Vocal hygiene is a specific system based upon well-regulated principles for a specific purpose and applying to a specific class in the family of nations. But there is the difference that, whereas the laws governing the general health of the community have legislative sanction and are strenuously enforced by official authority, the laws of vocal hygiene bear no seal of state or municipal power, save in the broadly general sense indicated, but rely for enforcement upon the individual who is most nearly involved, and who must pay swift penalty for any infringement, however slight and however innocently committed.
While this is a truism, yet it cannot be too strongly emphasized nor too often reiterated; for with all their notable precautions, singers are often taken unawares and fall when most they desire to stand. Why? They are simply paying the penalty of a broken law, and it does not help them with a disappointed club committee, or in framing a telegram of regret, accompanied by a physician's certificate, to say that they have erred through ignorance. The aphorism that ignorance of the law is no excuse is just as valid in the court of the hygienic judge as in any common law court between the oceans.
It is the prevalent practice to use the physician as the court of last resort. But it would be vastly better and far more sensible if the singer could be made to act with swift authority as an agent of prevention over the weaknesses of his or her own nature. The subject, thereby, would be vastly simplified. It would not be so profitable to the specialist; but I can vouch for it that he would not only forgive, but praise the discretion of his patient, and lend all possible aid to educate him along a new scientific path—that of prevention. Not a new path, either, for in its last analysis what is hygiene but the science of prevention? Preservation of health means the prevention of disease. This answers the cry of every artist's heart, especially that of the vocal artist, teacher and student: How can I prevent disease and weakness of the vocal machinery? Briefly and plainly: How can I keep well?
In this important matter of vocal hygiene a prominent part is played by the mucous membrane. What is the mucous membrane? It is the membrane which in this special sense covers or lines the respiratory tract from the very outlet of the nose to the terminal bronchi; in fact, to the very air-cells of the lungs themselves. Its function is that of supplying the involved passages with moisture, and it secretes a glairy or watery substance called mucus. Now, mark this well. The entire area of the respiratory tract, from the nose to the bifurcation of the bronchi, it is said on good authority equals one square foot of exposed surface, and the amount of secretion per day equals about sixteen fluid ounces, or a pint, which must be secreted by a person in the normal condition of health. It also has the power of absorption of certain diverse substances, such as alkaloids, fluids of all kinds, hence the danger of alcoholic indulgence to the singer. Alcohol coagulates. It causes the epithelium to contract and to become so disintegrated as to be utterly incapable of performing its functions until such time as the underlying tissue shall have created new cells to take the place of those which have been destroyed. To illustrate briefly the varied functions of this membrane: Whereas alcoholic stimulant destroys it, another powerful drug, cocaine, is absorbed, often to such an extent that the patient is prostrated by the poison introduced into the system by this means, and yet without impairing the membrane to any extent except through persistent indulgence.
The mucous membrane is the telltale of conditions. If a man's tongue is coated with detritus—which, anglicized, is nothing more than the products of decomposition, a coating formed by over-stimulation of the glands lying at the base of the tongue—and this has been previously superinduced by a disordered stomach, we know that the cause is indigestion. If the follicles in the back part of the pharynx or throat appear distended, and even the tonsils themselves are affected—and these again are part and parcel of this same mucous membrane—we can say this is due to one of several causes: either to a reflex condition from the stomach, due to over-eating or over-indulgence of some other equally deleterious sort, or to inactivity of the bowels, or to suppressed perspiration, or to improper or undue use of the vocal organs.
Again, let us glance for a moment at what a good many people deem a superfluous appendage, the uvula. A patient comes into my office with a badly swollen uvula. The upper tones of the voice are gone. He has no complicating quinsy, and in that case I can say without hesitation that he has outrageously misused his voice. I ask him where he was the previous afternoon, and find he was jubilantly "rooting" for the New York Giants in an exciting baseball contest. Now, it in nowise lessens the force of my illustration that this patient was not a singer and did not acquire, if you please, his swollen uvula in orthodox fashion. It is only a short time ago that a man came to me with a pronounced case of oedematous uvula, or swollen soft palate. He announced to me that he was no longer a tenor singer, although he had sung tenor for three years; that lately he had been persuaded that his voice was baritone; and, indeed, he had been singing, up to the time of coming to me, a baritone part in opera. It was this which brought him under my hand as a patient. He had changed his teacher, who had insisted that he was a tenor, within two months, and since that time had been under the instruction of the master who had declared that he was a baritone. I had known him for some time, and the only perceptible change to me in the voice was a decided tendency to cover and sombre the upper tones. Upon examination, the only thing abnormal was the condition of the soft palate and the surrounding tissue extending down both pharyngeal pillars. The soft palate was swollen to nearly three times its original size and hung down upon the tongue. The symptoms he complained of were inability to sing above F, and all high tones were husky. The production of the upper tones was accompanied with considerable pain. An emollient gargle was given and, soon after, astringent applications; but in vain. It was necessary three weeks afterward to amputate the uvula. Within three weeks more the operation was demonstrated a success in that the upper tones were fully restored; but I leave the question with the teachers whether this operation would have been necessary had not this young tenor been drawn aside on the purely theoretical issue as to whether he was not a baritone instead.
In the case of one of New York's most experienced singers, it required two years of persistent effort on the part of both patient and physician to overcome the habits of a lifetime. The case is of general importance for the reason that the habits he had formed are more or less common to all of us, though perhaps not to such an aggravated degree. He was an inveterate smoker and a confirmed coffee drinker. These habits reflected themselves upon the poor, defenceless mucous membrane, whose function was perverted as shown in the constantly congested appearance of the respiratory tract. I have seen this artist with congested vocal cords rehearse an oratorio in the afternoon at a public rehearsal and sing the same work in the evening at the regular concert performance, when, to use his own words, "I feel as if every note will be my last. I have no grip on my voice." It was a clear case of indomitable will and sheer physical strength carrying the singer over obstacles that even to my mind seemed well-nigh insurmountable. A cure was effected in this obstinate case simply by insisting upon observance of hygienic law. There is no better instance of efficacy of vocal hygiene than in the case of this man. The gradual reassertion of nature, as indicated by the clearing up of the inflamed mucous membrane of the nose, the thickened condition of the pharynx and the chronically congested cords, was an all-sufficient reward for anxious thought spent upon an important subject. You may ask what was the remedy in this case. It was simply advice given and heeded, together with needed incidental treatment. I cut off his coffee and cigars, not immediately but gradually. He had sufficient force of character to aid me by heeding the counsel. The result was a diminution of secretion of the mucous membrane and a return to normal conditions.
Right here there is another phase of the situation to which I desire to call particular attention, not alone because of its vital importance to the singer, but also because of the danger to the unschooled student of neglect of what we ordinarily term a cold in the head in its first stages. By the first stage of the cold I mean that condition which obtains before the stage of secretion is arrived at, where the mucous membrane is being congested, where it is almost impossible to distinguish what is the highest point of normal stimulation under which the membrane may be expected to do its best work. This point may be aptly illustrated by comparison with a singer under perfectly normal conditions. Then, as is well known, it is the mental impulse that stimulates nerve, muscle and membrane to do their best work. But in the other condition this result is attained without the mental impulse, as we have the mucous membrane and the blood-vessels carried to a temporary climax of effectiveness due to the systemic disturbance. By this I wish to make clear my point, that artists have often noticed an unusual brilliancy of voice under circumstances which were all the more mysterious because of the sudden collapse of the vocal organ under stress of use, and the alarming suddenness of the catastrophe which overtakes them and leaves them totally incapacitated. Then they say, "I have a cold;" whereas it requires from twenty-four to thirty-six hours for the fulfilment of these conditions. They should have reached this sensible conclusion just two days before. I take issue with those physicians who urge that certain exercises should be given to the artist when the vocal cords are in a state of congestion, for the reason that it requires a period of from ten to fourteen days for the complete relief of this inflammation. During that period, the blood-vessels are fully employed absorbing the products of the inflammation, and any attempt to interfere with this necessary process of nature can end only in disaster or in a prolongation of the difficulty. This is the law of pathology, unalterable and not to be evaded. Physicians at times resort to soothing and astringent applications in an emergency, to carry the artist through a performance; but the lack of edge to the voice for weeks following is an all-sufficient indication of the revenge nature takes for this trespass upon her domain.
The cause of the sudden disaster to the voice which I have described is not far to seek. The cold has caused over-stimulation of the mucous membrane of the larynx, and a consequent loss of voice. This cold begins in the head, and on the third day, perhaps before, it has attacked the larynx. Why? Because the mucous membrane has become so swollen that the nasal passages are obstructed and the mucous membrane of the larynx has to perform a double function, that of heating the air as it is brought to the lungs in the process of respiration, as well as carrying out its own obligation to the scheme of nature. By a strange coincidence, this membrane of the larynx is supplied with sensation by the same nerve that conveys motion to one of its tensor muscles. This is the superior laryngeal nerve. By the thickening of the mucous membrane, all the intrinsic muscles of the larynx are interfered with, and, consequently, total extinction of the voice follows swiftly upon excessive inflammation. There you have it in a nutshell. The mucous membrane of the larynx and the bronchial tubes, to enlarge upon its duty for a moment, is endowed with very fine, hair-like processes called cilia, whose action is to waft secretions from the interior of the lungs outward. Hence the danger of promiscuous spraying with all sorts of everyday nostrums, or of anything which may interfere with the activity of these minute bodies or the media in which they operate.
This intimate relation of nerve and muscle and mucous membrane is best illustrated by the sneeze. The explanation of this is an over-stimulation of a part of the mucous membrane of the nose called the Schneiderian membrane. If we analyze the sneeze, we find that it simply consists of a spasm of the pharynx, larynx and diaphragm through the reflex action of this membrane. The over-stimulation of the membrane, in the case of the singer especially, may generally be set down to an incipient cold; but any inflammation of this part of the mucous membrane of the nose alone may give rise in reflex action to vocal disability.
There are some peculiarly interesting isolated instances of disturbance of the vocal mechanism, which are unique in that, while apparently harmless and uninteresting from the standpoint of even the specialist, they have, on occasions, developed most alarming influence over the voice. They have no precedent; experience alone can determine their influence for evil. They are not a matter of record, they are simply Études, interesting studies in the bypaths of vocal hygiene, and must be dealt with as they appear. An exceptional example was one wherein the voice of the singer was perfectly even except as to the G sharp in the medium, which was entirely wanting—as though it had never existed.
The singer in question came to me after an Easter rehearsal. I tried her voice with the E-scale before using the laryngeal mirror, and to my utter surprise found the medium G sharp missing, while all the rest of her scale was perfect even to the G sharp above. This experiment was tried repeatedly with the vowels a, e, i, o, and u, and with consonants prefixed, but invariably with the same result. Upon examination, no deviation from the normal anatomy was found, save in the left anterior nostril. Here a sharp spur of bone projected from the septum into the turbinated tissue. This condition had remained in this singer for four years, according to my previous observation, without causing her any inconvenience. A similar condition was seen by me in the case of Mr. Santley, the famous English baritone, when I made an examination, and he declared that he was not aware of its producing even discomfort—such a capital illustration of the necessity for non-interference until the laws of reflexes are disturbed, that I cannot refrain from alluding to it.
In my patient, however, in addition to her nasal trouble, I found an enlarged follicle about the size of a pea back of the posterior pillar of the pharynx, at the junction of posterior pillar and pharynx. This follicle was removed by a simple process, when, as if by magic, the G sharp responded and has since remained unimpaired. My explanation of this case is simply one of reflex action; that is, by a singular complication this follicle fell in the track of the glosso-pharyngeal, the pharyngeal-plexus, the external-laryngeal and the recurrent laryngeal nerves, which, as it were, sounded the alarm for retreat of the phonating muscles whose harmonious action was necessary to produce the medium G sharp.
There are numerous instances of affections of the vocal cords that might be cited, all superinduced by straining the voice from various causes, but especially by using the voice under improper physical conditions or of singing in rooms filled with foul atmosphere.