearing weeds, it is important to know how 
far one may expect the pollen to be active. By 
means of glass slides exposed to the wind, it has 
been found that some pollens travel a very con- 
siderable distance, even several miles. Owing to 
wide distribution and dissemination by the wind, the 
potency of pollen is greatly decreased, this decrease 
being estimated to be “inversely as the square of 
the distance.” For this reason pollen is not often 
capable of producing pollinosis at a distance of 
more than half a mile. According to this rule a 
patient at 1,000 feet, or about three ordinary city 
blocks, would inhale only 1/1000 part of the pollen 
to which he would be exposed at 100 feet. 
Recently a drug known as calcium chloride has 
proven effectual in some cases. This has been of 
value in various types of asthma as well, and is 
supposed to benefit by its sedative action on the 
nervous system. It is not ulikely that it acts as an 
“antibody” against the foreign proteins and disease 
germs which gain entrance through the debilitated 
nasal mucous membrane. 
So-called “hay-fever vaccine” is now prepared by HAY FEVER OR POLLINOSIS 
157 
manufacturing chemists and biologic laboratories 
for physicians’ use. Hypodermic injections are 
given in graduated strengths at least thirty days 
before the expected attack, and continued at five- 
day intervals. When relief is secured, one weekly 
injection during the pollinating season may be suf- 
ficient to establish complete immunity. There are 
no contraindications to the preventative or curative 
use of this form of treatment, but experience is 
required for the adjustment of dosage to the indi- 
vidual case. Commercial vaccines used in the 
autumnal type of pollinosis contain protein extract 
from the pollen of ragweed, maize and goldenrod, 
dissolved in physiologic salt solution and accurately 
standardized. When relief is not prompt, the 
patient is probably susceptible to some pollen not 
contained in the vaccine. In such cases tests must 
be made to determine which pollen is causing the 
continued symptoms. A special vaccine can be pre- 
pared then, including a suspension of this pollen 
extract. 
The control of the “hay-fever malady” is just at 
hand. What has been set down here represents the 
latest advances in the study of causation and treat- 
ment. The stigma which the medical profession 
has been obliged to bear for so many years, because 
of its inability to afford marked and permanent re- 
lief, is now removed. Thus has the conquest of 
disease continued slowly, very slowly but surely, 
throughout the ages. Man is at last coming into 
control of those unseen and unknown enemies which 
have made life almost unendurable, or have deci- 
mated and depopulated human habitations from 158 
HYGIENE OF THE VOICE 
valley to mountain peak. In this twentieth cen- 
tury a great war is being waged against disease, a 
war more successful, farther reaching, than any yet 
known; but the fruits thereof are not to be fully 
appreciated and enjoyed for some years to come. CHAPTER XVI 
MANAGEMENT OF ACUTE INFECTIONS OF THE 
AIRWAYS 
It is going to be recognized more and more that 
the majority of acute infectious diseases find a site 
of origin somewhere along the tortuous path of the 
airways. Recent studies of “carriers” have shown 
that a great number of people in a fair state of 
health are harboring in their systems enormous 
numbers of pathogenic bacteria which are capable 
of starting a new and severe infection when trans- 
ferred through ordinary contacts of social customs 
to new and favorable soil. The diphtheria bacillus, 
the bacillus typhosus, the pneumococcus, strepto- 
coccus, meningococcus and many others may exist 
in the nose and throat without giving any signs 
of their presence. Physicians and nurses in the 
wards of hospitals frequently carry all of these bac- 
teria at various times in their airways, but go about 
their work unconscious of any danger to themselves 
or their charges. Such are for the most part tem- 
porary carriers and, once they are away from the 
contagious atmosphere or source of supply for a 
few days, the bacteria are no longer to be found. 
The most dangerous type are the latent or un- 
known carriers which, while not giving any evidence 
of disease themselves, are capable of transmitting 
it to others in virulent form. An acute carrier is 
one who has recovered from an attack of a disease 
159 160 
HYGIENE OF THE VOICE 
and who through convalescence and for a few days 
thereafter shows the organisms to be still present. 
If the bacteria persist in the cultures taken for some 
months or years, the infected person is said to be 
a “chronic carrier/’ The study of carriers in the 
war period has shed new light on the spread of 
communicable disease, and has emphasized the 
necessity of taking at least two negative cultures 
from all cases before discharging them from quaran- 
tine. 
The difficulty of sterilizing any mucous membrane 
tract after infection is obvious, but it must be done 
if public health is to be safeguarded, and the newer 
science of medicine must see that it is done. This 
is especially true regarding the so-called “missed” 
case where the patient suffers only a slight indis- 
position and no one thinks it worth while to ex- 
amine the discharges bacteriologically. 
The experience of Great Britain in the outbreak 
of cerebrospinal meningitis in the camps during the 
war has been of great help in working out the 
problem of the carrier in this country. The find- 
ings of the British Commission which studied this 
matter exhaustively have been of aid to us in study- 
ing our own epidemics. It is too extensive to be 
more than mentioned, but will well repay a careful 
reading. This commission came to the conclusion 
that every case of cerebrospinal fever was an in- 
stance of an overlooked carrier. When a man re- 
ported sick, cultures from the nasopharynx enabled 
one to make a positive diagnosis within forty-eight 
hours. This only emphasizes once more how im- 
portant the respiratory tract is in giving origin to 
many hitherto obscure diseases. Research workers MANAGEMENT OF ACUTE INFECTIONS 
161 
on the higher animals (anthropoid apes) are as- 
sembling a mass of evidence showing how frequently 
the portal of entry is in the nose and throat. It 
is thus that meningitis has been studied, the me- 
ningo-coccus isolated from the naso-pharynx, and a 
serviceable serum invented to overcome the ravages 
of this dreaded disease. 
In reality the exanthemata are all examples of 
acute local infections of the nose and throat which 
quickly become generalized and offer the well-known 
signs which lead to a diagnosis of constitutional 
disorder. Of these scarlet fever is the type, and it 
would seem that very much could be done to shorten 
the course of this infection and prevent imminent 
and dangerous complications by cutting off the 
supply of the infective agent in the nose and throat. 
The respiratory tract has always been gravely con- 
cerned in such diseases as measles, diphtheria, 
whooping cough and parotitis, but it would seem 
that no concerted effort has been made to attack 
these from the nose and throat viewpoint. Tuber- 
culosis is doubtless in many instances an inhaled 
infection, although primary tuberculosis of the 
upper air tract is looked upon as a rarity. The 
bacillus of leprosy has frequently been found in 
the nasal secretions, and its incidence in the upper 
air tract has been the cause of heated discussion in 
various learned societies from time to time. 
We need to know a great deal more than we do 
at present about the causes of diminished resistance 
to disease. Exposure to cold, wet and fatigue have 
been often set down as predisposing causes, but no 
one has explained the mechanism of their working. 
Acidosis has been receiving some attention of late 162 
HYGIENE OF THE VOICE 
as favoring the action of bacteria in the system, and 
it has been rather a constant factor in the influenza 
epidemics,—so much so that the use of acid fruits 
to form tartrates, malates, etc., has been strongly 
indicated, and the exhibition of such drugs as 
sodium citrate in large doses has had enthusiastic 
supporters. 
Students of metabolism are laying great stress 
upon imbalance of the endocrines as a cause of 
lessened resistance. After acute infections, the 
adrenal glands are supposed to function less effi- 
ciently; therefore, fatigue, headache, malaise, loss of 
appetite, etc. The pituitary, the thyroid, and the 
sex glands may all be involved, and it may be neces- 
sary to feed extracts of these glands to a patient be- 
fore any considerable degree of immunity can be 
established. This is possibly one reason why we 
sometimes fail in our use of vaccines,—the endocrine 
balance must be restored first before the body 
resistance can be improved. The subject is very 
fascinating, but to date it is highly speculative, 
and hardly, as yet, established on a sound, scientific 
basis. 
The principles of treatment in every acute respi- 
ratory infection are as follows: (1) A culture should 
be taken on nutrient or blood agar. (2) The nose 
should be opened by means of astringents. (3) 
From a pint to a quart of irrigating fluid (normal 
saline) should be applied at stated intervals. (4) A 
sufficient quantity of a non-irritating antiseptic 
should be dropped or sprayed on the diseased sur- 
face to kill as many of the specific bacteria as 
possible. (5) This procedure should be repeated 
twice a day or oftener if the need be urgent. MANAGEMENT OF ACUTE INFECTIONS 
163 
These principles vary in detail only according as 
one is working with the nose, pharynx, larynx, 
trachea or bronchi. As to the culture, one must 
be sure that no antiseptic has been applied for at 
least three hours preceding the taking. Irrigation 
may be carried out by a process of combined irriga- 
tion and suction as exemplified in the Nichols’ nasal 
syphon. This the patient can learn to use at home, 
and it seems safer with respect to the ears than 
any other method. But one must remember that 
the ears may be invaded nevertheless, and all blow- 
ing of the nose after this suction treatment must be 
interdicted. 
The successful use of respiratory antiseptics is 
based upon the following protocols: (1) The anti- 
septic must be sufficiently lethal for the bacteria 
with which we have to deal in a given instance. 
(2) The antiseptic must not injure the mucous 
membrane either through its chemical or mechanical 
action. (3) There must be thorough contact with 
all infected areas, and care must be taken to see 
that the antiseptic action be not vitiated through 
dilution by the normal secretions. (4) Concentra- 
tion of the antiseptic must be sufficient but not 
excessive in amount. (5) All conditions necessary 
to thorough bactericidal effect must be maintained 
for a sufficient length of time. Some commonly 
used antiseptics are argyrol 5 to 10 per cent; silvol 
5 per cent; and silver nitrate 2 per cent in a De 
Vilbiss atomizer No. 52, fitted with a hard rubber 
bottle-stem. Personally, I use silver nitrate much 
and believe it to be one of the best remedies for 
mucous membranes which we have, but only when 
wisely used. Menthol in oil, 5 to 25 per cent, is 164 
HYGIENE OF THE VOICE 
excellent in acute laryngitis, if dropped (one-half to 
one cc.) directly into the larynx. For the larynx, 
trachea and bronchi, an excellent remedy is 2 per 
cent guaiacol in liquid petrolatum. About one-half 
to one cubic centimeter can be dropped directly into 
the trachea. Recently, two authors have published 
experiments on animals which seem to prove that 
oil when thus introduced into the trachea may be 
dangerous, even causing pneumonia. They used, 
however, several cc. in these experiments. After 
15 years experience with sterile oily suspensions, I 
have never seen anything but good follow their 
use if not more than one cc. be used. Much of the 
oil is promptly coughed out and in this way spreads 
over a large area, thus disinfecting places reached 
only with difficulty by other means. 
My method of procedure in the treatment of 
singers or other patients who come in with an acute 
diffuse infection of the respiratory tract which bears 
the time-honored name of a “cold” regardless of 
the causative agent is as follows: 
1. Get the nose open. 
2. Irrigate with warm normal saline, at least 1 
pint. 
3. Spray in silver nitrate 1 to 2 per cent, just 
enough to get a fine white layer of albumenized 
silver over the entire nasal mucosa, even up under 
the middle turbinate. Turning the tip up, an ap- 
plication is also blown into the post-nasal space. 
4. Protect with Chloretone or any other pleasing 
antiseptic. 
5. For further soothing effect, one may use the 
old formula of the late Prof. O. B. Douglass: MANAGEMENT OF ACUTE INFECTIONS 
165 
3 
Thymol grs. x 
Eucalyptol grs. xx 
Menthol grs. xxx 
Oil of Cubebs 3 ss. 
Benzoinol 5 ii 
Oil Rose q. s. 
Sig. Spray nose with oil atomizer as directed. 
The patient is given full instructions as to home 
treatment. If there is a good deal of stuffiness, I 
order the following: 
Adrenalin (1-1000) m. xxx 
Liquor Antisepticus Aik.. — 
Aquae aa 5 i 
Sig. Spray nose as directed. 
At the same time I order a De Vilbiss atomizer, 
No. 16. This has two bottles, in one of which is 
placed the above, and in the other any good oily 
antiseptic,—the solution is to be followed by the 
oily suspension. Sometimes I also order one of 
the less-irritating silver salts, most of which are 
proprietary and by many considered to be unethical, 
but again we must remember that only results count 
and we must put aside our prejudices. 
The method of washing out the nose at home is 
explained as follows to the patient: Procure an 
ordinary glass medicine dropper. Remove the rub- 
ber cap. Then attach this glass tip to the rubber 
tubing on any ordinary douche bag. Most douche 
bags sold in drug stores hold two quarts and are 
furnished with various hard rubber tips which need 166 
HYGIENE OF THE VOICE 
not be considered here. Of course, some kind of 
a check should be on the tube so that it can be cut 
off when necessary. If there is much crusting, I 
order the patient to use one quart of warm water 
about body temperature, two level teaspoonfuls of 
common table salt and two level teaspoonfuls of 
sodium bicarbonate. This is stirred up and poured 
into the douche bag. The bag is then hung about 18 
inches above the head with the patient in the posi- 
tion that he intends to assume during the irrigation. 
The head should be inclined forward at an angle 
of 45 degrees, and the glass tip or nozzle directed 
upper and backward so that the water will flow 
freely through one side of the nose and out of the 
other. The advantage here is that the nose is not 
blocked up by any tight fitting hard rubber or other 
tip. This I regard as one of the chief causes of 
water going into the ears. Where suction is used, 
complete closure is absolutely necessary, but where 
irrigation only is employed, the above described 
method is the most satisfactory. This hot douch- 
ing is especially beneficial in acute inflammations 
of the nasal sinuses and may be carried out every 
two or three hours during the day. Again, it is 
necessary to warn against blowing the nose, and 
any fluid left behind should be drawn back into 
the naso-pharynx and expectorated. 
Home treatment of the larynx and lower airways 
is less satisfactory. For self-medication, Dr. Yan- 
kauer of New York City has invented a very large 
medicine dropper which the patient takes into his 
mouth, and then, while inhaling, squeezes the rub- 
ber bulb and throws the medication downward into 
the trachea. If this seems desirable in case the MANAGEMENT OF ACUTE INFECTIONS 
167 
patient is going out of town on a journey, or for 
any other good reason, the guaiacol suspension men- 
tioned above can be used in this Yankauer pipette. 
One may also recommend the compound tincture 
of benzoin which had such a vogue among practi- 
tioners of other days, and is still widely prescribed. 
I prefer to add about 20 grains of menthol to each 
ounce of the benzoin, and have the patient use a 
teaspoonful to a pint of boiling water three or four 
times a day. The water must be boiling hot so that 
the steam comes off freely. The patient may make 
a funnel out of an old newspaper, and, putting the 
large end over a pitcher, he should inhale from the 
small end, breathing deeply through the mouth and 
blowing out through the nose. It is not absolutely 
necessary to make a fresh solution each time. One 
may boil it again, remembering that it boils over 
very quickly, and, if on a gas stove may put out 
the gas, causing danger if neglected. 
Constitutional reaction to local infection should 
be treated symptomatically. A prescription which 
I use much is 
Acetphenetidin grs. v 
Salol grs. iii 
Ext. Aconiti gr. 3d} 
Caff. Cit gr. ss. 
M., Sig. Make into powders or caps, and take 
one every 3 or 4 hours. 
Instead of the above, one may use 10 grains of 
aspirin every two or three hours until free perspira- 
tion is secured, or the salicylates alone or in com- 
bination with other drugs. In many patients who 168 
HYGIENE OF THE VOICE 
are susceptible to infections of the airways, there 
is said to be an acidosis of the system; it is, there- 
fore, in order to administer alkalies. There are 
good alkaline waters on the market which are re- 
freshing and palatable such as the Vichy Celestins 
or French Vichy, as it is known, and Kalak Water 
which is made in this country. In this connection, 
lemons have their uses, taken either in the form of 
lemonade or as one may wish. The acid juices are 
changed in the blood into alkalines,—the malates. 
tartrates, citrates, etc. In any case, much fluid 
should be taken, five or six quarts in the 24 hr. 
period, and very little food. A “starvation diet” 
is the best kind. Rest in bed has been very widely 
emphasized and if the patient has a temperature 
of 100 degrees Fahrenheit or more he should not be 
allowed out of the house. It then becomes neces- 
sary to treat him at home. Many ear, nose and 
throat specialists do not like to do bedside work, 
but there is sometimes great necessity for it, and we 
ought, undoubtedly, to do a certain amount of it. 
Special equipment is required, but in houses where 
there is no electricity one cannot do justice to the 
patient. The essentials of the equipment are: I. A 
pump or blower for spraying solutions. II. Four 
spray bottles. The first should contain an alkaline 
mixture with perhaps a little cocaine 1 to 2 per cent 
with adrenalin. The second should be one of the 
silver salts such as silvol or argyrol or collene. The 
third bottle should contain 1 or 2 per cent silver 
nitrate solution, and the fourth an oil spray, guaia- 
col 2 per cent or any other oily antiseptic most 
favored by the practitioner. III. A glass laryngeal 
syringe and laryngeal mirror. IV. Hays’ headlight. MANAGEMENT OF ACUTE INFECTIONS 
169 
This is a little storage battery light which is attached 
to a headband, and gives satisfactory illumination if 
one makes sure that the battery is fresh. V. Ap- 
plicators upon which to wind cotton. These may 
be of metal or wood as one prefers. Along with 
them should be a bottle of adrenalin and some 
cocaine crystals. VI. A nasal speculum, preferably 
one with a solid blade, Vienna model, and tongue 
depressors, wooden and metal. The metal spatula 
is especially desirable for examination of cases of 
stiff jaw or tongue, or where the mouth cannot be 
widely opened as in peritonsillar abscess. If there 
is no general practitioner in attendance, and one 
cannot be readily consulted, it is the duty of the 
throat specialist to examine the patient’s chest with 
the idea of differentiating a bronchitis from a pneu- 
monia. It is always wise to call in a general practi- 
tioner in every case to share the responsibility. 
The nose and throat specialist in these latter days 
is widening his field more and more, but he must 
respect his limitations and not encroach upon the 
field of the general practitioner more than is ab- 
solutely necessary. CHAPTER XVII 
MANAGEMENT OF CHRONIC INFECTIONS OF 
THE LOWER AIRWAYS* 
Any person who has more than a passing interest 
in respiratory diseases must have been impressed in 
an increasing degree by the large number of so-called 
chronic conditions of the larynx, trachea, and lungs 
which are met with not only in daily clinical experi- 
ence, but outside of the consultation room and hos- 
pital ward. Many cases at one time acute, are now 
chronic because of neglect or improper or unskillful 
treatment and have gone on to such marked patho- 
logical change that they go about seeking relief 
where none is found and become the bane of many a 
practitioner. 
It should be understood that I am speaking here 
of infectious processes only and not of conditions 
the result of tumor, such as aneurysm, or the chronic 
passive congestion of valvular heart disease, or 
structural changes found in such incurable entities 
as emphysema and advanced tuberculosis. 
There is undoubtedly a rather large group of 
patients who are suffering from an unrecognized in- 
fection of the respiratory mucous membrane, not 
merely a surface infection, but an infection where 
the bacteria live, thrive, and grow deep down in the 
* Published in Acta-Laryngologica, Vol. IV, Fasc. 4, Stockholm, Sweden, 
1922. 
170 MANAGEMENT OF CHRONIC INFECTIONS 
171 
submucosa, causing there, in time, abundant con- 
nective tissue proliferation and complete functional 
change. Such patients are, in the light of present- 
day knowledge, carriers of certain types of micro- 
organisms attenuated in virulence, to be sure, but 
culturable on satisfactory media, again becoming 
lethal when used experimentally. It is remarkable 
how resistant the body becomes to the ulterior 
effects of such a chronic infective process, and even 
a superadded acute infection such as that caused by 
the pneumococcus does not always destroy the life 
of the patient, contrary to what might be expected. 
Many such cases recover from the acute process 
only to have for the remainder of their lives the 
annoying symptoms of an old chronic condition. 
Our profession at large has been slow to learn the 
nature of infection of the respiratory mucous mem- 
brane save in pneumonia and tuberculosis which 
have been studied assiduously. A sputum is sent 
to a health laboratory for examination, the specimen 
is reported as containing or not containing the 
tubercle bacillus although it may have swarmed 
with myriads of other organisms which are regarded 
as simply incidental—a “mixed infection,” if any- 
thing is said about it at all. The pneumococcus, for 
instance, is recognized as a potent enemy, but it is 
only within a very short time and as a result of 
academic rather than actual clinical interest at the 
Rockefeller Institute that the pneumococci have 
been classified into four distinct groups according 
to their virulence and prognostic importance. It 
is now known that every case of pneumonia falls 
under one of the four headings according to what 
the laboratory specialist has to say about the 172 
HYGIENE OF THE VOICE 
sputum; and, consequently, we have had placed in 
our hands a specific serum for each type according 
to the identity of the enemy we are fighting. Work 
of this kind is not only far-reaching but epoch-mak- 
ing in that it gives us a wider acquaintance with our 
bacterial enemies, and affords a constructive plan of 
battle out of which we have greater reason to expect 
victory than ever before. 
Without meaning to offer any drastic criticism it 
is only fair to say that no class of disease is more 
unskillfully treated by the average medical man 
than infections of the lower respiratory tract, and 
especially so if they be chronic. Fortunately the 
acute cases have a remarkable tendency to recover 
whether they be accorded all, any, or no treatment 
whatever, and it is undoubtedly due to this fact that 
the family practitioner makes light of a simple 
“cold” and considers his duty well performed if he 
prescribes almost anything that comes to his mind 
just to make the patient feel that something is being 
done. This is, in the last analysis, the fault not of 
the doctor but of medical teaching. In all diseases 
of the lower respiratory tract indirect treatment has 
ever been the rule. Too much attention has been 
paid to the bowels, the liver and kidneys, to the 
temperature, pulse and respiration, to calomel, 
squills, ammonium chloride, ipecac, rhinitis tablets 
and the compound tincture of benzoin; and not 
enough attention, may one say no attention at all, 
to the microorganisms causing the difficulty and 
how they may be combated. 
It has not been emphasized that cough medicines 
do not cure but only increase or diminish the secre- 
tions and stop the tickling through the beneficial ac- MANAGEMENT OF CHRONIC INFECTIONS 
173 
tion of some paralyzant such as heroin, which con- 
stipates and may set the stage for the entrance of 
that arch villian, Opium, who has probably de- 
stroyed more lives than he has ever saved. 
A primary requisite is to have the hearty coopera- 
tion of a skilled laboratory worker, preferably an 
able bacteriologist, who must be interested in the 
clinical side of his work as well as in the test tube 
and microscope. In every case the sputum should 
be obtained, and cultures taken from the nose and 
throat if secretion is available. It should be a stand- 
ing order that the culture is to be saved with the 
purpose of making a vaccine if this be deemed 
necessary. 
The organisms most commonly found are some 
member of the streptococcus or staphylococcus fam- 
ily, the pneumococcus and the micrococcus catar- 
rhalis. Some attempt should be made to determine 
the site of bacterial growth. Not infrequently the 
voice is normal and the larynx looks healthy, but 
just below the vocal cords the mucous membrane 
looks swollen and red and the tracheal rings cannot 
be counted. This, of course, means that a tracheitis 
is present and the patient when asked where he feels 
the tickling will point to the episternal notch, to the 
area “directly behind the collar button.” Plaques 
of mucopus, mucus, and blood streaks are often seen, 
especially when the streptococcus mucous is present. 
A continuous desire to scrape the throat indicates 
the presences of mucus on the vocal cords, and not 
infrequently the patient cannot speak distinctly 
until this mucus is shaken off by the scraping or 
“hemming” process. 
In chronic tracheitis one often finds the mucous 174 
HYGIENE OF THE VOICE 
membrane over both true and false cords covered 
with crusts. The interarytenoid area is usually so 
covered. There is a dry, hard cough which be- 
comes easier when the crusts soften and can be 
coughed out. The secretion in all of these cases is 
very viscid in character owing to an excess of mucin, 
consequently when dried it becomes very firmly 
attached to the epithelium and on coming away 
leaves a raw, bleeding, eroded surface. The voice is 
very husky, and at times there is aphonia. Owing 
to increased connective tissue proliferation, the mu- 
cous glands are few in number and function abnor- 
mally so that the mucous membrane surface looks 
dry and glazed. Such a condition may be limited 
to the trachea or may extend downward into the 
larger bronchi. In one case, upon examination of 
the right superior bronchus with the bronchoscope, 
we entered a small abscess cavity which had appar- 
ently been encapsulated. Culture showed a staphy- 
lococcus organism. 
In those cases of so-called chronic bronchitis with 
copious, fetid discharge, one must always keep in 
mind the possibility of a foreign body in a bronchus. 
One such patient, the son of the president of a great 
mercantile company, had been the rounds in Europe 
before the great war, and a diagnosis of pulmonary 
tuberculosis had been made by several eminent 
physicians. An X-ray plate showed an encysted 
collar button far down in the right bronchus which 
had been there for about eleven years. This was 
successfully removed by Dr. Chevalier Jackson, then 
of Pittsburgh, and the patient recovered, although 
it rquired several months for all of the active symp- 
toms to subside. This is by no means unique, as MANAGEMENT OF CHRONIC INFECTIONS 
175 
several bronchoscopists have reported similar ex- 
periences. 
The method of procedure in all cases is as follows: 
A careful history, especially as to how the condition 
began; its probable origin; whether following pneu- 
monia, grippe, etc.; question of associated disease, 
heart, kidneys; duration; local symptoms; character 
of cough, worse at night or when lying down; what 
periods of ease if any; effect of climatic or barome- 
tric factors; amount, character, odor, color, and con- 
sistency of sputum; and the kinds of treatment 
that have been already employed. 
In the local examination the nose and naso- 
pharynx must be studied for obstruction and the 
presence of pus. Occasionally the patient complains 
of coughing and gagging, which we find to be the 
result of a chronic nasal sinus disease with postnasal 
discharge and dried secretion which gets down into 
the hypopharynx, drags on the epiglottis and rima 
glottidis, and sets up severe spasms of choking until 
the offending discharge is loosened and spit out. 
The larynx and trachea must be studied with the 
laryngeal mirror, and it is often necessary to cocain- 
ize quite thoroughly with ten or twenty per cent 
cocaine before we can get a view of the region be- 
low the cords.1 In case this indirect method fails, 
we can proceed with the direct speculum and inspect 
the trachea and bronchi by bronschoscopic meth- 
ods. In every case a specimen of secretion must be 
secured, either during the examination or when the 
patient coughs it out. This is cultured and care- 
1 In a recent communication Dr. Chevalier Jackson writes that he no longer 
finds it necessary to anesthetize directly down into the larynx but that good 
insensibility can be obtained by applying the local anesthetic to the supra- 
laryngeal region, so that the superior laryngeal nerves will be acted upon. 176 
HYGIENE OF THE VOICE 
fully gone over by the laboratory man who furnishes 
a full report of the bacterial flora. 
X-ray examination of the nasal sinuses and of 
the chest may be essential in a given case, and a 
Wassermann may throw surprising light on a baffling 
problem. 
Physical signs afford some help as to the location 
of the lesion—that is, which lung and what part of 
the lung is affected. In our experience, however, 
physical signs, even when determined and recorded 
by an expert examiner, are not of nearly so much 
Fig. 17.—Papilloma or wart-like growth between the cords having 
its attachment in the anterior commisure, and causing hoarseness with 
some difficulty of breathing. 
value as the X-ray, although this latter is also 
capable of being misread. 
Naturally the entire question of treatment re- 
solves itself into two factors: the improvement of 
the patient’s general resistance, and the destruction 
of the bacterial parasite. The former has been the 
chief weapon of the lung specialist these many 
years, and is too well known to need mention here. 
A newer phase of treatment which does require 
special mention is the use of vaccines. These have 
proved so successful in my hands in increasing the 
general bodily resistance that it is surprising how MANAGEMENT OF CHRONIC INFECTIONS 
177 
many men seem opposed to their use. Where dis- 
appointment is experienced, there must be some- 
thing in the way the vaccines are made which affects 
their efficiency. Personally, I use autogenous vac- 
cines whenever possible. Dr. T. S. Schlauch, of 
New York City, has made these for me for some 
years and I cannot testify too strongly to their value. 
This excellence probably lies in the fact that he does 
not destroy the bacteria by heat in making the vac- 
cine, but uses cresol or a very mild carbolic solution. 
Heating is capable of exerting some lipoid change 
which renders the vaccine inert or at least ineffec- 
tual, and it is entirely unnecessary. The vaccine is 
counted as 500 million in one cubic centimetre. We 
begin with fifty million in most cases and wait for 
the reaction, both local and general, to subside be- 
fore giving another dose. Quite often one can in- 
crease a half c. c. at each dose. Whenever a too 
marked or violent reaction is obtained we usually 
discontinue vaccine treatment temporarily and 
watch for recurrence of old symptoms or absence of 
them as the case may be. A vaccine does two very 
helpful things, it increases the appetite and makes 
the patient sleepy, and is therefore a better tonic 
than most of the commonly used drug combinations. 
If a drug combination seems desirable, the French 
ampoules of Clin & Cie. (No. 627) are excellent. 
These contain glycerophosphates of iron and soda, 
arseniate of soda, and sulphate of strychnine. One 
of these sterile ampoules is used hypodermatically 
twice a week, rarely three times. After the third 
dose the patient will often say that he feels much 
improved. 
As for the destruction of the microorganisms by 178 
HYGIENE OF THE VOICE 
direct treatment, this is a matter which has been 
sadly neglected. Even the nose and throat specialist 
has not always made the most of his opportunities 
in applying bactericidal medication, chiefly because 
most agents have acted severely on the normal body 
cells as well as on the bacteria, and thus the patient 
has been made worse instead of better. Silver 
nitrate has been the old standby, and when judi- 
ciously used it is very helpful. It should not be 
swabbed into the larynx with an applicator as that 
method is very disagreeable, and by bruising the soft 
tissues may engender a reaction which does more 
harm than good. With a De Vilbiss5 atomizer (No. 
52) it can be sprayed directly into the trachea, or if 
it is desirable to reach the bronchi it can be dropped 
in with a laryngeal syringe. A two per cent solution 
is sufficiently strong, about five minims at each 
instillation. Recently a proprietary combination 
known as collene has been put on the market and 
has the merit of being a “colloidal silver in per- 
manent suspension” and does not stain handker- 
chiefs, towels or clothing. Occasionally where direct 
medication of a given bronchus has been desirable, 
we have passed the bronchoscope under local anes- 
thesia and have instilled our antiseptic through a 
soft rubber catheter passed through the lumen of 
the bronchoscopic tube. 
The silver preparations are especially helpful 
where one has to do with crusting, for they increase 
all secretions to a marked degree, render them less 
viscid, and by stimulating the mucous glands help 
to remove from the submucosa great masses of bac- 
teria which have been intrenched there. 
1 These are made by the De Vilbiss Mfg. Co., Toledo, Ohio. MANAGEMENT OF CHRONIC INFECTIONS 
179 
Much is to be looked for from the dichloramine-T 
of Carrel-Dakin. This is now made up with an oily- 
base known as Chlorcosane and is fairly stable as 
compared with the earlier solutions which were 
readily spoiled by contamination and decomposed 
by light and had to be made up fresh every day. 
Either a one per cent or a two per cent solution may 
be used in the trachea and bronchi by instillation or 
spraying. It should not be used on normal mucous 
membrane in the nose as a violent reaction is in- 
duced which may last several days. In beginning 
treatment of those cases where there is much dis- 
charge or crusting it is better to use a silver prepara- 
tion for a few days, and then change to dichlora- 
mine-T when one can be sure that this agent will 
come directly into contact with the infected surface. 
One reason why treatment of this class of patients 
has failed in the past is because neither patient nor 
doctor has realized the importance of persistent and 
repeated applications of bactericidal agents. In- 
halations such as the compound tincture of benzoin, 
while of value in certain acute cases, are not usually 
concentrated enough in action and not frequently 
enough applied. Bacteria grow at an enormous rate 
on the lower respiratory mucous membrane where 
heat, moisture, and absence of direct sunlight make 
cultural conditions ideal; therefore, ammunition 
must not be frugally used, but a nearly continuous 
barrage fire must be maintained to win the battle 
against such overwhelming propagation. It is use- 
less to administer treatment by direct instillation 
and tell the patient to “come back the day after to- 
morrow,” for by that time the effect of the bacteri- 
cide has long since been lost. These patients must 180 
HYGIENE OF THE VOICE 
be treated at least once every day. In private prac- 
tice the effect is so marked that patients do not at 
all object to coming in morning and evening and 
thus shorten the time of convalescence very mark- 
edly. Twice a day is the rule in all severe, chronic 
cases and in all of the acute ones with active symp- 
toms or tendency to complications in the ears and 
sinuses. The gratitude of these sufferers more than 
repays the physician for the time and patience he is 
obliged to give to them. 
Conclusions.—From an intimate and intensive 
study of a number of cases of chronic, chiefly pyo- 
genic, infections of the larynx, trachea, and bronchi, 
both in hospital and private practice, it would seem 
that such infections are seldom diagnosed in the 
acute stage. Questioned as to previous treatment, 
nearly all of these patients said that they had taken 
much medicine by mouth without seeing any per- 
manent benefit, and that the activities of the physi- 
cians whom they had consulted were limited to chest 
examination, sputum tests, and a negative report 
as to the presence of pulmonary tuberculosis. In 
many cases, the patients had been carefully advised 
as to diet, fresh air, exercise, etc., but very few had 
received any kind of local treatment other than 
inhalations to be carried out at home, and an occa- 
sional swabbing of the pharynx and larynx with a 
silver or iodine preparation. 
In the light of such evidence it would seem wise 
for those who make a specialty of throat and lung 
disease to enlighten the profession as to the method 
of procedure in the diagnosis and treatment of cases 
manifesting chronic hoarseness and disturbing MANAGEMENT OF CHRONIC INFECTIONS 
181 
cough. Especial emphasis should be placed upon 
the importance of systematic and thorough treat- 
ment in all acute respiratory infections with a view 
to decreasing the number of chronic cases now so 
frequently seen in all branches of medical practice. CHAPTER XVIII 
FUNCTIONS OF THE DIAPHRAGM AND SOME 
NOTES ON THE PHYSIOLOGY 
OF BREATHING 
Authorities on anatomy are pretty well agreed 
that the diaphragm is not merely a voluntary, but is 
also an involuntary muscle which separates the lungs 
from the stomach and intestines. 
The partition serves a double purpose in acting 
as a floor to the chest and a roof to the abdomen. 
The diaphragm is attached at its circumference all 
round to the margins and upper borders of the 
cartilages of the lower six ribs, in front to the lower 
end of the breast bone or sternum, and behind to 
the spine by two strong muscular bands named 
“crura.” 
It will thus be seen that the diaphragm is at- 
tached to the rim of the lower outlet of the chest 
cavity. 
The diaphragm is peculiar in having in its centre 
a tendinous expansion in the form of a clover leaf, 
hence named the trefoil. The three segments of 
the leaf are not of equal size. The largest is situated 
to the right, and rests upon the upper convex surface 
of the liver. The smallest is to the left, and rests 
upon the large end of the stomach. 
The diaphragm is, to be sure, an important muscle 
of inspiration, but, from the singer’s viewpoint, in- 
spiration is the phase of minor value, the phase of 
182 FUNCTIONS OF THE DIAPHRAGM 
183 
major value being expiration. The singing voice 
is produced during expiration, not necessarily by 
the letting free of a great volume of air, but by the 
control and regulation of, perhaps, only a tiny jet. 
This control comes not from the diaphragm alone, 
but from the entire respiratory group of muscles,— 
those between the ribs, in the abdominal wall, at 
the shoulder blades, in the neck, etc., so that, in the 
last analysis, we have not one muscle nor one group 
of muscles at work, but the entire body acting as a 
unit. It is not true that “By the action of the 
diaphragm the inhaling as well as exhaling is regu- 
lated”;* for it is perfectly possible to have the dia- 
phragm at rest, and yet breathing will go on just 
the same,—shallow breathing, not deep breathing, 
of course. The diaphragm is not a muscle of expira- 
tion. Breath control does not come only or even 
chiefly from the diaphragm, but from the central 
nervous system acting on the entire respiratory 
mechanism as a whole. The muscles of the ab- 
dominal and thoracic wall are all-important in the 
control of the voluntary expiratory act. Without 
good, solid, abdominal support, no singer can ever 
hope to obtain great effects in his work. It is very 
easy to confuse the action of the diaphragm with 
the action of the abdominal wall, for it seems quite 
impossible to work the one without the other. In 
any case the wise singer will do everything he can 
to increase his muscular power, and then make this 
power subservient to his will in every detail. The 
combination of strength and skill rightly propor- 
tioned spells success in many cases where either 
alone would mean only a poor mediocrity. 
* Mr. Oscar Seagle in Musical Courier. 184 
HYGIENE OF THE VOICE 
To understand how any organ of the body func- 
tions, it is necessary to go into the anatomy in some 
detail. It takes the medical student of average in- 
telligence two years to learn the fundamental gross 
structure of the human body, and yet most patients 
insist on trying to find out from their medical ad- 
viser all there is to it in twenty minutes. It is 
difficult to learn vocal anatomy unless one has 
access to a dissecting room, and the supervision of 
a good teacher. All this is quite unnecessary for 
the vocal pupil, but it ought to be compulsory for 
the vocal teacher in order to establish a scientific 
groundwork. In this way many heated controver- 
sies might resolve spontaneously into a modicum of 
fact upon which all truth must ultimately be based. 
I should like to go into a description of the anat- 
omy of the diaphragm, but it is impossible to do so 
here. Besides, this has been very well done by 
hundreds of writers on anatomy, notably, in Eng- 
lish, by Gray and by Cunningham. These authors 
are recommended to anyone who wishes thoroughly 
to comprehend the subject insofar as reading can 
help him. It would then be in order to take down 
an up-to-date textbook on physiology and turn to 
the chapters of special interest to the student of 
voice and speech. No one who has not done at 
least this much is in any way entitled to an opinion 
on the vocal mechanism, let alone talking learnedly 
about “structure, form and function, resonators,” et 
cetera. 
The time has long since passed when a surgeon 
could buy a handful of instruments and begin his 
career by cutting into every organ that came under 
his watchful eye at the cost of the patient’s life. FUNCTIONS OF THE DIAPHRAGM 
185 
Likewise the time is rapidly passing when the sing- 
ing teacher can carry on his occupation without a 
previous course of study. It is written in the stars 
that sometime in the not too distant future, the 
would-be teacher will be obliged to attend a school 
for two or more years in order to perfect himself in 
what ought to be a worthy profession instead of an 
unworthy trade. The State will demand a rigid 
examination in the anatomy and physiology of the 
voice, a knowledge of physics, especially “sound,” 
the principles of phonetics, of “break in the voice,” 
and, of course, a thorough test in the fundamentals 
of music, with, at least, some degree of proficiency 
in playing the piano or violin. Before anyone is 
allowed to teach singing it should be determined 
whether he has an accurate sense of pitch or not. 
There are plenty of indications which seem to show 
that many singing teachers have an imperfect idea 
of pitch, and I feel quite certain that at least one 
whom I chanced to meet was pitch deaf. How can 
anyone judge whether a tone is good or bad if he 
has no idea of its proper production? 
Physiology of Breathing—Inspiration and Expira- 
tion. What bellows are to an organ, the lungs are 
to the human voice, with the additional function 
that they are a necessary mechanism for the ex- 
change of air and the support of life. The lungs 
are, of course, primarily breathing organs which take 
in the air during inspiration, thus supplying oxygen 
to the tissues,, and giving off, during expiration, 
waste products of the body. As regards the intake 
of air, the air spaces in the lungs are enlarged or 
decreased in size, according to the volume consumed. 
In spite of the increase and decrease in volume, the 186 
HYGIENE OF THE VOICE 
lungs are, however, not active but passive organs 
of respiration. They are contained in the chest 
cavity in a vacuum, and rise and fall with the ex- 
cursions of the chest movements occasioned by the 
accessory muscles of respiration. 
The surface of the lungs and the inner wall of 
the chest are both covered by a moist membrane 
called the pleura or pleural membrane which allows 
uniform expansion at all points. Inspiration requires 
that the airways, nose, pharynx, larynx and trachea 
be open. The increase in chest space is brought 
about through contraction, retraction and sinking 
of the diaphragm, and widening of the spaces be- 
tween the ribs. Expiration occurs when the in- 
spiratory power reaches its height and the elasticity 
of the thorax itself begins to return to the condition 
assumed before the inspiration. Herein come into 
consideration the weight of the thorax, the elasticity 
of the ribs and rib cartilages, which upon relaxation 
of the diaphragm, bring back the abdominal walls 
into the resting position; so that, in quiet expiration, 
the active muscular strength is exerted when this 
quiet expiration can be voluntarily interrupted at 
any moment. It is assumed that the internal in- 
tercostal muscles are active also during quiet ex- 
piration. During forced expiration the abdominal 
muscles come into play, which, through their con- 
traction, press against the diaphragm and produce 
the pressure upward against the ribs. The inferior 
serratus posticus muscle draws the four lower ribs 
downward, upon which movement the remaining ribs 
must follow this downward motion. The quadratus 
lumborum muscles are accessory in this movement. 
The remaining abdominal muscles narrow the ab- FUNCTIONS OF THE DIAPHRAGM 
187 
dominal cavity both in the transverse and antero- 
posterior diameters. Speaking, singing, whistling, 
blowing, etc., result when the expired air-stream in 
the larynx, or in the accessory spaces encounters and 
overcomes resistance in the upper airways with 
regular or irregular interruptions. Of course, voice 
can also be produced in modified form during in- 
spiration. 
While the chest cavity is increased through the 
pull of the inspiratory musculature, and the lung 
surface comes in contact with the expanding chest 
walls, the inner spaces of the lungs must be widened 
also. There now takes place a rarefaction of air and 
the lungs are expanded through increase of atmos- 
pheric pressure. The balance between external and 
internal air pressure of the lungs cannot take place 
suddenly on account of the branching of the bron- 
chial tree. The more quickly the lungs are ex- 
panded, the greater is the differential pressure; and 
conversely the slower the lung expansion, the less 
is the differential pressure. It has been determined 
that the pressure in the airways during inspiration 
amounts to one millimetre of mercury. In expira- 
tion, the thorax is compressed and the lungs have 
the air pressed out of them. The more forcibly a 
person exhales, the greater is the differential pres- 
sure. This is also dependent upon the strength 
with which the inspiratory musculature of the thorax 
acts in ratio to the expiratory musculature. One 
can calculate directly the amount of differential 
pressure in the varying phases of breathing accord- 
ing to the strength of the breathing musculature. 
If after a more or less deep inspiration, the larynx 
closes and the air cannot pass out, pressure increases 188 
HYGIENE OF THE VOICE 
according to the more energetic contraction of the 
respiratory muscles which move the thorax until 
the larynx is obliged to open suddenly and the con- 
fined air is projected out with force, with a charac- 
teristic noise (cough), and everything lying free in 
the airways, such as mucus, pus, foreign body, etc., 
are driven before it. Therefore, during coughing 
an expiratory pressure of 80 or more millimetres 
may be observed, and during the corresponding in- 
spiration a negative pressure of 50 or more mm. 
During speaking and singing, there are likewise 
greater variations than in simple breathing, while 
the expiratory stream must encounter a stronger 
resistance in tone production than when the glottis 
is open. 
Everyone knows that he can vary the amount of 
expired and inspired air, but try as we may, we 
cannot entirely empty the lungs of air. The 
amount of air left behind after our greatest effort 
to exhale is called “residual air.” It is extremely 
difficult to calculate the amount of this residual air, 
but it is supposed that in an adult of average body 
size it is about 1,500 cubic millimeters. The volume 
of air which is inhaled and exhaled during quiet 
breathing is assumed to be about 500 c.mm. The 
“complementary” or supplementary air volume is 
the amount which can be inhaled after a quiet in- 
spiration has reached its height, which is about 
1,500 c.mm. In the same way “reserve air” is the 
volume of air which can be expelled after a quiet 
expiration. The total amount of air which can be 
taken up during the deepest inspiration and the 
deepest expiration is called the “lung capacity” or 
vital capacity. Vital capacity varies according to FUNCTIONS OF THE DIAPHRAGM 
189 
sex, age, size of body, weight of body, occupation, 
exercise and control in the use of respiratory mus- 
culature, and also depends upon race and climate, 
which latter cause very considerable variations. On 
an average it amounts, in the healthy adult male, 
to about 3,500 c.mm. and in the healthy female 
about 2,500 c.mm. The maximum vital capacity 
is found at the 35th year. From this point upwards 
to 65 years and downwards to 15 years, an average 
of 23 c.mm. are to be subtracted for each year of 
life. 
Those persons whose occupation makes great de- 
mands upon the muscles, expand their lungs and 
have an increased vital capacity; for example, pro- 
fessional singers, and blowers of wind instruments. 
A professional singer of average body size has a 
vital capacity of about 4,000 c.mm. A female 
singer from 2,800 to 2,900 c.mm. There is con- 
siderable variation in the number of breaths taken 
at varying ages; for instance, the newborn breathes 
from 62 to 68 times a minute. At the fifth year, 
26 times, at 21 years 18 times, and at from thirty 
to fifty years of age, 19 times per minute. It is 
further well known that the number of respirations 
increases with bodily exercise and psychic excitation. 
Increase of body temperature, living in a warm 
room, or bathing in warm water increases the num- 
ber of respirations. The respirations are also 
greater in number when standing, greater while 
sitting than when lying down, and greater during 
the waking than during the sleeping hours. Stout 
persons have a greater frequency of respiration than 
thin persons. 
The thoracic cavity (chest) is bounded by the 190 
HYGIENE OF THE VOICE 
sternum or breast bone, a part of the spinal column, 
and the ribs. 
The floor of the thoracic cavity is the diaphragm. 
The apex is made up of the muscles at the base of 
the neck. According to the motion of the ribs 
or diaphragm, the size of the chest cavity is in- 
creased or decreased. 
The types of breathing are abdominal, costal, 
diaphragmatic, and various combinations of these. 
There is also a type of breathing in singers which is 
relegated almost entirely to the upper part of the 
chest,—this is known as “high chest,” clavicular, or 
shoulder breathing. These various types of breath- 
ing are in a sense protective; for were it not so, 
life would be endangered. If, for instance, the 
diaphragmatic were the only variety and it were 
destroyed through tumor or inflammatory forma- 
tions in the abdominal cavity, the individual would 
suffocate. 
The influence of the various types of breathing 
upon the voice has a fairly practical significance. 
In the pedagogical literature of song, there has al- 
ways been much discussion as to which type is to 
be used in singing; but, accepting the physiologic 
facts in the case, such argument ought to be reduced 
to its lowest terms. 
In general it has been assumed and taught that 
in humans, the sexes show varying types of breath- 
ing,—that in quiet, normal breathing the male sex 
shows the diaphragmatic type, while in females the 
costal type is more common. This rule is, however, 
not absolute. In children, for instance, there is no 
difference in the sexes as to breathing type. 
In later life, the breathing type in women is FUNCTIONS OF THE DIAPHRAGM 
191 
Position of rest 
Abdominal breathing 
Costal breathing 
Costo-abdominal breathing 
Clavicular breathing 
Fig. 18. Outline of the torso, and position of the diaphragm in the 
various types of breathing. 192 
HYGIENE OF THE VOICE 
scarcely different from that in men, even in hard- 
working women as compared with those in other 
stations of life, and the diaphragmatic breathing of 
the male sex shows no constancy. During sleep, 
breathing in the male sex is said to be predomi- 
nantly costal. Observations show that a given or 
definite type of breathing has little relationship to 
sex and age. 
The amplitude of the up and down movement of 
the diaphragm may be well studied by the X-ray, 
since the diaphragm shows a distinct shadow upon 
the plate; but even before the invention of the 
X-ray, Hultkrantz and Hasse determined the am- 
plitude of those movements, the correctness of which 
observations can now be definitely proven. Even 
upon quiet diaphragmatic breathing, the central 
tendon of the diaphragm is not still but moves 
according to the stature of the individual between 
5/10 and 1-1/2 c.mm. 
In deep abdominal breathing, these excursions 
amount to from two to four c.mm., and, during 
coughing, the variation is the greatest even up to 
seven c.mm. Contraction of the diaphragm nar- 
rows the inferior diameter of the chest. Under 
normal conditions the diaphragm when contracted 
presses upon the abdominal wall, and at every con- 
traction of the diaphragm, the abdominal wall pro- 
jects forward. 
The costal breathing type is characterized by the 
fact that it causes enlargement of the thorax 
through sinking of the ribs. The movement of the 
ribs is dependent upon their joint connection with 
the vertebral column. Isolated thoracic breathing 
does not occur even in experienced breathers; even FUNCTIONS OF THE DIAPHRAGM 
193 
if we apply all the energy of the will to isolated 
expansion of the bony thorax, the diaphragm still 
makes associated movements of an active inspira- 
tory kind, while the expansion of the chest is 
actively increased. During clavicular breathing, 
the diaphragm, as can be determined by the X-ray, 
makes active inspiratory movements; that is to say, 
upon inspiration it is contracted, and upon expira- 
tion it is elevated. 
While, during chest breathing, the inferior chest 
aperture is widened and elevated, the points of at- 
tachment of the diaphragm undergo a change, so 
that in costo-abdominal breathing, the working of 
the contracting diaphragm is different than in the 
isolated diaphragmatic breathing. In costo-ab- 
dominal breathing there is an actual change in the 
maximum of the diaphragm. APPENDIX A 
FUNDAMENTAL PRINCIPLES OF BREATHING 
Submitted for discussion at the Convention of 
the New York State Music Teachers Association 
held in New York City, June, 1915. Offered by the 
Committee on Standards. 
1. In voice production, the motive power is 
breath. 
2. The breath is provided by the lungs, which are 
spongy bodies, having no activity of their own be- 
yond elasticity. 
3. The lungs are controlled by muscles of respira- 
tion. 
4. There are two sets of respiratory muscles, one 
for inspiration and the other for expiration, twenty- 
two or more in all. 
5. The principal muscles of inspiration are the 
diaphragm and the intercostal muscles that elevate 
the ribs and evert their lower borders. 
6. The chief muscles of expiration are the four 
sets of abdominal muscles and the intercostal mus- 
cles that depress the ribs. 
7. The ordinary act of expiration is merely pas- 
sive, the resilience of the ribs and the elasticity of 
the lungs being sufficient to produce it. 
8. The diaphragm is not a muscle of expiration. 
9. The lungs and the respiratory muscles may be 
termed the Motor of the voice-producing mecha- 
nism. 
194 APPENDIX 
195 
10. As the vibration of the vocal cords which 
originate the tone, and the continuation of this 
vibration depend entirely upon the breath, and as 
the breath depends on the lungs and the respiratory 
muscles, it follows that it is of the greatest impor- 
tance that the lungs and the respiratory muscles 
should be strong and well under the control of the 
singer; for without mastery of the motive power, 
all else is unavailing. 
11. To achieve this control as quickly as possible, 
physical exercises, apart from singing, are neces- 
sary for the developing and strengthening of the 
entire breathing apparatus. Such exercises have 
also a great value in building up the general health, 
the possession of which is an essential for the suc- 
cessful singer. 
12. In order to give the lungs the greatest possible 
freedom to expand, the chest should be held as high 
and as expanded as is comfortable. 
13. As the bony structure of the chest is largely 
suspended from above, being attached to other 
bones at the neck, shoulders and back, and as it is 
free and unattached below, the greatest motion 
during respiration should take place about its lower 
portion, where there is the greatest freedom. 
14. Therefore, during singing, if the chest be held 
high and fairly stationary, the point of greatest 
motion caused by breathing should be in the region 
of the diaphragm or below it. 
15. The control of the breath would most logically 
and most naturally be accomplished by the control 
independently of the muscles of inspiration and the 
muscles of expiration, or by a balancing or opposi- 
tion of one set against the other. 196 
HYGIENE OF THE VOICE 
16. No attempt to control the breath should be 
made at the larynx. 
17. In general, no action of the breath mecha- 
nism should be allowed which would tend to produce 
interference with the voice mechanism. 
18. Perfect control of the breath means: 
(a) Ability to fill the lungs to their ca- 
pacity either quickly or slowly; 
(b) Ability to breathe out as quickly or 
as slowly as occasion demands; 
(c) Ability to suspend inspiration, with 
the throat open, whether the lungs are 
full or not, and to resume the process 
at will without having lost any of the 
already inspired breath; 
(d) Ability to exhale under the same re- 
strictions; 
(e) Ability to sing and to sustain the voice 
on an ordinary breath; 
(f) Ability to breathe quietly as often as 
text and phrase permit; 
(g) Ability to breathe so that the fullest 
inspiration brings no fatigue; 
(h) Ability so to economize the breath 
that the reserve is never exhausted; 
(i) Ability to breathe so naturally, so un- 
obtrusively, that neither breath nor 
lack of breath is ever suggested to the 
listener. APPENDIX B 
FUNDAMENTAL PRINCIPLES OF VOICE PRODUCTION 
Submitted for discussion at the New York State 
Music Teachers Association Convention held in New 
York City during June, 1915. Offered by the Com- 
mittee on Standards. 
From the Standpoint of the Listener: 
I. Sound is a sensation produced through the 
organ of hearing by means of air-waves. 
II. Pitch is that characteristic of the sensation of 
sound which depends upon the rate at which the 
air-waves strike the ear drum. 
III. Volume is that characteristic of the sensation 
of sound which depends upon the extent of motion 
of the ear drum. 
IV. Quality is that characteristic of the sensation 
of sound which depends upon the manner of motion 
of the ear drum. 
From the Standpoint of the Producer: 
V. The voice is sound or air-waves. Vocal tone is 
always complex, being composed of several simple 
tones (fundamental and over-tones), varying in 
pitch and in intensity. 
VI. Voice production is sound or air-wave pro- 
duction. 
VII. Sound, air-wave, or voice production neces- 
sitates the use of a mechanism which has three 
essential elements: 
197 198 
HYGIENE OF THE VOICE 
1. A vibrator to originate the air-waves; 
2. A pitch mechanism to determine the rate at 
which the air-waves are originated; 
3. A resonance mechanism to reinforce the air- 
waves started by the vibrator. 
VIII. In the voice mechanism the vocal cords 
serve as a vibrator; the cartilages and muscles of the 
larynx form the pitch mechanism; and the cavities 
of the pharynx, mouth and nose form the resonance 
mechanism. 
IX. Pitch of the voice is determined by the 
length, weight and tension of the vocal cords. 
X. Volume of voice depends upon the extent of 
vibration of the vocal cords, which is caused by 
breath pressure, and upon resonance. 
XI. Quality of voice depends upon the vibration 
of the vocal cords as a whole and in segments, and 
upon resonance. 
XII. Vocal resonance, which is by far the most 
important factor in voice production, is due to the 
sympathetic vibration of the air in the resonance 
cavities. 
XIII. Resonance is more important than breath 
pressure in relation to volume of tone, and more 
important than the segmentation of the vocal cords 
in reference to quality. 
XIV. Correct voice production, or the action of 
the mechanism which produces the perfect vocal 
tone, consists of the free vibration of the vocal cords, 
the free motion of the cartilages and muscles of the 
larynx, and full use of the resonance space. This 
action produces the natural voice, or the voice which 
Nature intended a particular mechanism to produce. 
XV. Any muscular contraction which prevents APPENDIX 
199 
the free vibration of the vocal cords, the free mo- 
tion of the cartilages and muscles of the larynx, and 
full use of the resonance space, is termed an inter- 
ference. 
XVI. The principal forms of interference are: 
1. The contraction of the muscular fibres of 
the false cords, which prevents the free 
vibration of the vocal cords. 
2. The contraction of the muscles of the soft 
palate, which prevents the use of at least 
one half of the resonance space. *[Note 1. 
It should be remembered that the soft 
palate may be pulled downwards and for- 
wards as well as upwards and backwards. 
Assuming that it were possible to shut off 
the naso-pharynx completely, which it is 
not, even in extreme contractions and ad- 
hesions due to disease, the resonance spaces 
are still present and active; that is, sound 
is resonated by air-waves projected against 
the hard palate. If too great a vibrating 
volume of air-waves is sent up into the 
naso-pharynx, a hollow sound results which 
in speech is known as rhinolalia. The func- 
tion of the soft palate in singing has been 
much disputed and bandied about in teach- 
ers’ discussions, and there is still no una- 
nimity of opinion among them concerning 
this matter in so far as I am aware.] 
3. The contraction of the muscles of the chin 
and of the back of the tongue, which pre- 
* Material in brackets is not in the original, but was inserted by Dr. 
Voorhees. 200 
HYGIENE OF THE VOICE 
vents the correct action of the pitch mecha- 
nism. 
[4.] [A fourth form of interference should cer- 
tainly be added; namely, interference 
caused by physical obstruction. The causes 
of such obstruction have been rather fully 
considered in the body of this book. Sing- 
ing teachers, as a rule, are oblivious to this 
type, and some have even tried to deny its 
existence, absurdly claiming that “proper 
voice placement, breathing,” etc., will over- 
come any apparent abnormality or anom- 
aly. Such an authority as Dr. Floyd S. 
Muckey, for instance, who claims to have 
been at one time a laryngologist as well as 
a teacher of voice, denies the possibility of 
nodules on the vocal cords, or, more accu- 
rately, declares that he has never been able 
to see them. Interference because of ana- 
tomical or pathological configuration should 
head the list, because it is an actual organic 
type of disability. The three types or forms 
set down by the committee of teachers are 
functional or mental, certainly they may 
be “willed away.”] 
XVII. Every form of interference leaves its im- 
press on the quality of the tone. The ear of the 
teacher must be trained to hear in the tone quality 
the interference with the mechanism. This is the 
first step in the removal of interference. 
XVIII. The ability to remove interference is 
based upon a knowledge of the nature of the vocal 
muscles and of the interfering muscles; viz., the APPENDIX 
201 
vocal muscles are involuntary, and the interfering 
muscles are voluntary. Correct action of the voice 
mechanism must be induced and cannot be forced. 
On the other hand, interference, being under the 
control of the will, can be eliminated. 
XIX. The principal business of the voice teacher 
is to develop the voice. 
XX. Voice development consists of the develop- 
ment of the vocal muscles. 
[Note 2. Theoretically, at least, it would be pos- 
sible through training to develop vocal muscles as 
strong as the biceps, yet without development of 
voice in an artistic sense. One must not overlook 
the fact that ear training must go along pari passu 
with muscle training. Without proper sensation of 
vocal vibration in the ears, one can neither speak nor 
sing correctly. For example, Helen Keller, totally 
deaf, has been taught to speak; but, having no 
aural idea of sound, her voice is very decidedly 
guttural and unpleasant.] 
XXI. The principles of muscular development 
require alternate contraction and relaxation without 
strain. Short tones give the alternate contraction 
and relaxation required for development of the vocal 
muscles. Removal of interference eliminates strain; 
hence, short, soft tones without interference form 
the ideal exercise for voice development. 
XXII. The laws which regulate voice production 
are precisely the same in every singer and speaker. 
XXIII. Every mechanism which produces the 
voice is exactly similar. It is composed of the same 
elements—vocal cords, muscles, and cartilages of the 
larynx and resonance cavities. 202 
HYGIENE OF THE VOICE 
[Note 3. This is an incomplete statement. To 
produce voice at least three elements are necessary: 
1. The motor, represented by the thoracic and 
abdominal muscles. 
2. The vibratory, represented by the vocal 
cords; and 
3. The resonantic, represented by the mouth, 
nasal sinuses and chest wall. (Chest reso- 
nance is denied by Dr. Floyd S. Muckey.)] 
XXIV. All vocal cords are of the same material— 
yellow, elastic [connective] tissue. 
XXV. In correct voice production, the action of 
the muscles and cartilages of the larynx is precisely 
the same in every individual. 
XXVI. Those condtions which give full use of 
the resonance space are identical in every speaker 
and singer. 
XXVII. Differences in the size and shape of the 
elements of the voice mechanism account for indi- 
vidual characteristics of voices. 
XXVIII. The art of singing is composed of two 
elements, viz: the art of voice production, and the 
art of interpretation. 
XXIX. The art of voice production is based upon 
the facts of anatomy, physiology and physics. These 
facts apply to every voice mechanism with equal 
force and in precisely the same way, and are there- 
fore impersonal. 
XXX. The art of interpretation is based upon the 
personal experience, knowledge, musical taste and 
feeling of the singer, and is therefore individual. 
XXXI. This being true, it is evident that the art 
of voice production may be standardized, as the same APPENDIX 
203 
set of facts may be used to measure the product of 
every mechanism. 
XXXII. It also follows that the art of interpreta- 
tion cannot be standardized, as each singer’s inter- 
pretation is based upon a different set of facts. 
XXXIII. As there is but one set of facts under- 
lying the art of voice production, there can be but 
one standard method, and this must conform in 
every particular to these fundamental facts. 
XXXIV. Method in voice development is not 
only possible, but absolutely essential, while method 
in interpretation is an impossibility. APPENDIX C 
Give age of your mother 
when you were born 
Have you any physical 
disability that would 
likely interfere with 
your success as a 
singer, such as: artifi- 
cial iimbs, hands, 
feet, eyes or teeth; 
short upper lip, goiter, 
extremely narrow 
roof of mouth; dis- 
eased tonsils, impedi- 
ment of speech, de- 
fective sight or hear- 
ing, or catarrhal, 
heart or tubercular 
trouble? 
QUESTIONNAIRE-VOCAL MEASUREMENT 
(AFTER FITZ) 
Give exact height 
Give exact weight 
Give size of glove 
Give age nearest birthday 
•Place the end of a common tape line over the top of the right ear exactly 
where the ear joins the head, and pass across the forehead over the eye- 
brows to the same point over the left ear; draw the tape smoothly and 
mark the number of inches in the space to the right. 
Place the end of the tape under the right ear exactly where the ear joins the 
head, and pass over the apex of the nose and cheekbones to the same point 
under the left ear; draw the tape smoothly and mark the number of inches 
in the space to the right. 
Place the end of the tape under the right ear exactly where the ear joins the 
head, and pass over the upper lip to the same point under the left ear; 
draw the tape smoothly and mark the number of inches in the space to the 
right. 
Place the end of the tape under the right ear exactly where the ear joins the 
head, and pass around the tip of the chin to the same point under the 
left ear; draw the tape smoothly and mark the number of inches in the 
space to the right. 
State race (color) 
Are you a twin? 
Are you married? 
•Have some one assist you in taking the measurements. 
NAME 
STREET. 
TOWN. 
STATE. APPENDIX 
205 
To Be Filled Out By Male Applicant 
Do you enjoy games of chance and venturesome 
amusement in general? 
Do you have heavy, medium 
or thin beard? 
During boyhood did your 
voice “break” or was the 
change gradual? 
Give your choice of athletics 
To what extent have you studied music? 
Are you politically inclined? 
Are you inclined to argue? 
Are you moody? 
Are you sensitive? 
Are you a high school or business college graduate? 
To Be Filled Out By Female Applicant 
Are you a good mathematician? 
Give your choice of a profession 
What has been the general 
condition of your health? 
Give your age nearest first 
menstrual period 
What is your strongest do- 
mestic tendency? INDEX 
A-hem, cause of, 128, 173 
Air, complementary, 188 
reserve, 188 
residual, 188 
Airways, importance of freedom 
of, 78 
Alboni, Mme., 3 
Anesthesia, local, 134 
Art, control of voice and body 
as an, 56 
relation of life to, 13 
singing as an, 61 
tone guided by, 28 
Artist, an excellent, 115 
cabaret, 126 
successful, 118 
the great, 112 
Arytenoids, crossing of, 126 
Begin, when to, 1 
why, 70, 71 
Boy, choir, 6 
Breathing, abdominal, 192 
chest, 192 
control of, 25, 183 
costal, 192 
incorrect, 9 
mouth, 78, 80 
principles of, 75 
see Appendix I. 
relation of stuttering to, 34 
simplicity of, 59, 80 
types of, 81, 190 
Bronchitis, chronic, 174 
Capacity, lung, 188 
vital, 188, 189 
Career, essentials of, 126 
preparation for vocal, 23, 24 
short cut to, 23 
surgeon’s, 184 
Caruso, impossibility of imita- 
tion of, 18 
Childhood, diseases of, 121 
singing in, 2, 3 
Clothing, collars and corsets as, 
82 
proper, 82 
waists and furs, as, 82, 83 
Colds, “chronic,” 49, 127 
dangers of neglected, 46,47,54 
“grippy,” 44, 45, 46 
infectious nature of, 49 
local origin of, 45, 47, 51 
lozenges and troches in, 24, 51 
resistance to, 37, 48 
singing through a, 49, 125 
treatment of, 44, 46, 48, 51, 
52, 53 
vaccines in, 54 
Composers, study of lives of, 16 
Cords, diagnosis from the, 99 
edges of, 58, 132 
hemorrhage into, 130 
mobility of, 134 
secretion on, 128 
vocal, movements of, 29, 30, 
33 
Cough, mechanism of, 188 
remedies for, 172 
Coup de Glotte, 60 
Defects, physical, 69 
Dentistry, American, 108 
207 208 
INDEX 
Diagnosis, case for, 119 
taking time for, 111 
Diaphragm (See Chap. XVIII), 
amplitude of, 192 
an inspiratory muscle, 183 
control of, 34 
functions of, 182 
position of, 182, 183 
Diet, meat or vegetable, 84 
mixed, 83 
vocal effort and, 84 
wine in the, 84 
Diphtheria, 118 
Disability, vocal, 127, 131 
vocal, latent, 127 
Discharge, nasal, 133 
post-nasal, 133 
Discipline, vocal, 2, 30 
Ear, abscess in the, 40, 42, 43, 
78, 118 
defective vs. musical, 37, 38, 
39 
message from ear to, 20 
pain around the, 41 
scarlet fever and the, 36 
training of the, 14, 16 
water in the, 40, 41 
Element, laryngeal, 123, 126 
motive-power, 123 
resonating, 123 
Examination, fear of the, 91, 
110 
importance of history in the, 
95 
importance of physical, 76, 78, 
101 
neglect of, 116, 121 
nose and naso-pharynx, 175 
points in the, 90, 91, 92, 93 
record of the, 94 
sputum, 171, 173 
Exercises, breathing, 81 
phonasthenic, 65 
physical, 81, 82 
Exercises, recommending, 76 
vocal, 3, 9, 63, 113 
Experience, stage, 16 
Failure, causes of vocal, 118 
Falsetto, distinction of head 
voice from, 25 
“flute-like,” 26 
production of, 26, 31 
uvula in, 26 
Fatigue (See Phonasthenia), 
vocal, 24, 104 
Fear, neglect and, 102 
Fitz, Theophilus E., 8 
Garcia, Manuel, 3, 7 
Gift, natural, 118 
Growths, cordal, 111 
question of, 104 
Habits, vocal, bad, 23, 28, 33, 34 
Hay Fever, alcohol injections 
in, 157 
American Association for 
study of, 151 
calcium chloride in, 156 
case of, 129, 151 
causes of, 151, 152 
foods and, 152 
protein tests in, 152, 153 
symptoms of, 155 
treatment of, 155 
vaccines in, 156 
Hearing, catarrh and, 37 
insidious loss of, 38, 39 
islands of, 21 
mistakes in, 39 
normal range of, 39 
soprano voices and, 21 
History, case, 128 
Hoarseness, phonasthenia as 
cause of, 128 
vocal nodules causing, 110 
Hygiene, body, 82 INDEX 
209 
Imitation, effect of listening 
upon, 14 
importance of, 72 
influence of phonograph upon, 
15, 38 
occasional impossibility of, 18 
Infection (See Chap. XVIII, 
p. 170), airways, carriers 
of, 136, 160 
chronic focal, 108 
chronic, of lower airways, 170 
respiratory, 121, 122, 127 
respiratory, acute, 133, 134, 
159, 169 
treatment of acute, 162, 163, 
164, 165, 166 
Inhalations, 134, 167 
Interference, tongue, 60 
vocal, kinds of, 31 
Intubation, influence of, 118 
Languages, importance of study 
of, 15 
Larynx, asymmetry of, 126 
dry, 129 
examination of, 32 
experiments on, 30 
movements of, 32 
tests for the, 65 
training of, 30, 31 
treatment of, 167 
ventricles of, 124 
Laryngologist, co-operation of, 
with teacher, 77, 118 
examination of voice by, 117 
Life, artistic, 116 
studio, 103 
Lind, Jenny, Mme., 3 
Lungs, filling and emptying of, 
25 
Mackenzie, Sir Morell, 3, 4, 6, 
7, 20, 28, 30, 34, 35, 72, 73 
Malibran, Mme., 4, 8 
Mastoiditis, 42, 101 
hearing after, 42 
operation for, 42 
Measurement, vocal, 8 
Messa di Voce, 30, 76 
Muscles, chest, poor develop- 
ment of, 120 
exercises for, 81 
interference with, 57 
tensor, fatigue of, 31 
throat, gripping of, 28, 29 
Music, history of, 16 
writers of, 16 
Mutation, 3 
Fitz’s rule of, 8 
in female, 5 
in M. Lablache, 6 
in old age, 5 
use of voice during, 7 
Naso-Pharynx, 26 
examination of, 98 
growths in, 98 
resonance in, 124 
Neglect, tendency to, 103 
Nodules, case of, 130 
causes of, 112 
removal of, 114 
results of, 113 
soft, 113 
vocal, 22, 99, 110, 111, 134 
Nose, bactericidal secretion of, 
48' 
blowing the, 41 
crusts in the, 77 
douching the, 78, 79, 80 
early examination of, 62, 97 
growths and deformities of, 
58, 64, 70 
“hump,” 105, 106 
infections of, 48 
septum of the, 78, 96, 125 
Obstruction, cordal, 128 
nasal, 104, 105 
Pain, importance of, 101 
Patti, Adelina, Mme., 3 210 
INDEX 
Phonasthenia (See Fatigue, vo- 
cal) 
causes of, 6, 22, 28, 55, 58, 64 
chronic diseases and, 58 
onset of, 61, 128 
prevention of, 62 
relation of age and sex to, 57 
symptoms of, 58, 59 
tests for, 65 
treatment of, 62, 63, 64, 65 
Physician, voice, 118 
Pitch, idea of, 37 
Placement, bad, 24, 86 
shifting of, 22 
Poison Ivy, 153 
Pollen, air-borne, 154, 156 
effect on singer, of, 154 
Polypi, nasal, 105, 125 
Prevention, importance of, 102 
Production (See Appendix II), 
artificial, 26 
change of method of, 76 
fundamentals of voice, 132 
most essential feature of, 30 
principles of, 75 
throaty, 2, 28 
Puberty, larynx at, 4, 5 
Pupil, control of voice of, 30 
happiness of the, 117 
reliance of, 12 
Ramfis, performance of, 115 
Range, building the, 22 
maximum, 22 
three octaves of, 132 
Region, subglottic, 127 
Registers, explanation of, 21 
“long reed,” 27, 31 
mistaken ideas of the, 74 
“short reed,’’ 26 
speaking, 64 
uniting of the, 73 
use of several, 30 
vocal, 21 
Resonance, causes of poor, 78 
chest, 124 
Resonance, defective nasal, 103, 
104, 125 
testing nasal, 105, 134 
Rheumatism, focal origin of, 
137 
Rhinolalia, 129 
Rodriguez, M. Visconte, 7 
Rousseau, 26 
Sensitization, protein, 129 
Septum, deviation of, 104, 120, 
123, 125, 130 
in children, 123 
nasal, 104 
posterior edge of, 125 
Scarlet Fever, voice and, 118 
Singer, criticism of, 17 
demands upon, 17 
ignorance of young, 127 
Singing, esthetics of, 13, 28 
forte, 72 
greatest effects of, 21 
“methods” of, 60 
psychology of, 116 
stutterers and, 21 
the art of, 60, 61 
Sinuses, children’s, 122 
latent disease of, 133 
nasal, 122 
X-ray examination of, 176 
Society, demands of, 17 
Song, gift of, 10 
Herbert Spencer’s definition 
of, 20 
mastery of art of, 34 
relation of speech to, 19 
Soprano, case of a lyric, 130 
making of, 21 
types of, 11 
what happens to boy, 6 
Sound, laryngeal production of, 
28 
noise versus, 38 
Speech, defects of, 34 
relation of song to, 19 INDEX 
211 
Speech, sound and, 28 
vocal compass in, 21 
Spencer, Herbeit, definition of 
song by, 20 
Sports, bicycling, swimming, 85 
walking, 85 
Standardization, 70 
effort to bring about, 74, 75 
music teachers’ efforts at, 75 
Strain, vocal, 113 
Stutterers, influence of singing 
on, 21 
stammerers should avoid, 34 
use of strychnia in, 34 
Surgery, excellence of, 105 
plastic, 105, 107 
Talent, demand for, 16 
histrionic, 106, 118 
Teacher, blaming the, 126 
choice of a, 71 
co-operation of laryngologist 
with, 67, 68, 75 
man or woman, 72 
skilled, 114, 121 
the instrumentalist as, 71 
the intelligent, 74 
the successful, 72, 73 
Teaching, importance of good, 
12, 35, 67 
Teeth, extraction of, 109 
importance of good, 108 
missing, 109 
swallowing the, 109 
Throat, clearing the, 128 
dry, 127, 128 
relaxed, 128 
sore, 136 
Timbre, influence of race upon, 
11 
Tone, beauty and fullness of, 
28, 69 
“big,” 11, 24, 61 
dampening of, 125 
effect of dry throat upon, 45 
production of, 11, 112 
Tone, unsteady, 128 
working out the, 23 
Tongue, teeth and, 109 
Tonsils, adenoids and, 122, 136 
chronic disease of, 133 
construction of, 137 
diseased, 134, 137 
effect of removal of, 139, 140, 
141, 142, 143, 144, 145, 146, 
147, 148, 149, 150 
examination of the, 98, 136 
function of, 136, 137 
pillars of, 31, 64, 70, 134 
removal of, 130, 139, 149 
Tonsilitis, symptoms of, 137,138 
Toxin, absorbed, 153 
body manufacture of, 137 
germ, 137 
Trachea, bleeding from the, 174 
inflammation of, 173 
inspection of, 175 
Travel, influence of, 16 
railway, 84 
Training, bad, 23 
breath, 81 
methods of, 76 
question of foreign, 15 
Treatment, bactericidal, 179 
bedside, 168 
direct, 178 
factors in, 176 
indirect, 172 
vaccine, 176 
Tremolo, beginners’, 24 
causes of, 24 
Turbinates, enlarged, 105, 121, 
130 
Uvula, position of, 26, 31 
removal of, 122 
Viardot, Mme., 4, 8 
Vigor, mental and bodily, 102 
Vocalization, approximation of 
cords during, 111 
deferring of, 2 212 
INDEX 
Vocalization, perfection in, 109 
seriousness of, 14 
Voice, analysis of the, 63, 76 
bad use of a good, 127 
“broken,” 6, 8 
critical point of, 22 
daily exercise of, 24 
duration of, 68, 86 
Eunuch’s, 21 
forcing of, 22 
head and chest, 26, 27 
hearing one’s own, 25 
hygiene of, 62, 78 
influence of sex upon, 8,20,21 
loss of, 149 
mechanism of, 57, 123 
muscular development and 
the, 103 
mutation of, 3 
Voice, possibilities of, 10 
predetermination of, 8 
range of, 18 
“resetting” the, 131 
rest of, 33, 85 
“screwing up” the, 59, 99, 100 
“shipwreck” of, 22 
skillful use of, 22 
smoothness of, 29 
three elements of production 
of, 123 
the unmusical, 56 
“throaty,” 28 
trying out the, 117 
two uses of, 19, 30 
violin and the, 72 
vowel development of the, 20 
when to begin cultivation of 
the, 1, 2 
Vowels, use of, 20