HX00033596 THE TONSILS AND THE VOICE RICHARD B. FAULKNER, M.D. ^^tintmt Ktbrarg Digitized by tine Internet Archive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/tonsilsvoiceinscOOfaul The Tonsils and The Voice IN Science, Surgery, Speech and Song A COMPREHENSIVE MONOGRAPH ON THE Structure, Utility, Derangements and Treatment of the Tonsils, and of their Relationship to Perfect Tone Production A RESEARCH STUDY With Original Contributions from the Highest Medical and Voice Authorities BY RICHARD B. FAULKNER, M.D. (COLUMBIA UNIVERSITY) WITH AN INTRODUCTION BY PROFESSOR GEORGE M. SLEETH Instructor in Elocution, Western Theological Seminary THE PRESBYTERIAN BOOK STORE PHTSBURGII. I'A. COPYRIGHT, 1913, BY RICHARD B. FAULKNER, M.D. THE BLANCHARD PRESS NEW YORK PREFACE Tonsils! What are they? What are their functions ? Who knows ? What textbook tells ? I have made a research investigation, and this book gives the result. Lights and side-lights fell upon my path. Delicate, difficult, complex, technical questions of the voice arose. Two pro- fessions became involved. No treatise on the tonsils is complete unless it includes the questions of the voice, for the tonsils and the voice are inseparable subjects. This is the only work in which a systematic effort has been made to connect the viewpoints of both the medical and voice professions, in an or- derly and authoritative manner. This is the only work on the subject published in any language. This is the only work in which, in addition to its physiological functions, the ton- sil is treated as a mechanical body, and the action of its mechanism fully expounded. This work contains all the facts of a world's re- search on the structure, uses, disorders and treat- ment of the tonsils ; many new facts in the science of the vocal art ; and in addition, a full exposition of the modern hygiene of the tonsil, the hygiene of the voice, and the care and health of the nose, mouth and throat. That "the voices of singers and public speakers are benefited by complete removal of the ton- sils"; that "the loss of the tonsils may cause a IV PREFACE permanent loss of the singing voice is a puerile and senseless belief" ; that "If the tonsil in a ?zor- mal state is removed in toto, there is no disastrous after effect, but on the contrary, the individual is improved in health, and the richness in qualit}^ of voice and the volume of tone are increased one hundred per centLmi" ; are common statements in the standard works of the American medical pro- fession. These statements are important. Are they the truth? What is the answer of the voice profession ? I am gratified at the courteous contributions, and also with the expressions of regard for the importance of the work I have undertaken, which I have received from such distinguished medical and voice authorities as Von Chiari (Vienna), Frankel (Berlin), Von Schrotter (Vienna), Brieger (Breslau), Von Levinstein (Berlin), Mar age (Paris), Jacohi (Xew York), Es- cat (Toulouse), Moure (Bordeaux), Castex (Paris), JLeimoyez (Paris), Sir Felix Senion (London), Beverley Robinson (Xew York), Von Giitzmann (Berlin), Gleitsniann (Xew York), Schmiegelow (Copenhagen), Van Bag- gen {The Hague), Liihet-Barbon (Paris), Z/WC (Paris), Natter (Paris), Helsnioortel (Ant- werp), Loezvenherg (Berlin), St. Clair Thom- son (London), H. Holbrook Curtis (Xew York), Scripture (Xew York), Miller (Xew York), Baonlt (Xancy), Zund-Burguet (Paris) , Massei (Xaples) , Knight (Xew York) , Barth (Leipzig), Holmes (Boston), Mackenzie (Baltimore), Gleason (Philadelphia), Cassel- berry ( Chicago ) , Eo.^s ( ^lontreal ) , ■ JLaniperti PREFACE V (Berlin), Mme. Cappiani (New York), Mme. Mott (New York), De Reszke (Paris), Mme. Lehmann (Berlin), Sehastiani (Naples), Shakespeare (London), Sii' Charles Santley (London), Sabatini (Milan), Mme, Patti (Bre- conshire, Wales), Mine. Nordica (New York), Mme. Schumann-Heink (New York), Mme. Tetrazzini (New York), Mme. Clara Kathleen Rogers (Boston), Bond (New York), Bispham (New York) , Curry (Boston) , and others. The object of this work is to present known facts, the latest views of the most eminent authori- ties, and the indications which denote safe lines of treatment as against the apparent indiscriminate and reckless disregard of tonsillar function. The author will feel rewarded if his efforts please the expert laryngologists, and other inter- ested members of his own profession, as well as the voice mechanicians, voice trainers and voice users. My thanks are due to Dr. Kniffler (now of Wiesbaden), Mr. Charles H. Read, and Profes- sor George M. Sleeth, for their valuable assist- ance in the preparation of this work. Richard B. Faulkner.. 100 Fifth Avenue, Pittsburgh, 1913. INTRODUCTION Dr. Richard Biddle Faulkner needs no intro- duction. He received the degree of Doctor in Medicine from the College of Phj^sicians and Sur- geons in the City of New York, Columbia Uni- versity, and also received special instruction under Professors Alonzo Clark, Charles McBur- ney and John G. Curtis. Many scientific contributions from his pen have appeared in the leading medical journals of America. The starting point of the present treatise, the author says, was a question asked him by the writer of this introduction. Being a teacher of the voice and delivery for over thirty years in the same city with Dr. Faulkner, and having had oc- casion for many years to avail myself oip his skill in laryngology, both for myself and my students, I one day asked the doctor, "What are the tonsils for?" This book is the answer. Behold how great a matter is kindled by how very small a fire! He started upon a new and thorough in- vestigation. He has ransacked Europe and America to give us the answer. And he presents the testimony of those best qualified to speak on the matter. The book contains contributions from world- renowned artists and teachers and scientific inves- tigators. Not the least interesting and profitable part of viii INTRODUCTION the work is that which gives the most recent and authoritative treatment of the tonsils, and the great discoveries which have been made in the science of the voice, as regards its mechanism, its preservation, its use and its treatment. As a result of the investigations, teachers of the voice, both in speech and song, will be more careful in recommending tonsil surgery as a panacea for voice users. The treatment of the vocal apparatus is a specialty. The ideal expert would be one who combined laryngological skill and a sound knowledge of the theory and practice of the voice. Literature on the subject of the connection be- tween the tonsils and the voice is scanty. And when reference is made to the subject, it is gener- ally some wild surmise, or bare, unsupported dogmatism, or sheer tradition. There is an originality of investigation and a freshness in the method of treatment of the sub- ject, which renders this work unique. Specialists will be grateful to have so much information and such a gathering of famous opinion, in so com- pact and orderly a form. George M. Sleeth. CONTENTS PAGE Preface iii Introduction by Professor SleEth vii Chapter I. Research Investigation 1 Chapter M. Anatomy of the Tonsil 7 Normal Tonsil, Definition 7 Anatomy 8 Histology 9 Special Anatomy 12 Surgical Anatomy 19 Chapter III. Physiology of the Tonsil 22 Chapter IV. Causes of Tonsil Diseases 76 Chapter V. Classification of Tonsil Diseases. ... 82 Chapter VI. Adenoids 85 Chapter VII. The Tonsils and the Teeth 106 Chapter VIII. Six Medical Questions 119 1. Have the normal faucial' tonsils any function ? 119 Addenda from original sources ... 125 Addenda showing wide diversity of views 134< 2. What are they.^ 155 'f^L What effects are directly due to their removal.'' 160 rf4. )Have phonetic changes been ^-^ noted? 166 5. Would you advise the removal of normal tonsils ? 174 6. Remarks? 178 ix CONTENTS PAGE Chapter IX. The Science of the Vocal Art 181 Chapter X. Six Voice Questions 241 1. Are the normal faucial tonsils of any use to singers? 241 Addenda .;.... 246 2. HoWj or in what manner, are ,^ they of use to singers ? 248 -^. Do you know of any instances in which the voice was improved /^A after their removal? 251 \^ Do you know of any instances in which the voice was impaired ;-N or ruined after their removal?. 256 ' §r. Is removal of tonsils advisable in singers ? 259 6. Remarks ? 265 Chapter XI. Diagnosis of Tonsil Diseases 272 Chapter XII. Hygiene of Tonsils and of Voice. . . . 306 Hygiene of Tonsils 306 Hygiene of the Voice 310 Chapter illl. Treatment of Tonsils 328 ILLUSTRATIONS 1 Portrait of the Author Facing Title Page 2 Plate showing position of the tonsils . . . Facing Page 9 3 The vowel siren and buccal resonators. Marage " " 181 4 Photographs of the voice in singing the same exercise. Marage " " 193 1. French method. 2. Italian method. 5 Molds of the buccal cavity pronouncing the vowels. Marage " " 195 6 Photographs of the voice in singing and speaking. Marage " " 209 1. Speaking. 2. Singing. 7 Photographs of the voice in medical practice. Marage " " 211 1. Singer's nodule. 2. Pharyngeal catarrh. 8 Facsimile letter of Signor Lamperti. . . " " 241 9 Vertical section of nose, pharynx and larynx " " 307 10 Facsimile letter of Mme. Adelina Patti (Baroness Cedarstrom) " " 389 CHAPTER I RESEARCH INVESTIGATION. Research investigation lays bare, explains and connects the facts which form the foundation of every science. Science is the knowledge of ascertained facts, arranged in orderly series, and referred to gen- eral truths and principles on which it is founded. Science is a record of truths. Science accepts no statement as one of fact, unless its truth can be proved from every possible point of view. The man with facts is an authority. The man without facts is no authority. Every fact ascer- tained is a scientific asset, and adds one unit to the sum total of human knowledge. Knowledge is power. The educated physician of to-day is a man of broad culture and trained in the funda- mental sciences that underlie medicine; he has a good knowledge of the history of medicine and of the means by which advances have been made. He knows the past and looks into the future. He is familiar with the results of modern scien- tific research, and is able to maintain the dignity of a learned profession. He knows that medical and surgical science are inseparable, that preven- tive surgery is identical with preventive medicine as the great aim of modern medical research ; that operative surgery and practical medicine have the same object, namely: the restoration of phys- iological function. The complete restoration of physiological function is ideal surgery. The prevention of small-pox by vaccination; 2 THE TONSILS AND THE VOICE the cure of diphtheria by antitoxin; the cure of lock-jaw and of hydrophobia by the injection of serum; the discovery of the germ of Asiatic cholera, of the bacillus of tuberculosis, of leprosy, and of epidemic infantile paralysis ; the discovery of the mosquito as the cause of yellow fever and malaria, and the prevention of these diseases by the destruction of the breeding places of these in- sects, are examples of the value of modern medi- cal research. The discovery of the action on the blood vessels of the secretion of the suprarenal gland; the re- markable mental and physical improvement of backward and defective children by the adminis- tration of the extract of the thyroid gland; and the fact, as stated by Sajous, in his great work on "The Internal Secretions," that "the vermi- form appendix is not, as now taught in text- books, a functionless structure of low vitality, but that it secretes a relatively large quantity of suc- cus entericus containing auto antitoxin to insure asepsis of the appendix, and of the caecal cavity particularly exposed to the accumulation of putrefactive material," are further examples of the benefits of research investigation. Recent research has enriched our knowledge in physiologico-acoustics and in the mechanism of voice production. The doctrine of ages that the human voice was produced by a stringlike vibra- tion of the vocal chords is disproved and aban- doned. The mechanism of production of vowel sounds, and the photographing of the human voice where- by the voice teacher is enabled to demonstrate RESEARCH INVESTIGATION 3 good voices from bad and also to illustrate the progress of the pupil in tone production, and whereby the physician is enabled to show by means of photographs the correctness of his diag- nosis in voice complaints, are new lines along which research studies have extended. The re-education of the hearing in cases of sclerotic deafness is another interesting advance. In every science, art and industry, energies are strained in the pursuit of original research. George Crocker's legacy to Columbia University of more than six hundred thousand dollars, for the sole purpose of research investigation into the cause and prevention of cancer, indicates a deplo- rable absence of knowledge upon this subject. The causation of tumors needs investigation. Every field of medical science is in urgent need of the light of scientific research. Many questions concerning the tonsils await the light. What is a normal tonsil? Has the normal faucial tonsil any function? Has it an internal secretion? Is it a protective organ? What is the object of the system of closed lym- phatic canals that occupy the follicles of the ton- sil? What is the cause that leads to the constant ap- pearance of the strong fibro-aponeurotic sheath that encases the faucial tonsil like an armor-plate, unperf orated by blood vessel, nerve or lymphatic ? What function is served by this fibro-muscular capsule that its growth becomes a necessity? Has the tonsil a mechanical function? 4 THE TONSILS AND THE VOICE Has it a phonetic function? Has the normal tonsil any influence on the voice, in singing or speaking? M. Hicguet, in presenting his research report to the Societe Beige D'Otologie, De Rhinologie et De Laryngologie, on the ''Function and Util- ity of the Palatine Tonsil'' stated that "the diver- sity of theories which he had met with in his work had put him to much pains to form the conclu- sions at the end of his report; and he explained why he is not enthusiastic about any of them." I have made a research investigation concern- ing the functions of the f aucial tonsil. My first inquiry brought this answer, "If you will define what you mean by a normal tonsil, I will be pleased to reply." Therefore, a definition of what constitutes a normal tonsil became at once a necessity. My definition is arbitrary, but was essential as a base for inquiries. yiy inquiries were sent to every professor of physiology, physiological chemistry, biology, pathology, bacteriology and laryngology in the world of whom I had any knowledge. Some an- swered categorically ; some said that they had no knowledge; some sent literature; some made no reply. I also addressed all of the most noted voice physicists, voice trainers and voice users. The highest authorities expressed personal in- terest in my work, and they contributed with the greatest detail. Professors Frankel, Marage, Brieger, Von Levinstein, Von Gutzmann, Jacobi, Raoult and others courteously sent me copies of their original works, in place of routine answers. RESEARCH INVESTIGATION 5 And still others sent me personal communica- tions, not for publication but containing views of such general interest as to induce me to overstep just enough to permit these convictions to become known without divulging the privacy of their authorship. Among others, I received the following replies, from professors in Columbia University, Har- vard, Pennsylvania, Johns Hopkins, McGill and other universities: "I have delayed answering your letter until I might consult with some of our younger laryn- gologists thinking that they might help you. I find though, from what they tell me, that their facts as regards the physiology of the faucial ton- sil are too meager to be of any real service, though they admit that occasionally there is re- moval of what are subsequently found to be his- tologically normal tonsils." "There is at present a startling onslaught upon the tonsils, which often passes the bounds of reason. Whether the present attitude of the profession results in more good or harm I do not know, and I hope that you will find out." "I feel that it means much to know when not to operate upon the tonsils. And we must if pos- sible know their function and the evils of sacri- ficing that function." "I am very glad to know that you are investi- gating this subject, because I believe, as the re- sult of my own observation, that there is alto- gether too much operative procedure in relation to these important organs." "Particularly in nose and throat work there has 6 THE TONSILS AND THE VOICE been published a lot of fake work which is simply a matter of personal advertisement for the author, and it is beneath the contempt of the pro- fession to further countenance it." "Nothing offends me more than the indiscrimi- nate tonsillar slaughter that is just now having what, I hope, will be a very short-lived vogue, and I am exceedingly glad that your voice has been added to those 'discordant' ones of which that of Lermoyez is an encouraging example." "It seems pathetically strange to me that so many educated and experienced men can be led so easily and so far astray from the paths of common sense surgery and pathology by the hue and cry of a lot of raw and unbalanced fanatics." "I have done many hundreds of tonsillotomies, never a tonsillectomy. I agree with Chiaris terse statements. I hope the 'ectomy' fad will soon be buried without mourners." The authorities at the above mentioned univer- sities, from whom I received the foregoing re- sponses, evidently do not grant carte blanche permission to their students for the promiscuous performance of tonsillectomy. Among the hundreds whom I addressed, only one medical professor refused to answer, and just one singing teacher took time to write (from Paris) that she had not time to reply. As a result of my research, I will present some facts that show an important relationship of the faucial tonsils with science, surgery, speech and song. CHAPTER II ANATOMY OF THE TONSIL. THE NORMAL FAUCIAL TONSIL. In the pursuit of my research into the physi- ology of the faucial tonsil, it was necessary to de- fine what I meant by a noi'm al organ, in order that responses might be based upon identical condi- tions. No complete or satisfactory definition of a nor- mal faucial tonsil is to be found in any textbook. DEFINITION. By the term, normal fau- cial tonsil, I mean the tonsil situated in the fau- ces, between the anterior and the posterior pala- tine arches, in healthy condition, and of such size as not to project beyond the lines of the palatine arches, nor press upon surrounding tissues, of a size so small as not to interfere with the perfect anatomical outlines of the walls of the pharynx. Upon this definition my inquiries were made, and responses received from Von Schr otter. Von Chiari, Schviiegelow, Earth, Escat, Moure, Cas- tex, Luc, Van Baggen, Luhet-Barhon, JLer- moyez, Massei, St. Clair Thomson, Gleitsniann, Miller, Loewenherg, Mackenzie, Gleason, Holmes, Casselherry, Laniperti, Sehastiani, Shakespeare, De Reszke, Lehmann, Sabatini, Cappiani, Mott, Curry, White, Rogers, Von Klenner, Sweet, Rice, Hubbard, Schumann- Heink, Nordica, Tetrazzini, Bond, Bispham, and others. My definition therefore having been accepted 8 THE TONSILS AND THE VOICE and responded to, may he considered as a reason- able definition of a norinal faucial tonsil. Loewenberg says : "By normal tonsils, I mean tonsils of a healthy color, those not enlarged in length or thickness, and showing no evidences of chronic inflammatory processes." Semon speaks of "tonsils projecting under normal conditions nearly, or quite up to, or even a little beyond the palatine arches." The question of determining what is a normf^l tonsil is no longer difficult. THE NORMAL TONSIL possesses a nor- mal histologic structure. The microscope will determine this without question. Tonsils of nor- mal structure vary in size, in different persons. A large tonsil in a large mouth is as natural as a small tonsil in a small mouth. A tonsil of normal histologic structure may be of abnormal size; it may be so large as to interfere with the natural functions of the pharynx, or it may be too small to properly perform its own functions. ANATOMY OF THE TONSIL. The anatomy of the tonsil becomes more important as research progresses. Formerly, the word "ton- sil," meant the faucial tonsil; the organ which Escat and other continental ^vriters name the palatine tonsil. But in the light of modern re- search, the term tonsil is now used to designate various collections of lymphoid structures that exist in the post nares, pharynx, larynx, and at points throughout the alimentary canal ; so that it now becomes necessary to specify the particular tonsillar organ to which you refer, as the pharyn- geal tonsil, the faucial, the lingual, the laryngeal. |J1\ Hard Palate. '^\l*^l\ Soft Palate. Pharynx. Tongue. Plate showing position of the tonsils. ANATOMY OF THE TONSIL 9 and so on. Without this distinction, it is impos- sible to discuss intelligently the subject of tonsils, because these organs, while identical in histologi- cal structure, are not identical in their gross anat- omy. Neither are they identical in their physio- logical function. A remarkable anatomical formation is Walde- yer's lymphatic ring (described in works on anat- omy), consisting of the two faucial tonsils, the two tubal, the lingual, and the pharyngeal tonsil, the last of which is sometimes unfortunately called ''adenoids." Connected with Waldeyer's ring, there is another, a secondary ring, formed of similar hut smaller bodies: and yet beyond this secondary ring there are countless thousands of still smaller bodies, microscopical in size, scat- tered about in the post nares, mouth, pharynx and larynx. HISTOLOGY.— The histological constitu- tion is the same for all the pharyngeal lymphoid tissue. The pharyngeal, tubal, lingual and fau- cial tonsils are absolutely identical in their histo- logic constitution. Koelliker, Luschka and Frey have proved these observations. (Mar age.) The organs of the Waldeyer's ring consist mainly of what Frdnkel calls nodules and tonsils. He defines a tonsil as "an organism surrounded by connective tissue which consists of adenoid tis- sue with genuine follicles around the fossula. "Formerly large pockets in the tonsils were called follicles, but the Anatomical Society now calls the large cavity a fossula, and has reserved the name follicle for the microscopic formations. "The nodule is a conglomeration of lym- 10 IHE TONSILS AND THE VOICE phatic tissue with genuine follicles. The smaller noduli are discriminated from the tonsils by hav- ing a smaller fossula and are less complicated in structure. In the pharyngeal tonsil the fossulae are not as straight and simple as in the faucial." (Frdnkel.) "Lymph nodes are structures so placed in the course of the lymph vessels that the lymph, in flowing toward the larger central tnmks, passes through them, undergoing a sort of filtration as it percolates through the traheculae of the lymph sinuses. There is considerable variation in the situation, number and size of lymph nodes, in special regions of the body." (Dela field and Prudden.) These bodies, according to size, may be desig- nated as tonsils, nodes and nodides. Von Levinstein "considers the tonsil to he an organ which consists of a number of lymphatic nodides, between which there is a variable amount of tissue [which latter in case of a hyperplasia of the organ, also shows adenoid character.)'' In the faucial tonsil ten or twelve round or oval nodules are rather regularly grouped imme- diately below the walls of the fossulae. They consist of an extremely delicate reticulum of con- nective tissue. The lymph nodules surround a number of fossulae. These fossulae are lined by a mucous membrane having the ordinary func- tions of other mucous membranes so far as known. "'Stohr states that small gaps exist between the normal epithelium of the surface of the tonsil crypts, but Frdnkel and other distinguished in- vestigators den}^ this statement." (Levinstein.) yVNATOMY OF THE TONSIL H "When we remove a particle of muciiis from the surface of the tonsil of a person in good health, we always find that it contains leucocytes, especially microphages, filled with micro-organ- isms of all kinds." (Metchnikoff.) "The lingual tonsil sometimes overlaps and blends with the faucial tonsil. The lingual ton- sil atrophies at fourteen years of age, and after it has disappered, the base of the tongue becomes carpeted over with adenoid follicles." (Escat, Moure.) Von Levinstein says : "We find a great many mucous glands in the nearest surrounding neigh- borhood of the pharyngeal tonsil, and that these glands mainly send their exits not through the substance of the tonsils to their surface, but rather directly to the surface of those organs to which they belong — the soft palate and the fau- cial arches. To further illustrate this observa- tion, I have shown that the group of acinous mu- cous glands, in the well-known figure by Luschka of the faucial tonsil, does not belong to the fau- cial tonsil proper^ but to its neighborhood. Be- sides I have described the tonsil where it is impor- tant to observe that a great many mucous glands send their channels into the fossula of this organ — the tonsilla laryngis. "The anatomical structure of the faucial and pharyngeal tonsils contradicts the theory that the object of these tonsils should be to produce a slimy secretion." "The anatomical picture of the ordinary lym- phatic gland differs absolutely from that of the 12 THE TONSILS AND THE VOICE tonsils. Aside from the fact that the ratio of connective tissue and adenoid tissue in both or- gans is different, there also are missing in the lymphatic glands, especially those organs which give to the tonsil its characteristic structure, the fossula. Therefore, we can never identify the tonsil as simply glands, but we have to consider them as different organs." SPECIAL ANA TOMY. The faucial tonsil has remarkable anatomical characteristics not possessed by the pharyngeal and other tonsils. ( 1 ) Regarding situation. It occupies an ana- tomical situation quite segregated from the other bodies that compose the Waldeyefs ring. Be- cause of this segregation, and the possession by this tonsil of many features not possessed by any other body in the ring, it might well be separated from ring consideration. (2) Regarding surroundings, (a) ''There are no lymphatic sinuses around the tonsil." (Retterer, Labbe and Sirugue, Hodenpyl, Most.) (b) "The lymph current near the tonsil is less active than that of the pharynx at some distance." (Labbe, Hodenpyl.) (c) "Injections made into the neighborhood of the tonsil (not even into the tonsil itself) do not spread like those made into other parts of the nasopharynx." {Retterer, Labbe and Sirugue, Hodenpyl, Most, Jacobi.) "In cases of membranous throat disease (diph- theria) , whenever the membrane is limited to the tonsil there is little or no glandular swelling in the neighborhood, nor constitutional symptoms. ANATOMY OF THE TONSIL 13 It would therefore appear that the tonsil and its immediate neighborhood are rather inferior, in regard to facilities for absorption to the rest of the pharynx and nares." (Jacohi.) Hodenpyl "found that the tonsils in a normal condition absorb neither liquid nor solid particles from the oral cavity." (f) ^^The group of acinous mucous glands in the well-known figure hy Luschka of the faucial tonsil^ does not belong to the faucial tonsil, hut to its neighborhood." (Levinstein.) (g) "The function of secreting mucus does not belong to the faucial tonsil, but to the glands in groups outside of it." (Labbe and Sirugue.) (h) "The greater part of the lymph vessels are efferent, the smaller afferent." (Groher.) (i) "It has not been proved, and it will be very difficult to prove, because it is impossible to say from the histologic picture, which are the afferen- tia and which the efferentia lymphatic vessels of the tonsil." (Levinstein.) (3) Regarding external surface. (a) The external deep surface of the faucial tonsil is en- cased in a firmly adherent, strong, fibrous sheath. Nothing like this capsule surrounds any other lymphatic body. (b) "Contracting muscular fibres are inserted into the sheath derived from the superior con- strictor muscle of the pharynx." (Koelliker, Ja- cobi. Sett.) I am forced to believe that the strong musculo- fibro-aponeurotic sheath, that covers the faucial tonsil, deserves more serious consideration than it 14 THE TONSILS AND THE VOICE has yet received from anatomists and physiolo- gists. So dense and tendinous and strongly adherent is this capsule that one may consider the organ as being armor-plated. (c) It is not perforated by lymphatics, nerves, arteiies or veins. (d) "The sheath sometimes sends a network of fibrous tissue as outrunners along the walls of the blood vessels which prevents them from readily contracting after being cut." (Hodenpyl, Ja- cobi.) (e) "The sheath sends connective tissue into and between the folds of the mucosa.'' (Jacobi.) (f) "Thick or thin, the fibrous sheath is firm and solid. That is why abscesses of the tonsil do not open into the maxillopharj^ngeal space." (Jacobi.) (g) This dense covering of musculo-fibro- aponeurotic structure cannot be looked upon as an atavism; 7ior is it conceivable to view this con- stant and definite structure that envelops the tonsil, receives muscular fibres from the superior constrictor muscle, extends its fibrous outrunners along the walls of the blood vessels that run through the body of the organ and sends its con- nective tissue into and between the folds of the mucosa as a simple anatomical accident. These features are too constant to allow such interpreta- tion. Is it not reasonable to think that the develop- ment of the strong, musculo-fibro-aponeurotic sheath is a result of evolution to meet some phy- siological demand? ANATOMY OF THE TONSIL 15 The sheath' of the tonsil is always present. There must he some strong physiological reasons for the existence of this powerful anatomical con- trivance. What are they? Have the muscular fibres that enter the sheath no use? Why does the sheath send fibrous outrunners along the walls of the blood vessels and into the folds of the mucosa? Is swelling of the tonsil ever similar to that of erectile tissue ? Or ever due to muscular action ? Von Chiari, Moure, Frank E. Miller, Escat and others advise against the removal of the sheath in voice users. (h) Smaller nodules differ from the tonsil by having a smaller fossula, and less complicated structure. ( i ) ''The fossulae of the faucial tonsil are more straight and simple than those of the pharyngeal tonsilJ" [Frdnkel, Levinstein.) (j) The organ is of cartilaginous consistence and somewhat compressible. (k) The anatomical position of the organ is notable amidst a framework of muscles. It is both compressible and movable. It changes posi- tion both in swallowing and in phonation. In swallowing the palato-pharyngeus muscle draws the palate down upon, and the tonsil in upon the food, to force it downward. The tonsil is also pressed inward in the act of swallowing by the su- perior constrictor and drawn inward by the pala- to-glossus. There is a ceaseless and probably in- determinate, though important play, upon the faucial tonsils, by many muscles, in speaking and 16 THE TONSILS AND THE VOICE in singing. The faucial tonsil has probably more mechanical than physiological functions, I consider it highly important to note that while the faucial tonsil changes with age in char- acter^ size, shape and consistence, it never disap- pears, but always remains to give to the walls of the pharynx a needed solidity. The faucial tonsils resemble the cartilages of the larynx and trachea. But they are softer. The anatomical and func- tional advantages of the firmness they impart to the pharyngeal wall, may be readily conceived. They serve a purpose that hard, unyielding osse- ous formations would not serve. They are mo- bile, and compressible: and by multiple move- ments and innumerable re-adjustments in posi- tion, have undoubted influence and effects upon the acoustics of the oral cavity, and upon the reso- nance and timbre of the voice. (4) Regarding Internal Structure, (a) The vascularity of the faucial tonsil is slight. (b) "The periphery of the lobules is more vas- cular than the centers." (Retterer, Labbe.) (c) "It has little or no connection with neigh- boring lymphatics, through its surface." Grober demonstrated the comparative absence of a direct communication of the tonsil with the rest of the body through the surrounding fibrous capsule. His injections of the tonsils accumulated in large quantities under the capsule. Thus it happened that the organ was often enlarged to a consider- ible extent. The adipose tissue surrounding the ;onsil seems to be rather devoid of lymph vessels. (d) Von Lenart has proved the existence of a iirect communication betwen the lymphatic ves- ANATOMY OF THE TONSIL 17 sels of the nose and of the tonsil; and also of a di- rect communication between the two f aucial ton- sils. ( e ) Retterer, Krause, Lahbe and Sirugue, and Hodenpyl^ have proved the existence of a capil- lary network of lymphatic vessels occupying the entire follicular mass of the faucial tonsil, consti- tuting a system of closed lymphatic canals which do not open into the connective tissue reticulum by stomata nor by gaping extremities. (f ) Labbe and Sirugue have shown the origin of these lymphatic vessels in the reticulated cov- ering, whete they are represented by spaces, not partitioned, and covered by an endothelium. These lymphatic spaces are continued by the cap- illaries and the lymphatic vessels, furnished with a complete wall, which meet each other in the con- junctive envelope of the tonsil. (g) ''Retterer proved the existence of clear centers in the follicles of the tonsils, but did not admit their identity with the germinating centers of the follicles found in the ganglions." [Labbe and Sirugue. ) (h) "The follicles in their centers have a lighter zone. These are producing centers, be- cause the production of lymphocytes has been ob- served." (Frdnhel. ) (i) "The germinative centers have certainly the same functions as those of the ganglions which are, as Flemming has shown, the localities for the production of leucocytes. There is in the germi- native centers an incessant cellular renovation." (Labbe and Sirugue.) (j) "Ehrlich and Flemming have in fact 18 THE TONSILS AND THE VOICE shown the existence of several kinds of leucocytes, upon each of which devolves a different role, a particular function in the defense of the organism against microbes and toxins." {Labbe and Sirii- gue.) (k) We find in normal faucial tonsils always follicles with cell producing centers. (1) Retterer proved that the periphery of the lobules is more vascular than the centers. (m) The vascularity of the organ is slight. (n) The nerve terminations in the tonsil are not well known. The faucial tonsil varies in not only size, shape, consistency and color, but in weight and general appearance. It varies in different individuals, and the two tonsils often vary in the same person. The anatomical characteristics constantly change from infancy to old age. It does not remain for many years the same ; but it never entirely disap- pears. They are largest from three to eighteen years of age. Not so large under three j^ears. After eighteen years of age, thej^ diminish in size, their surface becomes smooth, and their consistence firmer and more cartilaginous. They frequently enlarge and annoy during childhood; they gen- erally cease to annoy beyond puberty. "Exposure and many diseases, change the sur- face and the structure of the tonsils. Cell infil- tration and cicatricial tissue render absorption less possible. Blood and lymph vessels are compressed and undergo atrophy. That's why in advanced life the tonsil gets harder and smaller, and infec- tions become less." (Jacohi.) ANATOMY OF THE TONSIL 19 The more highlj" complex tonsillar tissue oc- curs only in the highest type of animal develop- ment. If tonsils have no physiological function and are only an atavism, they likely would have disappeared, instead of continuing to reappear, in a simple form in the lowest vertebrate, to the high- est and most complex form in man. Surgical Anatomy. H ay mann sa.ys: "Opera- tions on the tonsils are looked on as being without danger. However, bad results do occur. Severe bleeding may follow operations on the tonsils. When they bleed too much, they call them hemo- philics." Mei'kel says, that "the veins between the mus- cles of the pharynx and the outer fascia form a strong irregular network, called the plexus pharyngeus. Injuries and bleeding from this network are not rare in excision of the tonsils." Von Chiari mentions, that "in some cases you can see at the side walls of the pharynx a large vessel pulsating, the arteria pharyngea ascendens. In such cases it is possible to injure this large ves- sel." Dupuy states, that he "has several times ob- served a vessel the size of a crow-quill, super- ficially situated, and pulsating, coursing along the juncture of the posterior and lateral walls of the pharynx." I have seen this vessel. Angioma of the base of the tongue is common. Networks of varicose veins are frequently seen at the base of the tongue and in the walls of the fauces and pharynx. Delavan states, that "Both carotid arteries are behind the faucial tonsil, the internal carotid one 20 THE TONSILS AND THE VOICE and five-tenths centimeters, the external carotid two centimeters, distant from its lateral periph- It is not uncommon for arteries and veins to follow anomalous courses and to be found out of their natural positions. The vessels in the neigh- borhood of the tonsil form no exception to this statement. In fact, the internal and external carotids with their branches are particularly crooked and irregular in their courses. Gray says, that "The internal carotid artery is remarkable for the number of curvatures that it presents in different parts of its course." The external carotid sometimes curves from its regular course inwardly toward the median Hne behind the tonsil. Branch arteries in the region of the tonsil are frequently enlarged. "Abnormal distribution of blood vessels is a more frequent cause, of hemorrhage than hemo- philia," according to Barrell and Orr. "In all operations upon the tonsil we should remember the close proximity of the internal car- otid arteiy. Instances have occurred in which this artery has been wounded during the opera- tion of scarifying the tonsil, and fatal hemorrhage has supervened." (Gray's Anatomy.) This statement is repeated in each and all edi- tions of Gray's Anatomy. In the 17th edition. Gray says, "The profuse bleeding which sometimes follows an operation for the removal of the tonsil is very seldom due to injurj^ of the internal carotid but to injurj^ of the ascending pharyngeal or r-ne of the palatine branches." ANATOMY OF THE TONSIL 21 "The arteries that supply the tonsil, from which dangerous bleeding also occurs, are the dor- salis linguae, the ascending palatine, and the descending palatine, from the external carotid." Schmiegelow has reported the case of an im- mediate death from injury of the carotid, by cur- ette, due to an anomaly in its course. William H. Pancoast, at his Clinic, at the Medico-Chirurgical College, Philadelphia, in cut- ting out a tonsil cut the internal carotid artery. ( Reported by George F. Steveson. ) Treves, in his Surgical Anatomy, reports a fa- tal accident from perforation of the ascending pharyngeal artery. Haymann reports injury of the ascending pharyngeal. Haymann says : "If the cavity of the mouth is highly arched and narrow, injury of the post nares cannot always be avoided in excising the tonsils." "The vomer has been injured. And injury of the back part of the nasal septum may cause severe bleeding." "Zarniko accidentally cut off the greater part of the back horns of the turbinated bones." Von Chiari states that "The atlas bone may be injured in enucleation of the tonsil." CHAPTER III PHYSIOLOGY OF THE TONSIL. To assign a physiological role to an organ, when its anatomy has not been clearly defined, is an injudicious and dangerous assumption. The anatomy of the triangles of the neck, or of the femoral region are not more complicated than the anatomy of the area composing the pharynx ; and the physiology of the pharyngeal region is vastly more complicated than that of any other. The anatomy of the pharynx is not thoroughly understood ; and its physiology remains unsolved. On account of the great difficulties naturally en- countered in this field, as for example, the appar- ent impossibility of determining the action of certain muscular fibres that always become lost in their final distribution, the details in the anat- omy and physiology of the phaiynx may never become known. Furthermore, clinical opportuni- ties will rarely be numerous enough to decide the exclusive or partial port of entry of a specific germ or poison into the circulation from the phar- ynx, as we are seldom in a position to separate the various anatomical structures from their neighbors during the acute invasion or the rapid progress of a microbic or toxic poison. The fauoial tonsil is a natural organ. Some questions pertaining to its physiology are settled. Judgment upon others is so uniform as almost to force conviction ; and some are unsolved. In the determination of its functions, it is par- 22 PHYSIOLOGY OF THE TONSIL 2a ticularly necessary to carefully separate, and to critically examine, the different anatomical struc- tures composing the Waldeyer lymphatic ring. It is also well to observe the anatomical position of the f aucial tonsil, and its relationship to neigh- boring organs. When we speak of the f aucial tonsil, we must refer alone to this organ. When we speak of the phaiyngeal tonsil, or the laryngeal, we must not think of the faucial, for these three tonsils have different functions. And when we speak of the Waldeyer ring, then our speech must represent a composite thought of composite bodies possessing varied functions. SPEAK ACCURATELY. ASSUME NOTHING. The faucial, pharyngeal and laryngeal tonsils differ in their functions as well as in their structure. Waldeyer's lymphatic ring is an important and complex physiological appa- ratus. The ensemble of adenoid bodies composing the Waldeyer ring situated at the entrance of the re- spiratory and digestive passages, constitutes the first line of defense against microbic invasion. It is composed of the pharyngeal, faucial, lingual and tubal tonsils. The first line of defense is sustained by a second, represented by the tribu- tary ganglions of all the pharyngeal lymphatic network so well presented by Escat, in his work on Les Maladies du Pharynx. FUNCTION OF LYMPHATIC GLANDS. The function of the lymphatic glands is to act as a sort of filter for the lymph. Should the lymph contain any foreign substance 24 THE TONSILS AND THE VOICE or toxic material, these tend to be stopped within the gland, not only on account of the anatomical peculiarities of the structure, but also on account of the cellular hyperplasia that results from the irritation. This barrier action, as will be readily understood, is a most important one. The lym- phatic glands are set like sentinels to guard all the orifices and channels of the body. This func- tion of the glands has been clearly demonstrated by Bizzozero, Ruffer and Ribbert. Lymph nodes are structures so placed in the course of the lymph vessels that the lymph, in flowing toward the larger central trunks, passes through them, undergoing a sort of filtration. If this fact be borne in mind the lesions of the lymph nodes, which are in the majority of cases secondary, are much more readily understood. "Particles of pigment, cells from malignant tumors, dead or disintegrating cells, red blood- cells, bacteria, etc., which in any way get into the lymph vessels, are carried along until a lymph node is reached, and here they are, in part at least, deposited among the trabeculae of the si- nuses, or are taken up by phagocytic cells, while the lymph passes on and out of the efferent ves- sels." (Delafield and Prudden. Teoot-hooh of Pathology, Eighth Edition, 1907.) Some years ago Stohr demonstrated that the wall of the intestine, and especially the tonsils and other lymphoid organs, "ire traversed by an enormous number of leucocy t'es, which exercise a kind of migration towards the cavities containing micro-organisms. This continual and normal condition is often termed Stohr^s phenomenon. PHYSIOLOGY OF THE TONSIL 25 "When we remove a particle of mucus from the surface of the tonsils of a person in good health we always find that it contains leucocytes, especially microphages, filled with micro-organ- isms of all kinds." (Metchnikoff , Immunity in Infective Diseases, 1905.) "The leucocytosis of infectious diseases may be regarded as the effort of the blood-producing organs to protect the blood and tissues by means of leucocytes against the invasion of micro-organ- isms and against the action of toxins in the circulation." {Dela field and Prudden.) Of the protective action of the Waldeyer ring, with its secondary tributary line of defense, it has been said, that the pathogenic agent must then traverse, theoretically, two stages before invading the general circulation, the one pharyngeal, the other ganglionic. This apparatus of physiologi- cal defense may at any time be inferior to its task, and powerless to arrest the microbic inva- sion and the toxaemia either by reason of its con- stitutional insufficiency or by reason of the exces- sive virulence of the enemy with which it enters into a struggle. The pharyngeal tonsil is a most important organ in the first line of defense of the system against microbic invasion. Hypertrophy of the pharyngeal tonsil consti- tutes the affection commonly known under the name of "adenoid growth" The process of pha- gocytosis long sustained will bring on chronic hypertrophy. Enlargement of the pharyngeal tonsil {"" ade- noids") being due to an increase in the process of 26 THE TONSILS AND THE VOICE phagocytosis, removal of this organ tvhile in the condition which represents the height of its bac- tericidal energy is a vital mistake. The line of defense against microhic invasion is thereby broken. Westenhoffer, in a most exhaustive research on the ''Pathological Anatomy and the Way of In- fection in Spinal Meningitis'' has given absolute proof that the "infectious germs enter the or- ganism through the pharyngeal tonsil and in no other way." "In all cases," he says, "the pharynx was in a condition of acute swelling and inflammation. This swelling extended in all cases down to the pharyngeal wall. In all cases the orifices of the Eustachian tubes were equallj^ swollen. In all cases the anterior part of the nose was free from inflammation. The increased mucus secretion was always in the superior 7iasal region, never in the anterior part of the nose. The faucial tonsil and arches appeared to be reddened or swollen in less degree; sometimes hardly at all. The phary7igeal tonsil is swollen. In all cases this tonsil was in a state of acute swelling and redness. I believe that the disease germ finds its entrance into the tissue of the body from the posterior naso-pharjTix, es^Decially from the pharyngeal tonsil. / have in cases of just beginning menin- gitis seen where the disease begins and it always begins at the hypophysis just above the sella tur- cica. We can judge from this that the menin- gitis infection gets there through the sphenoidal body or via the blood vessels which pass from the naso-pharynx to the sella turcica. It is impor- PHYSIOLOGY OF THE TONSIL 27 tant that in ten cases an inflammation of the sphenoidal cavities has been seen." (Westen- hoffer, Berliner Klinische Wochenschrift, June 12, 1905.) Westenhoffer has proved that the pharyngeal tonsil and the adjacent lymphatics act as a por- tal of entry for the germs of cerebrospinal meningitis. He considers the faucial tonsil as little or not at all involved as a port of entry for the particular germs of cerebro-spinal meningitis. He "considers the pharyngeal tonsil to he a protective organ, active as a barrier to the en- trance of germs, through the process of phagocy- tosis, except when by reason of extreme virulence and great numbers of the infective germs this protective influence is overcome." The pharyngeal tonsil as we have now seen is a protective organ; and in some circumstances an avenue of entrance for infective germs, a filtra- tion organ for material that enters by way of the nasal passages. Von Levinstein "has described the tonsil where it is necessary to observe that a great many mu- cous glands send their channels into the f ossula — the tonsilla laryngis. The function of this tonsil consists in the production of a slimy secretion to keep the vocal cords limber." "Stohr discovered that an interrupted immi- gration of leucocytes takes place from the follicle and adenoid tissue through the epithelium into the fossulae and buccal cavity. The phenomena described by Stohr present themselves under va- rious aspects: sometimes as a passing of poly- nuclear leucocytes through the epithelium, some- 28 THE TONSILS AND THE VOICE times as a multiplication of epithelial cells caused by irritation of the mucosa. And finally per- haps sometimes of the penetration of some lym- phocytes coming from the reticulated skin. But in all these hypotheses, the signification of the phenomena is identical; it is always a phenome- non of cellular reaction, having for its aim the defense of the mucosa against the invasion of mi- crobes which vegetate at the surface of the tonsil. This phenomenon is in no way special to the ton- sillar mucosa ; it is produced at the level of all the mucosae and has already been well studied and described by Cormil and Ranvier, in the buccal mucosa." {Labbe and Sirugue.) "There is in the germinative centers of the ton- sil an incessant cellular renovation. Stohr admits the passage of leucocytes through the epi- thelium into the buccal cavity." (Labhe and Sirugue, ) "The phenomena of absorption at the level of the tonsils has been studied experimentally. In HodenpyVs experiments, the epithelium of the tonsils prevented absorption, which only becomes possible if it is destroyed, or if the substances are introduced under the epithelial bed, and even under these conditions, the absorption is very slow. Hodenpyl experimented with fatty sub- stances, powders and colored solutions." {Lab- be and Sirugue.) "The epithelium has the same protective role at the level of the tonsils as at the level of the buccal mucosa. The crypts augment its extent." "Even in the normal state the epithelium is PHYSIOLOGY OF THE TONSIL 29 always more or less irritated, and above all, at the bottom of the crypts and we have seen that it is the seat of the incessant phenomena of cellu- lar renovation. This epithelial irritation is due to the presence of dust, or small foreign bodies which penetrate into the crypts; it is due above all, to the existence at the surface of the tonsil of pathogenic microbes, which are found constantly in the normal state. These microbes, although in the crypts, are on the exterior of the tonsil, and it is the defense reaction of the epithelium which prevents their penetration." "It is only where the epithelium is destroyed that the microbes penetrate and in such cases they rarely pass beyond the conjunctive bed; it is only in the case of the complete destruction of the epithelium that they may be found in the follicle. The leucocytes have not solely a pha- gocytic role, in regard to microbes, but they de- stroy also their toxins in producing antitoxins and divers substances; nucleins and oxydases, which have positive chemico-toxic properties in regard to white corpuscles and exalt their vital- ity." (Lahbe and Sirugue.) "Tubercle bacilli reach the lungs by the bronchi or via the blood vessels. Valland claims that the infection of the lungs can occur via the tonsils and infected glands of the neck. Many authors claim that healthy tonsils do not allow the en- trance of bacteria." {Groher, Die Tonsillen als Emtrillspforten filr Krankheitsneger^ besondes filr der Tuberkelbazillus.) Acute catarrh of the tonsils shows increased infiltration with leucocytes, which causes enlarge- 30 THE TONSILS AND THE A'OICE ment of the organs, also increased amount of lymph in the intercellular spaces. The increased exudate is an agreeable medium for many parasites, therefore inflamed tonsils are suited for the settling of the microbes. The microbes having entered the tonsils are mostly destroyed because the serum kills them. The power of the leucocytes as phagocytes kills them also. Packard claims that the microbes of the acute inflammator}' rheumatism are streptococci weakened through the action of the tonsils,, other- wise we would see septic diseases oftener. "It is also possible that the microbes enter the system through the blood vessels." (Grober.) "The tonsils seem to he a less favorite settling place for tubercle bacilli than the lymph glands for ice find scrofulous glands oftener than in- fection of the tonsils. The latter see?n to sen'e as an entrance portal for the tubercle bacilh." (Grober.) "The more radical prophylaxis would be to remove all tonsils wliich is not possible without a serious operation, and even then many equiva- lent parts of the hmiphatic throat ring would be left to take the role of the tonsils." (Grober.) Another question would be whether the chron- ically diseased tonsils should not be removed. "Many authors have considered diseased tonsils as more liable to microbial infection, than healthy ones. If that «■ true, it is not proven.'' ( Grober. ) "Besides the medical science shows that the entrance of microbes into the system does not always produce the disease. It is important how strong the defensive processes of the body are. PHYSIOLOGY OF THE TONSIL 31 Therefore, infectious diseases are mostly consti- tutional diseases." (Groher.) Has the faucial tonsil a protective mechanism to protect itself against infection? Or, does this organ serve as an entrance for most infections which attack the general system? Two theories, which concern the physiological function of the tonsils, consider chiefly the be- havior of these organs towards infections. One theorj^ saj^s that the tonsils through a protective mechanism, are protected against infection — ^the theory of Brieger and Goerke. The other theory says that the tonsils offer no resistance at all to any infection, and that they sei'^'e as an entrance for most infections which attack the organism. Brieger shows that the elements of the adenoid tissue are not leucocytes, but lymphocytes, and that to these latter the faculty of active movement has to be denied, as it is impossible, Brieger saj^s, that "the lymphocytes enter the epithelium on their own accord. On the other hand, it can be proven through the microscope that lymphocytes in lesser or greater degree are always present in the epithelium of the tonsils. We have to assume a vehicle which carries the Ij^mphocytes from the adenoid tissue; this vehicle," according to Brieger, "is the lymphatic juice which fills all crevices between the tissue and which gets to the surface through the finest canals. The cause of the movement of the lymphatic current is to be found," according to Brieger and Goerke, "in a difference of pressure in the afferent lymphatic vessels and the free surface. Increase of blood 32 THE TONSILS AND THE VOICE pressure increases the force of the Ijrmphatic current. Therefore, if the blood pressure is in- creased, the lymphatic juice flows stronger, and quicker through the epithelium, and carries along a larger amount of lymphocytes out of the adenoid tissue." "The stronger the lymphatic current flows through the epithelium, the larger the amount of the lymphocytes, the more the epithelium will have to suffer." But Brieger and Goerke do not speak of a destruction of the epithelium in such a case. "But," according to these authors, "the continuity of the epithelium in a particularly strong lymphatic current is only temporarily torn by the strong lymphatic juice, and the con- tinuit}^ is re-established immediately as soon as the intensity of the lymphatic current is dimin- ished." "Beside the theory of Brieger and Goerke, that the mechanism of the tonsil furnishes a protec- tive function, there is another protective theory, that of Gullandj, Kilmmel and JLindt. Ghillund believes that the tonsils are enabled to hinder germs from entering deeper into their substance and thus to work against an infection of the organism. Gulland, Kiimmel and Lindt say that the tonsils can do this through the leucocytes which possess amaeboid motion as well as the faculty of phagocytosis." "Gulland states that as soon as an infectious germ gets into the depth of the organ, leucocytes devour it and bring it back to the surface." ''Brieger opposes this opinion, showing that in the tonsils we have no leucocytes, but mainly PHYSIOLOGY OF THE TONSIL 33 lymphocytes, which have no amaeboid motion. Brieger ascribed the power of the tonsils to pro- tect themselves against infection to the fact that the tonsils have a continuous lymphatic current running from the inside to the outside of the organ. This current works against the entrance of germs, as the current assisted by the lym- phocytes washes the infectious germs away. Goerke mentions the observation of Frdnkel that children with hyperplastic tonsils are less easily affected by diphtheria than children with normal tonsils. Goerke thinks that the bacteria enter the tonsils, not through the parenchyma of the tonsils, but through the other mucous membranes of the pharynx." "In this view, the researches of Menzer are of great interest, which prove that just in that dis- ease wherein the entrance of the cause through the tonsil was considered assured, acute articular rheumatism, the infection took its way through the adjoining tissue, while the tonsils only be- came diseased secondarily from the inside. Goerke claims as a proof for his theory the ex- planation of Frdnkel, given for angina trau- matica, that infectious germs in the nose (after nasal operations ) can be transported via the lym- phatic vessels to the tonsils and there produce local symptoms." "We see," Goerke says, "in the Waldeyer ring, a mechanism in action which in a nearly perfect way makes the tonsils the most important protective organ in the body, and in this sense we dare speak of the function of the tonsils." "Finally, Goerke calls attention to the fact that 34 THE TONSILS AND THE VOICE it has been attempted to assist the active physio- logic moment in the tonsils, by means intended to accelerate the lymphatic current, that is, by the suction treatment of the tonsils in different in- flammatory processes of these organs." (Levin- stein.) '' S choenemann says, the tonsils very rarely be- come diseased primarily, but almost always sec- ondarily. According to Schoenemann, acute tonsillitis has to be considered as an inflammation following an inflammation of the neighboring tissue. The angina fossularis, according to Schoenemann, in most cases is caused by infec- tious germs which get into the tonsils via the lymphatic vessels from the primarily diseased mucous membrane of the nose and produce a secondaiy disease of the tonsils. Schoenemann mainly blames acute coryza as being the origin of angina, assuming that many infectious germs present on the affected mucous membrane of the nose reach the tonsils by the tymphatic vessels and produce acute inflammation of the tonsils. A proof that this opinion is right Schoenemann finds in the fact that he has often observed that angina (tonsillitis) often relapsing did not occur again after the nasal mucous membrane had been carefully treated." {Levinstein.) "The immigration of leucocytes from the in- side of the tonsil through the epithelium, as dis- covered by Stohr, at certain places is so strong that it is difficult to find the epithelium. By this discovery of Stohr the idea was formed that the tonsils represented an open wound of our body, PHYSIOLOGY OF THE TONSIL 35 SO that it was easy for micro-organisms to enter here into the tissue." "On the ground of Brieger's observations, it is generally assumed that leucocytes only occur occasionally, and that we have here mainly lym- phocytes." "The lymphocytes, as you know, have a nu- cleus with little protoplasm, while the leucocytes have much plasm and a certain amaeboid move- ment." "The lymphocytes do not possess this motion, and if lymphocytes pass through the epithelium, we have to assume that they are forced through by the lymphatic current which flows from the tissue through the epithelium. If we assume that the lymphatic current simply takes along the Ij^mphocytes like logs in the river, we have to omit the idea that we have here to consider an open wound hut that we have to learn to consider it a protective mechanism, for the micro-organ- isms have to swim against the current and meet cells which possess a certain phagocytosis. Therefore, the idea of Brieger that the tonsil is a protective mechanism has to be generally ac- cepted, and we cannot talk any more of the tonsil being an open wound." (Frdnkel.) ''A surface lesion must always be supposed to exist when a living germ or toxin is to find access. It looks rational to admit that where there is merely a surface lesion, though ever so slight, there may be an invasion into the tonsil. When, however, the vessels are exposed to pressure by newly formed cells or tissue, there is no invasion. 36 THE TONSILS AND THE VOICE certainly not beyond the tonsil itself, no gangli- onic swelling, no toxic poisoning/'' "It is even rational to believe that now and then, when tonsils, or what is more common, a single follicle, becomes inflamed, the very venous obstruction will exert the bactericidal influence of the stagnating blood serum/^ "Cell infiltration and cicatricial tissue render absorption less possible. Thus, even when the surface is broken, the tonsil must not be con- sidered as a sure port of entry for infectious germs. Whenever the membrane of diphtheria is limited to the tonsil, there is very little, or no, glandular swelling in the neighborhood. Dozens of years ago, I could prove that diphtheria, when limited to the tonsils, was least danger- ous. These clinical observations have stood the test of time and must be reckoned with." (Jacobi.) Thus the tonsils are proved to have little or no absorptive power when attacked by diphtheria. Schmiegelow looks upon the tonsil as a part of the protecting system, which is represented by all the lymphoid tissue to be found everywhere in the mucous membrane of the pharynx and naso-pharynx. Escat believes that the faucial tonsil has the function of phagocytosis as studied by Metchni- Massei believes the faucial tonsils have a biologic function similar to the lymphatic tissue which forms the so-called Waldeyer ring. "The question, what object have the lympho- cytes which are forced through the epithelium? PHYSIOLOGY OF THE TONSIL 37 leads to the opinion that it must be a certain safety valve action which prevents the continuous formation of lymphocytes placing the lymphatic vessels under too high a pressure. The epithe- lium itself does not need for this process to have large channels. If, in the imniigt^ation of white corpuscles through the walls of the blood vessels 7iO holes are made in those vessels, neither is it necessary that a hole he formed in the epithelium of the tonsil when lymphocytes pass through'' (Frdnkel.) "The infection from the outside of the tonsil is the same as on other j)arts of the body. The infection of the tonsil from the blood has not been sufficiently considered, at least I do not find it often enough in the ideas of physicians. If one injects into the veins of rabbits colored particles we can show them in the tonsils. After certain operations in the nose, in many cases two days later, angina (tonsillitis) occurs." "If we try to understand these observations we must assume that microbes from the nose have entered the tonsils, that the operation in the nose has opened the door through which the micro-organisms could get into the lymjihatic circulation to affect the tonsils. If you inject Chinese Tusche (black color) under the lining of the nose of rabbits, dogs and hogs, you can show in a short while these color particles in the tonsils. We can think now that angina is caused from distant organs, especially from the nose, and perhaps the preparatory coryza which we often find in angina is because of the angina it- self. This idea affords for infectious diseases 38 THE TONSILS AND THE VOICE another consideration. We can now not think any 7nore that this is caused by microbes advan- cing through the mouth/' "We observe angina in many secondary diseases. One of the best known is the periton- sillar abscess. The micro-organisms invade the tissue surrounding the tonsils." "It is important to understand that the tonsils can be infected from the blood and the lymjjhatic vessels with tuberculosis, just as from the surface, but I believe that most infections which we find in the tonsils are secondary, mostly from the nose. These cases belong mostly to the latent tuber- culosis. Children are comparatively healthy." (Frdnkel.) "The protective theory of Brieger and Goerke would seem to have a great deal of probability if it were proven absolutely that the lymphocytes have not the power of locomotion. So far this does not seem to have been proven. The current has not been seen by anybody or proved by any- body. In the current theory at this time we can see nothing but an erudite hypothesis." (Levin- stein. ) "There is no doubt that a great number of the ordinary anginas have to be co7isidered as a pri- mary acute infection of the tonsils. Of course, the tonsils become diseased secondarily, like the one we see in secondary lues and condylomata. I have also to mention the well-known angina, following endonasal operations." "In these diseases, called by Frdnkel angina traumatica, the infection occurs in this way, PHYSIOLOGY OF THE TONSIL 39 namely, that the germs are transported from the nose to the tonsils and produce local symptoms." (Levinstein.) ''Btieger assumes a current which permanently flows through the whole organ from the inside to the outside and which carries along more or less lymphocytes. If this current is very strong the number of lymphocytes is larger and the alter- ation of the epithelium more pronounced." "The insult to the epithelium by the current loaded with lymphocytes does not produce the effect that microbes get more easily into the tissues, as the intervals in the epithelium are con- stantly filled with the current and the possible lesions to the epithelium are never lasting defects but disappear as soon as the intensity of the current is diminished. But nobody has seen this current and that the lesion of the epithelium is only transitory has not been proven.'" "We are not entitled to see in the histologic picture of the tonsil a proof for the existence of the current flowing from the inside to the outside of the organ." "There is not a single experiment which proves that the tonsils possess the faculty to resist the entrance of microbes with greater success than the mucous membrane of the pharynx is able to do. Therefore, we must say that experimeiits so far do not prove a distinctive protective mechanism of the tonsils, although they do not oppose such a possibility." (Levinstein.) "There seems to be no doubt that the tonsils are very often diseased primarily, and that their frequent secondary infection does seem to be ap- 40 THE TONSILS AND THE VOICE provedj and that they are particularly "well pro- tected against infections'' (Levinstein.) "The infection theory of the tonsil considers that most diseases of the human being are pro- duced by a primary infection of the tonsils, JVinslow claims that the tonsils are a menace to the organism. I rather believe that the infection theory is too extreme, and I beheve that the ton- sils offer less resistance to infectious germs than the other lymphatic organs of the throat. But if the tonsil offers less resistance to infections than its neighborhood we are not yet entitled to talk of a danger to the organism. And if Bosworth, Hendelssohn, and others, come to the conclusion that the tonsils are a constant danger and should in all human beings be totally eradicated, I can- not come to the same conclusion, for if I know of an organ that becomes easily infected, this organ should not be destroyed, but we should try to per- fect it as much as possible against the danger of infection, which in the tonsils is not so difficult to do:' "We want to make the organ more resistible. We want to cure and not destroy. Total and lasting destruction is, as Goerke has proved, abso- lutely impossible. The tonsils as organs easily infected have to be particularly protected against the possibility of infection." {Levinstein.) Harrison Allen believed that a large per cent of children suff ermg from hyperplasy of the f au- cial tonsil, who mentally and bodily remain be- hind normal children, has to be considered as sub- ject to an inner secretion of the hyperplastic or- PHYSIOLOGY OF THE TONSIL 41 gan which produced a damaging effect on the or- ganism. Escat "beheves that the faucial tonsils have not for their only function that of phagocytosis studied by Metch^iikoff, but also a physiological and biological function, due to an internal secre- tion. He believes, in accord with Allen, that the tonsils secrete a principle the nature of which it has been unable to determine, but which should be useful in the development and to the growth of the subject, and probably to the growth of the skeleton.^' Masini "believes that the tonsil has an inner secretion similar to the suprarenal and other glands. "He injected many animals with the extract of tonsils, and produced an increase in the arte- rial pressure. Scheier made analogous experi- ments by which he produced a decrease in arterial pressure. Pugnat repeated these experiments, but could not produce either increase or decrease in the arterial pressure. Masini, Scheier and Pugnat had all three different results, and so proved nothing." The haematopoietic theory of Harrison Allen, Kayser, Pluder and Schoenemann considers the function of the tonsil to be that of producing new colorless blood corpuscles. As we find in normal tonsils always, follicles with cell producing cen- ters, we can claim with assurity that in the normal tonsil new lymphocytes are produced, and that in the hypertrophied tonsil the number of newly formed lymphocytes is always considerably larger 42 THE TOXSILS AND THE VOICE than in the normal tonsil. In the atrophic tonsil new lymphocytes are not formed. "The question as to what becomes of these newly-formed Ij'^mphocytes is not decided. That they are put into the circulation has to be con- sidered doubtful, so long as it has not been proved that the vasa efferentia of the tonsil contain a larger amount of lymphocytes than the afferen- tia. So far this has not been proved, and it will be very difficult to prove because it is impossible to say, from the histologic picture, which is the afferentia and which the efferentia." (Levin- stein. ) "Not a small number of the lymphocytes con- stantly leave the tonsil, by wandering through the epithelium. I have proved that a consider- ably^ larger number leave the hyperplastic tonsil than the normal organ. What we know is sim- ply the fact that new lymphocytes are formed in the normal tonsils. What becomes of them we do not know." {Levinstein.) ''I cannot approve of eradicating the tonsils. If one tells me that the tonsils have no distinct function, and on the other hand, become easily diseased, and therefore not the slightest cause exists to save these organs, I mu^t say that it is not impossible that the tonsils have a distinct physiological function, only thus far we have no proof of it. And then even if we were sure that the tonsils had no distinct function, I would not give up my conservative standpoint, for if an organ of our body and even one which is not necessary for the existence of the organism should prove less resistible than other organs, this air- PHYSIOLOGY OF THE TONSIL 43 cumstance does not at all entitle us to destroy this organ.'' (Levinstein.) In concluding his scholarly review and master- ly criticism of the many hypotheses regarding the f aucial tonsil, Von Levinstein says : "No theoiy considering the physiology of the tonsils can be approved of, A proof that the tonsils fill a peculiar function important for the organism has not been given by anybody. Whether they have such a function cannot yet be decided. It has not been settled whether the tonsils have a value or not for the organism." The eocistence of the lymphatic current from the inside of the follicle through the epithelium to its surface has not been seen by anybody. Brieger and Frdnkel assume that it exists. Stohr's idea that the epithelium of the tonsil represents an open wound has been well com- batted by Frdnkel and by Jacohi. The elaborate and conscientious research works of Retterer, Labhe and Sirugue and Stohr, and the original investigations of Brieger, Goerke, Gulland, Lindt, Kilmmel, Metchnikoff, Bos- worth, Hendelssohn, Leocer, Menzer, Allen, Kayser^ Pluder, Scheier, Masini, Hodenpyl, Pugnat, Wood, Fooc, Scanes Spicer, Schoene- mann, Merkel Frdnkel, Levinstein, Magouhy, Hicguet, Broeckaert, Von Lendrt, Groher, Poli, Frederici, Most, Goodale and Hartz have not proved that the f aucial tonsil has any physiolog- ical function. (1) There is no proof of a lymphatic current running from the inside of the tonsil to the sur- face of its epithelium, as suggested by Brieger. 44 THE TONSILS AND THE VOICE (2) There is no absolute proof that the lym- phocytes have not amaeboid movement^ as suggested by Brieger. (3) There is no proof that the tonsil possess- es the power of phagocytosis as claimed by Gulland. (4) There is no proof that the tonsils have a haematopoietic function, as claimed by Allen. (5) There is no jjroof that the tonsils have an intetmal secretion, as claimed hy Masini. (6) There is no proof that the epithelium of the tonsil ever presents an open wound, as stated bjr Stohr. (7) There is no proof that the tonsil is a port of entry for infectious germs — no proof that it has any absorbent power. (8) There is no proof as to the existence of afferent and efferent lyjnphatic ducts leading to or from the surface, into the body of the tonsil. ON THE CONTRARY, (1) There is the proof of Hodenpyl that he could not force absorption by the tonsil of fats, liquids or powders. (2) There is the proof of Grober, who demon- strated the comparative absence of a direct com- munication of the tonsil with the rest of the body through the surrounding fibrous capsule. His injections of the tonsil, under pressure, accumu- lated in large quantities under the capsule. (3) There is the proof of Jacobi, that the tonsil does not absorb the toxin of diphtheria. (4) There is the proof of Von Levinstein, that the groups of acinous mucous glands in the well- PHYSIOLOGY OF THE TONSIL 45 known figure by JLuschha, of the fauclal tonsil does not belong to the faucial tonsil proper, but to its neighborhood. (5) There is the proof of Frederici and Goerke that the tonsils are infected via the blood. If colored particles are injected into the veins, they appear in the tonsils. (6) There is the proof of Von Lendrt, of the statement of Frdnkel, that micro-organisms ab- sorbed from a wound in the nose are carried via the lymphatic circulation into the tonsil. "Science owes a great deal to the reasoning power of the thinker, and to the acumen of the guesser, but both are alike futile until facts are ac- curately determined." (Halliburton.) IF THE FAUCIAL TONSIL ( 1 ) Does not possess a protective mechanism ; (2) does not have a phagocytic function; (3) does not have a haematopoietic function; (4) does not have an internal secretion; (5) does not absorb infections, then WHAT DOES IT DO, IF ANYTHING? HAS IT A RIGHT TO EXIST? or, IS IT AN ATA VISM? Do the theories of Briefer, Gulland, Allen, Masini, and Stohr, cover the entire range of in- vestigation that pertains to the usefulness of the faucial tonsil? Are the unproved hypotheses of these learned searchers to he accepted as a finality, and their results permitted to hinder other re- search? Surely not. Betterer, Lahhe, Sirugue, JStohr, Gulland, Allen, Masini, Von Lendrt, 46 THE TONSILS AND THE VOICE Broechaert, Poli and Von Levinstein, may be con- sidered to have gathered all possible data within the range of their investigations; hut there are other fields open to investigation, which may elucidate the functions of the faucial tonsil. Not alone the biologist, the physiological chemist, the pathologist, the bacteriologist, the anatomist, and the surgeon, are to be consulted in regard to the function of the faucial tonsil, but considering these in one group, as that of medical men, there are three other groups, that may contribute to Our knowledge, namely; voice mechanicians (physicists, phoneticians, and acousticians), voice trainers, and voice users. In consideration of the sterility of biological and physiologico-chemical laboratory research, pertaining to the function of the faucial tonsil, I question the wisdom of classifjdng this organ as a component part of the Waldeyer lymphatic ring, BECAUSE, (1) It lacks the most ordinary and essential features of the ly7nphatic structures, and of the tonsils that compose the ring. (2) It possesses important mechanical, acous- tic and phonetic functions which are not possessed by any other body of the ring. The mechanical functions and mechanical af- fections of the faucial tonsil are nowhere men- tioned in medical textbooks. But they receive attention in the literature of the voice profession. Observing carefully the remarkable anatomi- cal situation of the faucial tonsil and its sus- pended position in the very center of a framework of curious, active and important muscles, it be- PHYSIOLOGY OF THE TONSIL 47 [ comes pertinent to ask whether it has mechanical functions, and whether it is subject to mechani- cal diseases ? In many respects the faucial tonsils resemble and are as soft as the cartilages of the larynx and trachea. They impart firmness to the pharyngeal walls. They evidently serve a pur- pose that hard, unyielding, osseous formations in their situation would not serve. They are mobile and compressible. The position of the tonsils changes rapidly and with great facility, thereby adding vastly greater measure to their mechanical usefulness. Their consistence, shape, size, position, pres- ence or absence give structural variation to the resonance cavities, and create, as well as deter- mine, differences in individual timbres of the voice. They play a role in tone formation; and they must be considered. The muscles of the fauces attract attention when at rest, by the remarkable bowed or arched appearance which they assume. They straighten when they contract. Therefore, I consider it most reasonable to believe that on account of its position between these bowed muscles, the faucial tonsil acts as a fulcrum over which these muscles play. John Howard, ''Physiology of Artistic Sing- ing/" states : "It is true that a muscle's contraction consists in an effort to shorten itself. If the muscle, be- fore contraction, has the form of a curve, then its contracting effort will shorten it to a straight' 48 THE TONSILS AND THE VOICE form, before it pulls upon its points of attach- ment." "If the two bodies to which the ends of the muscle are fastened are by some other force pulled farther apart, with a power greater than the contracting force of the muscle, then the muscle may still contract, or put forth its effort to shorten itself, although at the same time it is being actually lengthened. In this case, which is constantly occurring in vocal performances, the muscle actually loses in thickness, and becomes more slender during its own contraction." "If a muscle embraces in its curve any yielding part, it will, in its effort to draw itself straight, push this yielding part out of its straightening way, thus exerting a lateral or sidewise force, as well as that longitudinal or lengthwise force which draws its points of attachment nearer to- gether." "Even if the embraced or curved-about part is too firm lo be actually displaced by the sidewise push of a curved muscle, yet this part will be pushed upon and made more solid or dense. In this case the muscle will pull more or less strongly the more or less firm and unyielding the enclosed part may be." "Whenever an arched faucial muscle straight- ens, the tonsil is either pulled or pushed. It is drawn inward toward the median line of the mouth, by the palato-glossus muscle, which curves outward while at rest. The palato- pharyngeus muscle, also, upon contracting and straightening, draws the tonsil inwardo These palate-tongue muscles cannot have put forth PHYSIOLOGY OF THE TONSIL 49 their tongue supporting effort, if the tonsil re- mains unmoved instead of moving inward. The tonsil is pressed toward the median line by the superior constrictor of the phar3rnx." It is also pressed downward and inward be- tween the pillars of the fauces in the act of swal- lowing. "It has been shown that the inward straighten- ing of the outward-curving part of the supe- rior constrictor, which extends from the side of the tongue to the middle of the rear wall of the pharynx, was one of the three agents which could hold up the tongue. If the internal ptery- goid muscle, just outside, is relaxed, it will be so loose that it will readily follow the inward- moving curve of the glosso-pharyngeus muscle and the higher division of the superior constric- tor, outside of which it runs. But if it is held stiff by contraction, it will not yield, and may prevent the free inward straightening of the curve, thus interfering with the vocal action of the tongue, supporting the glosso-pharyngeus (tongue part of the superior constrictor) ." "Possible proof of this interference is afforded by touching one of the tonsils and then trying to bring it inward at first with, and then without, jaw setting or stiffening, when it will be apparent that the inward movement of the palato-larynx muscle is in some way (probably in this) checked to some extent during the jaw stiffening; for upon relaxing the jaw effort, the tonsils come nearer together with less vocal effort." "There can be no doubt that the palato-glossi muscles raise the tongue after having straight- 5 50 THE TONSILS AND THE VOICE ened themselves. It is also clear that they can draw the soft palate downward." "Push the end of a finger backward in the mouth over the lower teeth, till you press lightly against a smooth, lumpy mass, the tonsil; now sing a tone, and know that you are so far right, if this fleshy mass is drawn inward toward the middle of the mouth ; wrong if it does not move inward." "This mass, the tonsil, is drawn inward by the palato-glossus muscle which here curves outward while relaxed, and necessarily straightens inward drawing inward the tonsil." "These palate-tongue muscles cannot, then, be putting forth their tongue-supporting effort if the tonsil remains unmoved." "The tonsil may also be drawn inward by the palato-pharyngei muscles." There is an infinitely varied and ceaseless play upon the faucial tonsils by the muscles of the fauces, pharynx, larynoc, mouth and jaw. In this connection, mark well — that the fibrous capsule of the faucial tonsil is the point of inser- tion of muscular fibres derived from the superior constrictor muscle of the pharynx. Why are muscular fibres from the superior constrictor inserted into the tonsil? Is the inser- tion of these fibres in a soft and movable body like the tonsil, designed to give freer action, and to facilitate some special play upon the part of this muscle ? Does the yielding tonsil serve some function to the superior constrictor, which inser- tion in a bone would not ? And has the action of the superior constrictor led to the development of PHYSIOLOGY OF THE TONSIL 51 the tonsil with its strong aponeurotic sheath? These questions remain to be solved. The faucial tonsil is a fulcrum for the muscles of the pharynx. It is also a compressible and a movable fulcrum. The faucial tonsil is a muscular compensator, which supj)lies compensation by change in its po- sition, and by change in its pressure, and by change in its shape when compressed. Also, by its presence, it fills a cavity, which, if unoccupied, would cripple compensation. It's an idler. Acting as a fulcrum, as a compensator, as an idler, and by change in its shape when com- pressed, the faucial tonsil is an important factor in assisting the muscles and in the shaping and re-shaping of the walls of the pharynx. The normal tonsil is a normal part of the mechanism that engages in voice production, and the removal of the tonsil will derange and dam- age the mechanism. It is stated by Von Chiari that "in elder pro- fessional singers, in whom the tonsils are enlarged to a great degree, and press apart the faucial arches, extending them very much in the course of years, the tonsils act as a prop in supporting the soft palate ; the muscles of the faucial arches become insufficient, while the arches remain tense, being supported by the big tonsils. If these ton- sils are removed to the bottom of the sinus tonsil- laris, the faucial arches will lose their support, and the whole back part of the roof of the mouth will sag down, affecting the voice permanently." Howard states: "The soft palate may be 52 THE TONSILS AND THE VOICE roughlj" compared to a tongue which has its root at the rear edge of the hard palate, and after ex- tending backward turns its tip downward, leav- ing a small space unfilled between its downward curved part and the spine, or rear wall of the pharynx." "On both sides of it, the four pairs of muscles which really constitute nearly its whole substance, start out ; two stretching upward and two down- ward. The two downward ones are the palato- pharyngei and the palato-glossi. The two up- ward inclined pairs must be examined in search of the forces which can hold up this unsupported tongue-like palate against the do^vn-pulling muscles just mentioned." "For, if tliis support fail, the whole chain of muscles, from palate to breast bone, will be, in a sense, let down, enfeebled bj^ being shortened, and withheld instinctively from even making the effort still possible, from fear of midue straining upon a tender, unsupported fleshy mass." It is impossible to conceive of any calamity that would, with more certainty, permanently de- stroj^ the singing voice. Howard says: "To the anatomist or the physi- ologist, the surgeon or the general practitioner, no smallest j^art of the whole throat can seem un- important. Baron Cuvier said that 'not only the muscles of the larynx serve to modulate the voice, but also those of the hyoid bone, tongue and veil of the palate, without which one could not attain the degree of modulation necessary for singing.' " I have presented the foregoing data to show the mechanical relationship and influence of the PHYSIOLOGY OF THE TONSIL 53 action of certain muscles upon the faucial tonsil, and to form a groundwork upon which I will place evidence in support of the following state- ments : ( 1 ) The faucial tonsil plays an important role in the mechanism of voice production. (2) The mis-use of the voice by an incorrect method in singing or speaking acts in a mechan- ical way in causing enlargement, or disease, of the tonsil. (3) Tonsils enlarged, or diseased, through a wrong method of voice production, may he cured by the substitution of a correct method. (4) Tonsils that are swollen, tender and pain- ful, caused by the mis-use of the voice, will, in turn, by their abnormal condition, hinder the proper action of the voice mechanism, and this hindrance will be relieved by proper use of the voice. (5) Removal of the normal faucial tonsil in- terferes with the mechanism of the voice. (6) The presence of the faucial tonsil being essential as a factor in voice mechanism, its ab- sence necessarily interferes with the perfect ac- tion of the mechanism and is necessarily inimical to the formation of a good singing, or public- speaking, tone. (7) The mere absence of the normal faucial tonsil impairs and weakens — and the presence of adhesions, scars, and contractions incidental to its removal, interferes with — the mechanism of the voice. 54 THE TONSILS AND THE VOICE ( 1 ) The faucial tonsil plays an important role in the mechanism of voice production. The faucial tonsils assist in regulating the ac- tion of the faucial pillars. As muscular com- pensators, they undoubtedly act upon and change, direct or interfere with, the course of the vibra- tions of sound. They contribute to altering the timbre of the voice. They help to sustain the tone. Alewander Graham Bell says: "Every change in the shape of the passage way, through which the voice is passed, occasions a corresponding change in the quality of the voice." Manuel Garcia says: "Every sound of the voice may assume an infinite variety of shades apart from intensity. Each of these is a timbre. The path of the sound being formed of elastic and movable parts varies the dimensions and forms in endless ways, and every modification, even the slightest, has a corresponding and defi- nite influence on the voice." Van Baggen says: "The faucial tonsils play an important role in phonetics. Their situation in the mouth at a place where the voice receives an essential part of its specific qualities allows us to admit this assertion. The muscles of the an- terior and posterior fauces between which the tonsils rest are in constant movement when speak- ing or singing. Their action, combined with the movements of the muscles of the soft palate, changes the shape of the voice passage at the back of the mouth when we are forming the different vocals or producing tones of different pitch. The position of the tonsils, situated as they are between the fauces, are of great importance with PHYSIOLOGY OF THE TONSIL 55 regard to the exactitude and perfectness of these movements." "Also for the resonance the tonsils are of great interest for the voice. With their spongy tissue they can be compared to the felt in the piano which softens the tone and regulates the reson- ance. The quantity and quality of the accessory tones depend on the shape of the resonance cavity. By modifying the shape of the resonance cavities, tones of different qualities and in differ- ent quantities are put in co-vibration by the vibration of the keynote. The mis-use of the ac- cessory tones is frequently the cause of a husky and impure voice." Moure: "From a phonetic point of view, the normal role of the tonsils must evidently be to prevent in a certain measure the nasality of tone by maintaining the pillars in the midst of which they are placed." Lamperti: "The tonsils are most necessary for modulation in singing; without them it is very difficult, sometimes impossible, for the voice to modulate. They assist in expanding and with- drawing the tones — in crescendo and diminuendo. The tonsil is as necessary for the modulation of the voice as the nostril is to breathing." Mme. Luisa Cajj'piani: "The tonsils are neces- sary to the acoustics of the voice. They support the tone in crescendo and decrescendo. Without tonsils, you cannot always strike, and you never can sustain the singing tone ; it fades away. With the tonsils in the natural position, of the head, it is much easier to bring the tones into the sound- 56 THE TONSILS AND THE VOICE Ing board, the nasal bridge where the voice be- comes mellow and sonorous." Escat: "The pharynx in its entirety plays in the emission of the singing voice, the role of a powerful resonating box." Mme. Alice Garrigue Mott: "Normal faucial tonsils preserve the original structure of the throat, on which depends the beauty of the in- dividual voice." Frank E. Millet^: "It is especially the struc- tural differences between the resonant cavities of individual singers that determine differences of timbre or quality. There are innumerable timbres for the human voice, as many as there are voices, and all due to the pliability of the vocal tract. The walls of the pharynx are permeated by a network of muscles, susceptible of numer- ous adjustments and re- adjustments in size and shape. The vocal tract of an accomplished singer is capable of some 16,000 adjustments and re- adjustments, as many changes as a sensitive face is of changes in expression." "There are seventy-four muscles and sixteen nerves capable of influencing various points of the vocal apparatus, and by an arithmetical pro- gression we arrive at the enormous sum of 74,- 682,000 possibilities of different combinations in the action of these muscles." "That is, granting that they have individual and conjoint action and do not act in pairs, we have the gigantic possibilities of 74,682,000 alter- ations in the vocal mechanism. For every tone produced, there is a special adjustment through- out the entire vocal tract." PHYSIOLOGY OF THE TONSIL 57 One may well conceive the ease and certainty with which such a mechanism will become de- ranged by the removal of a tonsil. It will alter the entire mechanism. (2) The mis-use of the voice by an incorrect method in singing or speaking acts in a mechan- ical way in causing enlargement, or disease, of the tonsil. An incorrect method of voice production de- ranges the voice mechanism. Expert laryngo- logists, and experienced voice trainers, are familiar with the results of a bad method. These results with their causes are noted in works on the voice, and have been recognized for a long course of years. Tosi, in his "Observations on the Florid Song, 1723," states: "When a teacher obliges the scholar to hold out the semibreves with force on the highest notes, the consequence is that the glands (tonsils) of the throat become daily more and more inflamed, and if the scholar loses not his health, he loses the treble voice." Van Baggen, in the Medical Record, New York, January 5, 1907, states: "Every specialist for throat diseases knows that many of the sufferers from those affections are to be found among those whose profession demands constant use of the voice. It is obvious that the mis-use of the voice is in most cases the cause of the affliction." "Patients present the following characteristic symptoms: catarrh of the pharynx and of the larynx, with congested and swollen mucosa; pillars of the fauces are swollen and often highly 58 THE TONSILS AND THE VOICE developed; paresis of the vocal cords which are red or yellow in color, and which do not close well. Paresis of the vocal cords is mostly united with paresis of the anterior cricothyroid muscle, the internal thyro-arytenoid muscle, and the lateral crico-arytenoid muscle. In some serious cases, a swelling of the ary-epiglottic ligament is observed. The fault is purely functional." Mine. Emma Seller, in her work on ''The Voice in speaking f' says: "By false training, an artificial and unnatural way of speaking has been formed by many of our orators and singers. The result is that the vocal organs very often become diseased. The mucous membrane of the pharynx becomes dry and a peculiar huskiness of the voice occurs. The epi- glottis becomes swollen and injected. The aryten- oid cartilages become swollen and inflamed. The vocal cords become reddened and thickened. A slight paralysis of the cords is sometimes pres- ent. The mucous membrane of the trachea be- comes congested and thickened. These are the conditions of the parts in typical cases of this disease. But all the symptoms may be aggra- vated in severe cases where, sometimes, the ul- cerations extend into the trachea and up into the nasal cavities, involving the Eustachian tubes and the middle ear in a general sub-acute inflamma- tion. The real cause at the foundation of the disease consists, not in a long-continued use of the vocal organs, hut in a faulty way of using themr "Straining of the tensor muscles of the larynx, with added pressure of the expiratory muscles PHYSIOLOGY OF THE TONSIL 59 reddens and inflames the edges of the cords and the whole lining of the larynx." Shakespeare, London, 1912, says: "I suspect that most swollen tonsils are the result of a rigid manner of using the voice, both in singing and speaking." Charles A. Rice states that: "Nothing will enlarge the tonsils so quickly as bad placement of the voice. Not only are the tonsils enlarged, but the intrinsic muscles are often impaired, and sometimes this extends to a paralysis of the arytenoides. Then the tonsils are removed, with little or no relief, for the trouble has not been with the tonsils, but caused by strain on the en- tire vocal apparatus." Enlargement of the tonsils, caused by mis-use of the voice, may lead to mechanical interference with both deglutition and phonation. (3) Tonsils enlarged, or diseased, through a wrong method of voice production, may he cured by the institution of a correct method. When tonsils are enlarged, or diseased, through mis-use of the voice, it is plainly evident that the only proper way to cure them is by re- moving the cause. Tonsils enlarged, or diseased, by mis-use of the voice should not be enucleated. Mme. Lilli Lehmann states: "I never would advise the removal of anything from the throat (of a singer) and would always try to cure it without any operation. I am quite sure that every had standard of health in the throat can be cured by learning how to use the right method. Singers who sing well will never be troubled by anything," 60 THE TONSILS AND THE VOICE Mme. Emma Seller says: "The present in- ability to preserve the voice is the consequence of a method of teaching" unnatural, and therefore, imposing too great a strain upon the voice. Voices which by this overstrained and unnatural way of singing have become worn-out and useless may by correct, proper treatment recover; and even those chronic inflammations of the larynx which are so difficult of treatment may be cured by a natural and moderate exercise of the voice in singing." (4) Tonsils that are swollen, tender and pain- fid, caused hy mis-use of the voice, will, in turn, by their abnormal condition, hinder the proper action of the voice mechanism, and this hindranc. will be relieved by the proper use of the voice. In cases of this character, the removal of the tonsils is a blunder. (5) Removal of the normal faucial tonsil in- terferes with the mechanism of the voice. Lermoyez declares that "the normal, faucial tonsil is an organ that must be respected. The normal tonsil should never be removed more than a normal eye or a normal tooth." Manuel Garcia and Mme. Viardot-Garcia "always protested against any surgical, or other artificial means for improving the natural voice." Lamperti states that "If the tonsils are normal, they should on no account be removed, as the re- moval will never improve the voice. In almost all cases when tonsils were removed, I have found in the fifty years of my teaching, that the voice is injured, often beyond remedy." Richard Loewenherg says : "To prevent mis- PHYSIOLOGY OF THE TONSIL 61 understanding, by normal tonsils, I mean tonsils of a healthy color, those not enlarged in length or thickness, and showing no evidences of chronic inflammatory processes. Such tonsils should, ac- cording to my experience, never be removed by operations, neither on account of the effect upon the general health, nor of the functional activity of the organ itself. Even though the physio- logical significance of the tonsil still rests upon a hypothesis, this, like any other healthy organ in the body, should be left undisturbed. I do not know of any case in which a singer's voice was improved by removal of normal tonsils. On the contrary, I know of cases in which the removal of normal tonsils has caused permanent detri- mental effects to the voice, in consequence of the unavoidable injury to the arches of the palate (adhesions scar, tissue, etc.) ." "For these reasons, I disapprove of operations upon normal tonsils in all cases." Sebastiani states: "Often the voice has been damaged if the operation on the tonsils was not necessary, but simply performed to increase or improve the voice. In similar cases, the voice has been damaged and sometimes entirely lost. Such operations on so delicate an organ as that of the voice, are not good for the clearness, exercise, color and facility of the voice. The tissues, nerves and muscles always remain depreciated after an operation that was not compulsory to avoid greater damages. I would not advise the removal of normal tonsils in singers. The bene- fit that can be derived by excision of the tonsils, if of great utility in cases of hypertrophy to avoid 62 THE TONSILS AND THE VOICE greater damages, may be of some benefit to the human voice in general; but it may not be of any benefit to specialized organisms endowed with eoc- ceptional and valuable voices. In these cases of exceptional and valuable voices, any surgical operation whatsoever, it matters not how perfect, can harm the precious instrument/' "I have been able to verify that the greater the development of the tonsils, the more difficult is the resonance and the emission of the tones of the second register or high notes: even the removal of the normal tonsils does not facilitate these high tones/' Mme. Cappiani states: "I know of no in- stance in which the singer's voice was improved after removal of the tonsils. But the voice may be changed to higher or lower pitch. Often the compass may not be changed at all; only the sounding quality become more ordinarj^" Mme. Von Klenner states that after removal of the tonsils she "has always found a certain lack of sweetness in the tone quality, and difficul- ty in supporting the tone in certain registers." Hubbard states that "removal of the tonsils causes a difficulty in assuming different shapes of the pharynx necessarj^ in singing, causing a hard- ness in quality and laborious action." Mme. Schumann-Heink states that "in some cases the voice becomes acid, uncertain, weak or rough, or entirely ruined after removal of the tonsils." Bispham remarks that "there is always trouble after operations on the throats of singers; that after removal of the tonsils there is always some- PHYSIOLOGY OF THE TONSIL 63 thing gone which contributed to the good singing tone." Mme. Clara Kathleen Rogers declares that "the tonsils are factors in forming the perfect resona- tor." Mme, Alice Garrigue Mott states that "the tonsils preserve the original structure of the throat, on which depends the beauty of the indi- vidual voice." Von Schrotter (Vienna), Von Chiari (Vien- na), Schmiegelow (Copenhagen), Van Bag gen (The Hague), Lubet-Barbon (Paris), Semon (London), Masm (Naples), jEJsca^ (Toulouse), Moure (Bordeaux), Lermoyez (Paris), Frdnkel (Berlin), Von Levinstein (Berlin), Brieger (Breslau), Goerke (Breslau), Loewenberg (Berlin), Marage (Paris), Casteoc (Paris), Gleitsmann, (New York) , Barth (Leipzig) , Luc (Paris, Miller (New York), Lamperti (Ber- lin), Shakespeare (London), De Reszke (P avis) , Sebastiani {'N a-ples), Sabatini (Milan), Mme. Lilli Lehmann (Berlin), Mme. Luisa Cappiani (New York), Mme. Alice Garrigue Mott (New York), Mme. Schumann-Heink (New York), Mme. Lillian Nordica (New York), Mme. Luisa Tetrazzini (New York), Bond (New York), Bispham (New York), and all other authorities, without exception, advise against the removal of normal tonsils. (6) The presence of the faucial tonsil being essential as a factor in voice production, its ab- sence necessarily interferes with the perfect ac- tion of the mechanism. (7) The mere absence of the faucial tonsil im- 64 THE TONSILS AND THE VOICE j)airs and weakens — and the presence of adhe- sions, scars and contractions incidental to its re- moval, interferes with the mechanism of the voice. The presence of the faucial tonsil having been shown to be absolutely necessary to artistic sing- ing and public speaking, is it not reasonable to think that its mere absence will, at times, account for deterioration in tone? The absolute certainty of impairment of the voice which follows removal of the tonsil, I have shown to be well known to the voice profession. The phonetic value of the tonsil is proved by the phonetic defects which always follow after enucleation. For every tone produced there is a special ad- justment throughout the entire vocal tract. How, then, can enucleation fail to alter the mech- anism? ''The faucial tonsils are absolutely necessary in the modulation of the singing voice." (Lani- perti. ) "The tonsils regulate pillar action/' (Miller.) "They modulate the voice. They soften the tone and regulate resonance. They assist in changing the shape of the pharyngeal cavity, and the pitch and quality of vocal tone." (Van Bag- gen.) "They prevent, in a degree, the nasal tone of voice." (Moure.) "Excision of the tonsils, if of great utility in cases of hypertrophy to avoid greater damages, may be of some benefit to the voice in general: it may not be of any benefit to specialized organ- isms, endowed with exceptional and valuable PHYSIOLOGY OF THE TONSIL 65 voices, these voices being of great value precise- ly on account of their mucosae; for the softness of the muscles and nerves; for the perfection of the different cavities of resonance; finally for the marvelous structure of all the vocal passage. Then in these uncommon conditions any surgical operation whatsoever^ it matters not how perfect, can cause harm to the precious instrument. Often the voice has been damaged if the opera- tion on the tonsils were not necessary, but simply performed with the desire to increase or improve the voice. The voice has been damaged and sometimes entirely lost. It is not well for the clearness, exercise, color and facility. The tis- sues, nerves and inuscles always remain depre- ciated from an operation that was not compul- sory to avoid greater damages." (Sebastiani.) "When removed, I have always found a cer- tain lack of sweetness in the tone quality and difficulty in supporting the tone in certain regis- ters." {Mme. von Klenner.) "After removal of the tonsils the voice perma- nently loses much of its personal quality. The tone seems dispersed, and lacks the usual bril- liancy of resonance." {Mme. Marie Everett.) "Removal of tonsils causes a difficulty in as- suming different shapes of the pharynx necessary in singing, causing a hardness in quality and la- borious action." (Hubbard.) "They preserve the original structure of the throat, on which depends the beauty of the indi- vidual voice. I know many cases where the re- moval of tonsils has made a change for the worse in quality," {Mme. Matt.) 6 66 THE TONSILS AND THE VOICE A troublesome tonsil should never he removed if the affection from which it suffers is disease which arises from a mechanical cause and which disappears when the cause has been removed. I have proved that the tonsil plays an impor- tant role in the mechanism of voice production; that the mis-use of the voice causes enlargement, or disease of the tonsil; that enlargement or dis- ease of the organ may be cured by correct use of the voice ; that swollen, tender and painful tonsils hinder the normal action of the voice mechanism ; that removal of the normal faucial tonsil always affects the mechanism and always injures the quality of voice; that the presence of the faucial tonsil being an essential factor in the voice mechanism, its absence necessarily interferes with the perfect action of the mechanism, or, in other words, any interference with the mechanism of the voice leading to, or caused by, inechanical af- fection of the faucial tonsil, will become a posi- tive and perniane7it injury, if the tonsil is re- moved; that such an egregious blunder as the re- moval of an integral part of the mechanism of the voice cannot possibly be atoned for. Precious voices have the most delicate mechan- ism; the more delicate the mechanism, the more easily it is thrown out of order. The natural mechanism of the voice can never be improved by surgical means. The throat of the voice user requires more consideration and less treatment than any other throat. There are no opj)ortune times at which a voice user's throat requires radical treatment, or sur- PHYSIOLOGY OF THE TONSIL 67 gical operation, with any assurance of improving the voice. Hyperplasias. Enlargement of the faucial tonsil may be temporary, or permanent. En- largement is due to a great variety of causes, and presents many structural variations. Differen- tial diagnosis of the various forms is essential for the proper application of treatment. Diagnosis is of no value to those alone who consider it of no importance, or who minimize it in favor of abla- tion. Under a variety of conditions, cells, larger parts of the body, or entire organs become larger than normal. The structural change may be a simple increase in size of the elementary structure of the part, the cells. This is simple hypertro- phy. It is usually associated with some increased functional demand upon the cells and an increase in their functional capacity. On the other hand, in many cases the increase in size of a part or organ is due not only, or not at all, to the increase in size of its elementary structures, but to an increase in their number. This increase in number of the structural ele- ments of a tissue or organ is called numerical hypertrophy, or hyperplasia. Simple hypertrophy and hyperplasia are fre- quently associated. Simple enlargement of a part or organ does not necessarily involve hypertrophy of any of its structural elements. It is well to limit one's con- ception of hypertrophy to enlargement of specific structural elements of a part with maintenance or increase of functional activity, and to consider 68 THE TONSILS AND THE VOICE other instances, as increase of fat in a muscle, or wax}^ degeneration of the liver, as examples of pseudo-hypertrophy. Compensatory hypertrophy of the thyroid and adrenals has been eccperimentally induced. In most of these conditions hj^perplasia of the interstitial tissue is associated with parenchyma hypertrophy of the specific parenchyma cells whose response to increased functional demands is marked by simple hj^pertroph}^ Lymph-nodes, in addition to considerable hyperplasia due to inflammation, also become en- larged under a variety of conditions which we do not understand. This lack of knowledge of the etiology, together with our ignorance of certain functions of the lymph-nodes, and the morplio- logical similarity, or even identity, which these enlarged nodes present under various conditions, render it very difficult to decide upon the exact nature of the change, and in many cases to dis- tinguish one form of enlargement from another. Acute inflammation of the tonsil shows an in- creased infiltration with leucocj^tes, which causes enlargement, also increased amount of lymph in the intercellular spaces. Congestion by tymph, or increase in adenoid tissue, are not the only reasons for enlargement. So manj^ of the most profound thinkers con- sider enlargement of the tonsil to be sometimes symptomatic of, or associated with, in some way, the growth of the individual, that it is wise to respect this observation. It is well to heed Escat, who is "of the opinion that the faucial tonsil has not for its only function that of phagocytosis as PHYSIOLOGY OF THE TONSIL 69 studied by Metchnikoff, but also a physiological and biological function due to an internal secre- tion." "I claim, in accord with the opinion of Allen, that the tonsil secretes a principle which we are as yet unable to determine, but which should be use- ful in the develo23ment and growth of the subject, and probably to the growth of the skeleton. I have found a reason for this in the fact that the normal tonsils atrophy normally at about the age of 18 to 20 years, from the time that the subject has become fully an adult." Brieger states that: "(1) Enlargement of the tonsil by lymphatic scrofula has not been proved. (2) Clinical aspect is conditioned by tuber- culosis in a certain number of cases. (3) In very rare cases the hyperplasia is pro- duced by lues. (4) Hyperplasia of the glands appears in the whole lymphatic apparatus accompanying en- largement of the tonsils. These four represent only a minority of the cases. Generally they are very healthy people who have enlarged tonsils." According to Grober: "The tonsils seem to be a less favored settling place for tubercle bacilli than the lymph glands, for we find scrofulous glands oftener than infection of the tonsils. Many authors consider diseased tonsils as more liable to microbial infection than healthy ones. If that is true, it has not been proved." "It has been shown that the entrance of mi- 70 THE TONSILS AND THE VOICE crobes into the system does not always produce the disease. It is important how strong the de- fensive processes of the body are. Therefore, infectious diseases are mostly constitutional." Goerke asks: "What are the causes of the in- volution of the tonsils, and its importance for the organism ? Answer. Involution is an expression of im- munity against certain infections especially pecu- liar to childhood. (2) What are the microscopic (and macro- scopic) changes of the involution? Answer. Disappearance of follicular tissue, and appearance of indifferent tissue. (3) How does the final result of involution represent itself histologically? Answer, As a picture of the normal mucous membrane of the pharynx. (4) What are the causes that prevent involu- tion, and how do we learn these causes by histo- logic examination? Answer. Inflammatory processes, in the up- per part of the pharynx, or in the tonsil itself. (5) What picture represents the tonsil not completely involved? Answer. By changes connected with inflam- matoiy processes. ( 6 ) How will therapy be directed ? Answer. As we are not able to bring about involution of the tonsils in adults, the tonsils must be removed by operation." Goerke states: "After operation, the tissue regrows, and in this way seems like a lympho sarcoma." PHYSIOLOGY OF THE TONSIL 71 "Tuberculosis is of no importance as regards hyperplasia or return of the growth. The ade- noid tissue regenerates in all cases, after removal of the tonsil. Those same causes which led to the first hyperplasia also lead to the new hyper- plasia. These recurrences occur more often than we think, hut we do not know about them. Pa- tients don't speak about the return, because they dont want to be operated on again. The re- growth is never as great as the first hyperplasia.^' Grober says: "It is not possible to remove the entire tonsil." Marage says: "Lymphoid tissue always es- capes in surgical intervention no matter how well it is done." Von Levinstein saj^s: "Its total removal is not possible." Escat says: "Even in the most radical abla- tion of the tonsil, there is alwaj^s left a little ade- noid tissue. It is not necessary, in my opinion, to set one's heart upon completely extracting all the tonsillar tissue as various American con- freres proposed. The tonsil is not a cancer! After ablation, a kind of anaemia or weakness, a cachexia tonsilliprive, has sometimes occurred." Moure and IE scat state that "the lingual tonsil sometimes overlaps and becomes blended with the faucial tonsil." Truth demands a record of the statement, noted by many excellent observers, that a new growth occurs at the seat of the tonsil, after that organ has been removed. So constant is the oc- currence of this new growth that it must he con- sidered as the result of a natural, sequential, 72 THE TONSILS AND THE VOICE physiological process. The growth must per- forin some physiological function^ for nature never serves a useless purpose. Lennooj Browne says: "Beyond any ques- tion, there is a tendency not of recurrence but a continuation of the growth." Von Levinstein says : "Eradication of the ton- sil can never be completely done. A total and lasting destruction of the tonsillar tissue is, as Goerke has proved, absolutely impossible, for it regenerates always." Brieger, Wright, Semon, Mackenzie and Grayson agree with Goerke, Groher, Levinstein, Escat and Browne. Jacohi says: "It is not a matter of indiffer- ence whether the capsule of the tonsil is removed or not. Infection through the capsule is rather difficult. The capsule is a protection to the blood and lymph circulation." The capsule is a harrier in preventing the ex- tension of disease from within the tonsil to neigh- boring tissues in its vicinity. The capsule is a barrier in p)r eventing the extension of disease to the body of the tonsil froin the outside neighbor- hood. The capsule protects the tonsil against ex- ternal injury. It adds solidity to the structure of the tonsil, and contributes a degree of firmness to the faucial wall. I view the tonsils as BUFFER ORGANS. They are buffers. From their plainly visible ac- tion, I would call these bodies FAUCIAL CUSHIONS. They are cushions. They un- doubtedly serve as cushions to the pharynx. They PHYSIOLOGY OF THE TONSIL 73 are mechanical cushions. They are acoustic cush- ions. The act of swallowing involves consideration of the faucial tonsils. In the act of swallowing the upper part of the tonsil is pressed downward and inward between the pillars of the fauces. The inferior constrictors of the pharynx contract above, upon the morsel of food, and force it downward into the aesophagus. The palato- pharyngeus draws the palate down upon, and the sides of the pharynx in upon, the food, to force it downward. It also aids in swallowing by drawing the larynx upward. In the act of swallowing, as the mass of food passes through the pharynx, from the mouth to the aesophagus, the side walls of the pharynx ap- proach each other and press upon the passing bolus, imparting to it a slight push downward. The faucial tonsils occupy the forefront of the push. A morsel of fish containing a sharp bone, when pressed upon, may pierce the tonsil without evil result, without pain, without bleeding. In this way the tonsil acts mechanically both as a huf'er and as a cushion, and serves to protect the more delicate and important structures of the pharynx and larynx. If the tonsils are removed, then delicate and important blood vessels, nerves and muscles be- come exposed. Immediately behind the tonsil is placed the internal carotid artery — the size of a goose quill. Prick that! and you will quickly see what happens. The tonsil protects the inter- nal carotid artery. Its absence menaces this ar- tery. The internal carotid artery is twice threat- 74 THE TONSir.S AND THE VOICE ened by tonsillectomy; first by the operation, and second, by the absence of the tonsil. "The physiological act of deglutition is some- times considerably disturbed in affections of the oro-pharynx and of the laryngo-pharynx. En- largement of the lingual tonsil, acute or chronic inflammation, and tumors at the base of the tongue having their seat in the region of the epi- glottic fossettes, where the alimentary bolus is formed at the beginning of deglutition, are, above all, characterized by a constant sensation of a false alimentary bolus, which greatly incom- modes the patient." (Escat.) In the presence and also in the absence of these conditions, I have repeatedly observed elderly persons incommoded^ and sometimes choke, at the very beginning of the act of swal- lowing on account of an apparent slowing-up m the process of muscular contraction of the mus- cles of the pharynx — a sort of semi-paresis. I was once called into consultation in the case of an old gentleman, whose family physician had diag- nosticated "paralysis of the epiglottis and of the vocal cords," and was about to perform trache- otomj^, but in which case I changed the diagnosis to that of inflammation of the fossettes with ab- normally slow muscidar action. He recovered promptly without an operation. It admits of no question that, sometimes, in elderly people, abnormally slow muscular move- ments will be made still slower by removal of the tonsils, and that this will particularly follow in cases of removal of unusually enlarged tonsils PHYSIOLOGY OF THE TONSIL 75 which pressed upon, and gave support to, the palatine arches. Medical authorities have furnished no proof and are entirely undecided regarding any pos- sible physiologic, biologic, or bio-chemical func- tion of the faucial tonsil. I have presented the evidence and have fur- nished the proof that the voice mechanicians (physicists, acousticians, phoneticians), voice trainers, and voice users, agree that the faucial tonsil possesses important mechanical, acoustic and phonetic functions. While I have shown that the faucial tonsil pos- sesses highly important mechanical, acoustic and phonetic functions, I also believe that the anat- omy of this organ, with its germinating centers, and with its curious system of closed lymphatic canals indicates hio-chemical and physiologic functions which, as yet, have not been proven. The learned hypothesis of Brieger and Goerke seems to deserve the high endorsement of Frdnkel. And the theory of Allen, endorsed by Escat and other high authorities is surely worthy of further research. Von Lendrfs proof of a direct lyn^phatic communication between the nose and the tonsil is important. He has also proved an intimate connection existing between the two faucial tonsils. And Poli has shown that the lymphatic region of the two nostrils com- municate by anastomotic branches which at the back surround the free edge of the septum and at the front, though to a less degree, by vessels which pierce the septal cartilages. CHAPTER IV CAUSES OF TONSIL DISEASES. A clear understanding of the normal anatomy and physiology of any organ is essential to a clear conception of the cause of the disease that may affect it. Disease is an interruption of function, not something new, not something added to, hut an interference with physiological action. Injury of a cell by bacteria, toxins or other means disturbs its function. Agencies and con- ditions to which the body has not adapted itself which, swaying its normal capacities now one way and now another, induce the functional alterations by which disease is manifested. It follows from this that the functional abnormali- ties and the structural alterations which make up the signs, symptoms and lesions of disease in- volve the expression of no new functional capaci- ties which the normal body does not possess. The body in disease manifests no new func- tions, develops no new forms of energy , reveals no new capacities. In normal physiology attention is most keenly centered to-day upon the structure and per- formance of cells as the field richest in the prom- ise of significant revelations. Soj also, in pathology by similar methods and with equal persistence must the structure and performance of cells under abnormal conditions be studied if we are to hope with reason for a clearer comprehension of disease, 76 CAUSES OF TONSIL DISEASES 77 To the conception of pathological processes as essentially cellular processes are due the great advances which this phase of biological science has made during the past few decades. When we study the causes of diseases, we should remember always that underlying the manifestations of disease as well as sustaining the correlated processes which we name health, are the complex and ceaseless chemical transfor- mations which in both health and disease alike supply the energy which sustains all expression of life. So that what we are wont to call the senses, whether external or internal, of disease are really not primary causes, but liberating im- pulses or excitants which sway and modify the orderly transformations of energy constituting health with those manifestations of perturbed function or altered structure, or both, on which our conceptions of disease are framed. Delafield and Prudden (Text-hook of pathology) : "Pathology, then, deals with the disturbances of function and the alterations of structure in living beings, induced by unusual agencies and conditions." "The functional disturbances thus induced are embraced as symptoms of disease in pathological physiology, which so largely dominates the scien- tific activities of the physician, and forms the basis for the practice of his art." "Furthermore, so much depends upon the metabolism of the body in health and disease that it is to chemistry, both physiological and patho- logical, that the scientific physician looks most 78 THE TONSILS AND THE VOICE eagerly for the solution of problems which each day become more numerous and urgent." A knowledge of the processes of bacterial inva- sion, of the process of phagocytosis, of the action of opsonins, is essential to the understanding of the causes of tonsil affections. The air we breathe, the food and drink we swallow, are carriers of bacteria, toxins, and other deleterious matters. The nose and mouth are open avenues for inva- sion. The presence of pathogenic micro-organisms and other deleterious substances often interfere with the normal condition of the tonsil. Blood serum, and other body fluids, are capable of kill- ing bacteria with which they come in contact. Even more than in the action of living phagocy- tes the protective agencies are to be sought in the body fluids. The importance of this protective power of body cells and body fluids is not ex- hausted with their germicidal action. Not less significant is the role which these may assume in the establishment of other phases of immunity. Other exudates, serum, and fibrin may be useful to the individual in the dilution of locally engen- dered poisons and in their removal from a \Tilner- able region the fluid may at times be beneficial. Fibrin, too, by closing inflammatory foci, through temipOYSLTy adhesions, or by the healing of absorbent surfaces, may limit the extension of the injurious agents. This is the very point that Jacohi, in the Archives of Pediatrics, insists upon, namely: that where a lesion occurs on the surface of the tonsil, invasion of germs does not take place; first, because of the impaction of the CAUSES OF TONSIL DISEASES 79 tissue with fibrin ; second, because of the bacteri- cidal influence of the stagnating venous blood. That the regenerations and repair of tissue which may be associated with or follow the more active phases of inflammation are, as a rule, beneficent, is not doubtful. Inflammation is the local at- tempt at the repair of injur}^ The fundamental conception upon which this characterization is based is that inflammation is an emergency meas- ure incited by injurj^, in which the body adapts to unusual ends as best it can mechanisms and processes normally maintained for other purposes. This view of inflammation points the way to a broader interpretation of other abnormal condi- tions in which also the adaptation of physiologi- cal cell capacities to new conditions seems to fur- nish a clue to many manifestations of disease as yet but little understood. Delafield and Prudden say: "In the light of the new knowledge of opsonins and their rela- tion to phagocytosis, the recurrence of leucocy- tosis in various affections becomes of special sig- nificance. For if either a local or general leu- cocytosis be fostered hand in hand with the effec- tive production of opsonins, the conditions would appear to be most favorable for the control of the infective process." Leucocytes are apt to gather in regions in which micro-organisms are abundant, and are be- lieved to take up and destroy micro-organisms and to prevent further entrance, and possibly the entrance of their products also, into the circula- tion. The leucocytosis of infectious diseases may be regarded as the effort of the blood pro- 80 THE TONSILS AND THE VOICE ducing organs to protect the blood and tissues by means of leucocytes against the invasion of micro-organisms and against the actions of tox- ins present in the circulation. It is quite possible that in the blood stream leucocytes act as scaven- gers. According to Metchnikoff, leucocytes are manufacturers and storehouses both of immune bodies and complements. Hyperaemia must be viewed as a protective process. Increased blood supply to any part means an increase in the num- ber of leucocytes. Acute inflammation is a heightening of this process, caused by the pres- ence of bacteria, toxins or other noxious matter. Increased blood supply means a flushing of the part with defensive and protective leucocytes, and at the same time sustaining super-nutrition under conditions of distress. The inflammatory exudates are salutary in that they clean the tis- sues and wash away bacteria, toxins and other debris. The object of inflammation is always salutary. Acute hyperaemia and the flow of secretions should be encouraged, not interfered with. The new light upon inflammation bears with particular force upon the infections of the region of the tonsils, peri-tonsil, adenoid structures, the nose and mouth. Westenhoeffer has proved that the germs of cerebro-spinal meningitis enter the system by way of the nose and through the pharyngeal tonsil, after the protective power of that tonsil has been broken down by the superior force and the virulency of the invading germs. Fi^dnheVs statement that the faucial tonsil be- comes infected from the invasion of germs from CAUSES OF TONSIL DISEASES gl the nose by way of the lymphatic canals has been proved by Von Lendrt. The faucial tonsil becomes diseased from six common sources: ( 1 ) Prbnary, by infection from the mouth, or continuity of surface. (2) Secondary, from the nose, via the lym- phatic vessels. (3) SyinptomatiCj representing general blood disease, etc. (4) Reftecc disease, or sympathetic, from den- tal caries, nasal affection, etc. (5) Mechanical, due to pressure, false method in using the voice, etc. (6) Hyperplastic. CHAPTER V CLASSIFICATION OF TONSIL DISEASES. Anatomical and clinical considerations are both essential in a practical classification of tonsil diseases. The anatomy must be kept in view. The processes of bacteriology teach us that wherever a specific infectious micro-organism is to be found, the disease belongs to that organism. No matter what organ or anatomical structure is affected, if the bacillus tuberculosis can be demonstrated, it is always tuberculosis. Present knowledge of infectious processes has already proved of great advantage, both theoretically and practically; treatment is surer, prevention more certain, and mortality is greatly lessened. But we are still ignorant of a great number of infections and of infectious processes. Infective micro-organisms are varied and numerous and every year adds to our list of new diseases of hitherto unsuspected character. Physiological chemistry is constantly adding new poisons and reactions, while the sclerotic and hyperplastic processes have much to reveal. Diseases of the faucial tonsil may be conveni- ently divided into six classes: (1) Primary, (2) Secondary, (3) Symptomatic, (4) Reflex or Sympathetic, (5) Mechanical, (6) Hyperplasias. (1) The PRIMARY diseases are those that affect the mucous membrane covering the surface of the tonsil and lining the fossulae or crypts, 82 CLASSIFICATION OF TONSIL DISEASES 83 namely: acute inflammation of fossulae — syno- nyms — acute tonsillitis, acute lacunar tonsillitis, infectious tonsillitis, acute follicular tonsillitis, cryptic tonsillitis ; acute ulcerative lacunar tonsil- litis, herpetic tonsillitis, membranous tonsillitis; chronic inflammation of fossulae; lacunar cal- culus — synonym, tonsillith ; hyperkeratosis — synonyms, lacunar hyperkeratosis, mycosis lep- tothricia ; actinomycosis; 'pseudo-membranous tonsillitis; diphtheria; tubercidosis; lupus; spe- cific. (2) SECONDARY diseases affecting the in- terior of the body of the tonsil, as infections from nasal catarrh, and nasal trauma via the lymphatic vessels : secondary infection of the body, and also of the mucous membrane covering the surface, from inflammation or abscess, in the peritonsillar tissues. (3) SYMPTOMATIC diseases, due to in- fection of the blood, tuberculosis, lues, exanthe- mata, typhoid, rheumatism, etc. (4) REFLEX diseases, pain, tenderness, swelling, from eruption of teeth, nasal affection, etc. (5) MECHANICAL diseases, pain, tender- ness, swelling, etc., from false method in using the voice, mechanical pressure, etc. (6) HYPERPLASIAS, temporary, from augmented physiological function, absorption of nasal trauma, etc. Permanent hyperplasia from increase of ade- noid tissue, from tubercular and other infections via the lymphatic vessels, and also via the general blood current, etc. 84 THE TONSILS AND THE VOICE Papilloma, most common growth. Lipoma, rare. Angioma, rare. Fihro-enchondroma, rare. Cystorna, rare. Lymjjhadenoma, rare. Atrophy, common. Hypertrophy, common. Submerged tonsil, common. Carcinoma, more malignant than sarcoma and equally rare. CHAPTER VI ADENOIDS. A bright, beautiful, blue-eyed little girl went running home from school one day, in great alarm, to tell her mother that the school doctor had examined her and had told her that she "had adenoids and tonsils and unless they were taken out she would get an awful disease." "I was so frightened," she said, "that I cannot remember the name of the disease the doctor told me I would get; but I am sure he said either two berculosis or three berculosis." A lad of twelve years told me that the school doctor had examined him. "He put a stick in my mouth, and said 'You have one large tonsil and catarrh in your nose.' The doctor had four sticks. He examined seventy -five in our school; two were normal and seventy-three were ab- normal." A physician of over twenty-five years' experi- ence, a graduate of the University of Pennsyl- vania, called upon me to examine his throat. He remarked about adenoids. I asked him the question: "What do you mean by adenoids?" After some hesitation, he replied, "Adenoids is an enlargement of the lymphatic tissues. I think that is what they are. I have never looked up the definition." The word adenoid is not a pathologic term. It does not refer to enlargement, disorder or dis- ease, Webster defines the word. It is an ana- 85 - 4 86 THE TONSILS AND THE VOICE tomical term, a noun, a name applied to a natural structure. Adenoids are natural bodies, as nat- ural as your eyes, or your teeth. What they are, where they are, what they do, the dangers of their removal, and their return, are interesting ques- tions. I The word, adenoid, comes from the Greek words, aden, meaning a gland, and eidos, mean- ing like — like a gland. Adenology, the doctrine of the glands. Ade7iitis, inflammation of a gland. Adenotomy, a cutting or incision of a gland. Adenectomy, the complete removal of a gland. Tonsillotomy, the partial removal of a tonsil. Tonsillectomy, the complete removal of a tonsil. Tonsillectomy is synonymous with enucleation. The words adenotomy and tonsil- lotomy^ are sometimes used synonymously. So are the words adenectomy and tonsillectomy. There are three sets of circulating channels in the human body, arteries, veins and lymphatics. Through the lymphatic vessels a fluid circidates which protects the system from the invasion of germs and other deleterious substances. This fluid, called lymph, contains a vast number of bodies, microscopic in size, called lymph cells, lymphocytes, leucocytes and phagocytes. These attack, digest and destroy germs and poisons which gain entrance to the lymphatic vessels. The direction of the lymphatic current is alwaj^s from the surface toward the center of the body. Attached to the lymjjhatic vessels, especially those surrounding the oriflces of the body, as in the back of the mouth and behind the nasal passages, there are bodies called adenoids. Different names ADENOIDS 87 are given to these bodies. The smallest in size are called lymph nodules, the medium, lymph nodes, and the largest, tonsils. There are count- less thousands of the smaller adenoids scattered about in and underneath the lining membranes of the mouth and the parts behind the nasal pas- sages. Adenoids cannot be seen by the naked eye, excepting the very largest size, called tonsils. And as a rule only two tonsils can be seen ; those placed on each side, at the back of the mouth, called faucial tonsils. By means of a reflecting mirror placed in the back of the mouth, looking upward into the cavity above the hanging palate, behind the nasal passages, situated at the roof of the cavity, another tonsil, called the pharyngeal, may sometimes be seen. When the pharyngeal tonsil swells, the untutored change its name and call it ''adenoids." A mischievous misnomer, highly improper, wonderfully confusing. In the back of the mouth and in the cavity be- hind the nasal passages, there is a peculiar, elabo- rate and important arrangement of adenoid bodies, known by the name of Waldeyer's lym- phatic ring, which is composed of six tonsils — the pharyngeal, two faucial, lingual (located on the back of the tongue), two tubal (located at the mouths of the Eustachian tubes, in the cavity behind the nasal passages), with a secondary supporting formation consisting of numerous nodes and nodules. The bodies composing the ring are connected by lymphatic vessels, and com- municate with one another. Adenoids are so placed in the course of the lymphatic vessels, that the lymph in flowing toward the large central 88 THE TONSILS AND THE VOICE trunks^ passes through them, undergoing a sort of filtration as it percolates through the partition walls of the lymph passages. Germs and other deleterious matter which in any way get into the lymphatic vessels are carried along until an ade- noid is reached, and here they are deposited and destroyed by the lymph cells, while the lymph itself passes on. Adenoids are set like sentinels to guard the lymphatic channels against invasion. Adenoids are filters. When engaged in the active process of filtration, they always swell. The swelling is in direct proportion to the protec- tive requirement. There is no other cause for their enlargement than augmented function. The doctrine that they are filters is taught by Delafield and Prudden {New York) , Adami and Nicholls (Montreal), and other leading au- thorities of to-day. In the process of filtration, when germs and other poisonous matters have entered the adenoid, their presence in this body stimulates its activity and leads to a rapid in- crease in the number of lymph cells, lymphocytes, leucocytes, and phagocytes, the duty of which is to attack, neutralize or nullify the invadiiig sub- stance. Adenoids are readily eoccited by the mildest invasion. Nature is ever alert to protect herself. A good illustration of the filter and pro- tective action of adenoids is to be seen in the case of a cold in the head. When the lining of the nose is bathed in a secretion of mucus and pus, the faucial tonsils swell and are painful. The f aucial tonsil acts as a filter, as a barrier, to the foul secretions of the nose. This statement has been made by B. Frdnkel (Berlin), and con- ADENOIDS 89 firmed by Von Levinstein, Von Lendrt and other authorities. Adenoids always swell when active- ly engaged in the process of filtration. "Adenoids," "adenoid vegetations," "pharyn- geal adenoids," "epipharyngeal tonsil," are dif- ferent names for the pharyngeal tonsil. The pharyngeal tonsil is attached to the roof of the post-nasal cavity, above the palate, and behind the nasal passages. It is the first lymphatic organ in the line of exposure to invading germs by way of the nose. As the most advanced outpost, or sentry-box full of lymph cells, which increase rapidly in their number upon the slightest alarm, it bears the brunt of every battle, when germs are attempting to invade the system by way of the nose. It is the most important organ of Wal- deyer^s ring and is considered by Frdnkel as the most important protective organ of the entire human organis^n. W estenhoeff er {Berlin), by the most exhaus- tive investigation, has proven conclusively that the germs of the cerebrospinal meningitis find entrance to the general system through the nose and by way of the pharyngeal tonsil. The in- vasion of the system takes place, Westenhoeffer states, only after the protective influence of the tonsil has been broken down by great number and virulency of the invading germs. In the ex- ercise of its protective function, the organ always swells, and sometimes attains a very large size. Its enlargement is always in direct proportion to the protective requirement. There is no other reason for its enlargement than augmented function. The protective action of the adenoids 90 THE TOXSILS AND THE VOICE is advocated by Goerke and Brieger, (Breslau), Metchnikoff (Paris), and by all the most dis- tinguished living authorities. A very clear demonstration of the filter action of adenoids is observed in the case of nasal catarrh, acute or chronic, in which the Uning of the nose is swollen, and covered with irritating mucus, and in which also the faucial tonsils in the back of the mouth become swollen and pain- ful. In almost every instance of abrasion of the nasal lining, these same adenoids become swollen, tender and painful. Thorough cleansing of the nose will cause prompt subsidence of the tonsillar swelling and pain. This direct filtration and pro- tective action of the faucial tonsils, in case of the abrasion of the nasal lining, is taught by so great an authority as Frdnkel of Berlin, and is en- dorsed by Von Levinstein, Von Lendrt and others. The 2)7'otective action of adenoids is also advo- cated by Brieger, Goerke and Haymann of Breslau, Metchnikoff of Paris, Delafield and Prudden of New York, Adami of Montreal, and others. Popular medical writers advocate the com- plete removal of "adenoids" as the only appro- priate remedy for all the symptoms which they allege "adenoids" occasion. They say "adenoids cause" and "The operation cures, frog face, bow legs, pigeon breast, club feet, irregular jaw, twisted teeth, short thick upper Hp, narrow nos- trils, open mouth, expressionless and undeveloped face, misshaped nose, nasal catarrh, impaired smell, laryngitis, spasm of the larynx, false croup, cough, hoarseness, defective speech, stammering ADENOIDS 91 and stuttering, inflammation of the eyes, defec- tive eyesight, misshaped ear drums, inflammation of the ears, plugged Eustachian tubes, mastoid disease, deafness, impaired taste, bad breath, dis- ordered stomach and bowels, constipation, bilious- ness, weak bladder, incontinence of urine, bad dreams, snoring, grinding of the teeth, disturbed sleep, daytime restlessness, depression of spirits, lack of energy, stupidity, headache, listlessness, backwardness in study, retarded and impaired mental faculties, stunted growth of body, parox- ysmal sneezing, hay fever, asthma, bronchial affections, lung diseases, nervous diseases, epilepsy, St. Vitus' dance, wry neck," etc. Each and all of the symptoms above mentioned are quoted from standard text-books. This remarkable indictment of a swollen pharyngeal tonsil, the so-called "adenoids," is apt to stagger good judgment, and constantly demands the greatest skill in deternwiing the precise conditions that eocist in each and every instance. The full measure of value possessed by the art of diagnosis, by that art the knowledge of which leads to the determination of a disease by means of distinctive marks or signs, is always demanded wherever "adenoids" are suspected. The art of diagnosis is difficult. Experts in the art are few. The art exacts a profound knowl- edge of diseased conditions, and of their relation- ship to one another. To become an expert diag- nostician requires great experience. A correct diagnosis will clear the field of most of the terrors that surround cases of supposed ''adenoids." A positive opinion can not be safely 92 THE TONSILS AND THE VOICE based on "suspicious" circumstances. ''Adenoids" may exist without causing any symptoms. Symptoms may be present without ''adenoids." "The open mouth, frog face, stupidity, back- wardness and slow mental and physical develop- ment" are not always due to an enlarged pharyn- geal tonsil. Far from it. Ninety-five per cent of the so-called "adenoids," judged by the open mouth alone, are mistakes in diagnosis. Neither does the pharyngeal tonsil, when enlarged, the so-called "adenoids," appear as a soft jelly-like mass, bathed in a blanket of mucous secretion; but, upon the contrary, it is as firm and as hard as an enlarged faucial tonsil. Friedrich {Rhinology, Laryngology and Oto- logy in General Medicine) : "Any and all diseases of the nose and post- nasal space which are followed by obstruction of the nasal passages lead to passive hyperaemia in the mucous membranes, which in turn produces occlusion of the Eustachian canal. The recogni- tion of this important fact is comparatively re- cent." "The interference with nasal breathing may be due to a number of conditions within the nose, as hypertrophy of the mucous membrane, mucous polypi, tumors, foreign bodies, etc." "If I have included hypertrophy of the pharyn- geal tonsil or adenoid vegetations among the diseases which produce hyperaemia and swelling of the mucous membrane with occlusion of the tube, by interfering with nasal respiration, it is because I believe the occlusion is due to a general 'adenoid habit' of the nose and pharynx, rather ADENOIDS 93 than to the direct mechanical intrusion of the pharyngeal tonsil." "Two forms of adenoid enlargement are dis- tinguished: a diffuse, cushion-hke hyperplasia, and a villous variety consisting of the finger-like projections or true vegetations." "As the vegetations usually spring from the median line, they are not, when at rest, in contact with the lateral walls of the pharynx, and there- fore do not occlude the orifices, as we are fre- quently able to demonstrate in the post-rhino- scopic image." "The adenoid tissue is not the soft, gelatinous mass that it is sometimes compared to, but is comparatively firm, and returns to its normal position of rest, dependent on gravity, as soon as the constriction of the pharynx and the tensores and levatores palati relax and the post-nasal cavity regains its normal volume. But it is not clear to me how a momentary occlusion of the orifice can have the same effect as a permanent one, and I therefore consider the hyperaemia of the entire mucous membrane the most important factor in the production of aural complications." "Paralysis of the muscles of the soft palate, especially of the levator veli palatini and tensor veli palatini — muscles which effect the opening of the Eustachian tube — ^is followed by perma- nent occlusion with the usual appearances of the membrana tympani. The action of the muscles may be similarly affected by tumors, tubercular ulcerations, or their scars, and by cleft palate, so that these conditions are also occasionally ac- companied by middle-ear disease." 94 THE TONSILS AND THE VOICE There are two ways by which to prove the pres- ence of ''adenoids." They must he seen. They must he felt. They may be seen by reflection in a mirror, placed in the back of the mouth, looking" upward into the cavity behind the hanging palate. They can sometimes be seen by looking" through the nostrils. They can be felt by the finger in- troduced into the mouth and pushed up behind the hanging palate. Sight and touch alone can determine the presence of ''adenoids'* Is it easy to see "adenoids" in the glass or through the nostrils? No. It is most often impossible. Is it easy to introduce the finger behind the hanging palate ? Not always. Sometimes it is impossible. And it is always unwise to try to introduce a large finger. The precise facial expression of "adenoids" may be simulated by any nasal ob- struction. There may be very great enlargement of the pharyngeal tonsil without the typical facial expression. Natier insists that in some neurotic children a state of "false adenoidism" exists. W. Braden Kyle (Philadelphia, 1907), remarks: "The symptoms of adenoid vegetations are very much the same as those found in any nasal or post-nasal obstruction. I have seen many cases of post-nasal obstruction in children which on ex- amination would seem to indicate immediate sur- gical interference, in which complete relief was obtained by the correction of intestinal irregulari- ties, such as obstruction, constipation, or irrita- tion produced by intestinal worms, there will re- sult turgescence with watery infiltration of the nasal and post-nasal structures. The pharyngeal tonsil in childhood is a normal structure, and its ADENOIDS 95 enlargement as described above is frequently- mistaken, for an increase in cellular elements when in reality it is only the normal structure enlarged by fluid distention." Lejinox Browne (London) states: "The post- nasal space may be blocked l3y polypi, cysts, and hypertrophied turbinals or by fibrous and malig- nant tumors. But by far the most common af- fection is enlargement of the pharyngeal tonsil called 'adenoids,' 'growths' or 'post-nasal vegeta- tions.' The 'vegetations' are not new growths but merely outgrowths of the normal tissue of the region." Sir Felix Semon {Lo7ido7i, 1902) says: "Lym- phoid tissue being very vascular easity becomes the seat of catarrhal inflammation, when it swells considerabty, and pro tem, may present all the symptoms of 'adenoids.' I am a great skeptic with regard to reflex neuroses arising from the upper air passages in general, and particularly so, with regard to those said to be due to 'aden- oids.' Let me warn you against too hastily diagnosing 'adenoids' from facial appearance and nasal obstruction alone." Mar age (Paris): "Divides patients suffering from adenoid tumors into three classes: (1st) Those who have hard and large tumors; they pre- sent generally very serious complications either affecting respiration and its development, or by affecting the hearing. (2nd) In the second class we arrange the patients in whom the growths are soft, large and bleed readily under the pressure of the finger; there is a cessation of development of the patient, a deafness more or 96 THE TONSILS AND THE VOICE less persistent, an inaptitude for work. (3rd) The third class comprises those who with the growths hut little developed present in general only the following symptoms, intermittent deaf- ness, mouth partly open, snoring at night. Hos- pital patients are almost all comprised in the first category." "Adenoids" is not a fatal disease. Not one death from this cause has ever been reported. But thousands of deaths have occurred from the operation for their removal. The operation is always bloody,, always painful^ always dan- gerous. The most eminent operators in the world have reported deaths from operations, the list inclu- ding such skilful technicians as Lennox Browne, Mayo-Collier, Schniiegelow, Damianos and Her- mann, Sandfort, Marage, Escat, Delavan, Burger, Schuchardt, Stucky, Sachs, Prehle, Putnam, Barhan, Hooper, Bliss, Kenefich, Stewart, Newcomh, Thompson, Goldsmith and others. When these most experienced and skilful operators report deaths, then what of those with lesser experience and lesser skill? The operation for the removal of "adenoids" is followed by the most appalling list of accidents of any operation in the history of surgery. Serious accidents have been reported by such distinguished operators as, Gronbeck, Tilley, Castex, Coley, Browne, Win grave. Riviere, Hagedorn, Broeckhaert, Holmes, Lunin, Her- mann, Mygind, Thurly, Quinlan, Hope, Citcelli, Hennebert, Chappell, Weber, Woeblews, Bulso, ADENOIDS 97 Urban, Cline, Kan, Thomas, Ryan, Wilkinson, Nettlehrock, Avale, Henking, Henkes, Cun- ninghani, Cliapnian and others. ^ Among the accidents reported as following the operation are: "Death from hemorrhage, im- mediate or secondary; recurrent hemorrhage; asphyxia, mental disturbance; laceration of lining membrane of post-nasal cavity; injury of the nasal septum; recurrent nasal hemorrhages; permanent derangement of blood circulation in the nose; permanent redness of the nose; injury and laceration of the palate, palatine muscles and of the uvula; paralysis of the velum of the pal- ate; injury of the Eustachian tubes; acute in- flammation of the post-nasal region; inflamma- tion of the nasal lining membrane; infection of the wound; abscess; diphtheria of the wound; blood poisoning; scarlet rash; cerebral menin- gitis; arthritis; tonsillitis; laryngitis; inflamma- tion of Eustachian tubes; ear disease; mastoid disease ; rupture of ear drums ; running ears ; ear- ache; deafness; inflammation of the eyes; dis- turbance of vision ; alteration and impairment of the voice; removal of the first important line of defense against germ infection; awakening of latent diseases; development of sarcoma (can- cer) ; development of latent tuberculosis in adja- cent glands and in the lungs; neuralgia; head- ache; vertigo; syncope (faintness) ; general ner- vousness; spasm of the larynx; asthma; goitre; Basedow's disease; profound anaemia, loss of general health and strength; troublesome con- traction of wound; troublesome scars, return of^ 'adenoids,' " etc. 98 THE TONSILS AND THE VOICE It is impossible to completely remove adenoid tissues. This statement is made by Groher of Vienna, Von Levinstein of Berlin, Goerke and Brieger of Breslau, Marage of Paris, and others. Adenoids grow again after they have been re- moved. This is the teaching of Goerke, Von Levinstein and others. The same causes which led to the first growth lead to a new growth. Adenoids disappear spontaneously. This statement is made by Escat (Toulouse), Bos- worth (New York), Grayson (Philadelphia) and all other authorities. "Adenoids," or to speak properly, enlargement of the pharyngeal tonsil, is not so common as the doctors say, or as the public imagines. From reports courteously sent to me by S. Josephine Baker, M.D., of the Department of Health, New York City; the Re- port of the Department of Health of Chicago; Oliver P. Coonan, the Board of Public Educa- tion of Philadelphia; George P. Barth, M.D., Public Schools Medical Inspection, Milwaukee; the Superintendent of Instruction of Public Schools, St. Louis; H. B. Burns, M.D., Depart- ment of Public Health, Pittsburgh; Chas. H. Keene, M.D., Department of Public Schools of Minneapolis; the Annual Report of the Depart- ment of Public Health, San Francisco, I have made the following collaboration of the whole number of pupils examined, of the number that had enlarged adenoids, and of the number that had enlarged tonsils. ADENOIDS 99 Number Examined Nuniber with enlarged adenoids Number with enlarged tonsils New York City, 1910.... Chicago, 1910 Philadelphia, 1911 Milwaukee, 1910-1911 . . St. Louis, 1910-1911 .... Pittsburgh, 1911 Minneapolis, 1911 San Francisco, 1909-1910 266,426 126,847 25,000 19,616 16,788 12,704 7,102 2,207 40,946 4,702 852 506 204 1,324 2,042 173 50,012 24,286 714 3,834 952 2,322 2,474 409 476,690 50,049 85,003 The table shows that less than one in nine of the whole number eccamined had enlarged aden- oids. Less than one in five had enlarged tonsils. In the Eleventh Annual Report of the City Superintendent, New York City, 1909, there is an article on ''The Relation of Physical Defects to School Progress/' by Leonard P. Ay res, in which it is stated that "a careful tabulation was made of the records of physical examinations of 7,698 children who had been examined by school physicians. Nearly 80 per cent of the children who were of normal age for their grades were found to have physical defects, while only about 75 per cent of the retarded children were defec- tive. The percentage of defective children in the lower grades was decidedly greater than in the upper grades. Retarded children will be older than their fellow pupils in the same grade. In all cases it will always be true that the backward pupils will be the older pupils. Now, the older pupils are found to have fewer defects. This is true whether they are behind their grades or well up 100 THE TONSILS AND THE VOICE in their studies. Eighty per cent of all children of normal age have physical defects more or less serious, wJiile 75 per cent of the retarded children are found to he defective. About one child in every four has hypertrophied (enlarged) tonsils. About one child in eight has adenoids. The figures do not really show the retarding influence of each sort of defect separately for the reason that the same child is often suffering from sev- eral sorts of defects." In a pamphlet on ''What American Cities are Doing for the Health of School Children'' pub- lished by the Russell Sage Foundation of New York, covering a report of 1038 cities, it is stated that "medical inspection of the public schools is for the purpose and to best enable the child to take full advantage of the free education offered by the state. Let us have good men to do the work and let us pay them well. It will demand a special training and a careful technique. It is certainly to be regretted that this point of view has not been more generally taken in America.'' The fact is notorious that the medical inspec- tion of the public schools, as a rule, is made by the very youngest and least experienced physicians. Politics and inexperienced physicians will en- danger the entire system of inspection. The Russell Sage Foundation Report states that "There are 75 cities in which doctors donate their services. The average salary paid to doctors falls within from $200 to $300 per annum. Two hundred dollars per annum has come to be re- garded as a somewhat standard rate of remuner- ation for school physicians all over the United ADENOIDS 101 States f' The following table gives a partial list of cities taken from the Report of population and the number of doctors employed by each city. Population Doctors Employed 4,763,883 142 2,185,283 100 1,549,008 30 687,029 6 533,905 30 416,912 1 373,857 10 301,408 7 New York City Chicago .... Philadelphia . . St. Louis Pittsburgh . . . San Francisco Milwaukee . . . Minneapolis . . In the City of Pittsburgh, the school doctors receive one hundred dollars per month. And there are just as many school doctors in this City as in Philadelphia, which has three times the pop- ulation of Pittsburgh. The question becomes pertinent, Does Pittsburgh receive three times more efficient service than Philadelphia? And at five times more cost than the average inspection throughout the United States ? Does Pittsburgh receive more than thirty times the efficiency of San Francisco? By what gauge may the marked discrepancies be explained and may efficiency be best judged, or, is the whole situation at present really one of politics and graft? Inspection and inquisition are sometimes coupled in the Pittsburgh schools. What doctor attends your children? is sometimes asked of the parents. Sometimes parents are told to take their children to certain doctors whom the in- 102 THE TOXSILS AND THE VOICE spector designates for operation. And sometimes particular hospitals are favored. In a paper read before the Society of Medical Inspectors of the City of New York, December 4, 1908, Dr. Neustaedter stated: "Much stress has been laid upon such physical defects as enlarged tonsils, adenoids, refractive errors, and carious teeth, as the most prominent causative factors in backward children. But when we surs^ey the statistics and find 85 per cent of all school children are suffering from some physical ailment, and among the sufferers 96 per cent are bright pupils, and on the other hand some of the most vicious children whom I have personally examined pl*esented no physical de- fects that I w^as able to detect, it seems to me imperative that we look further than tonsils and adenoids." He mentions drug habits, bad food, impure air. Under date of April 25, 1911, he continues: "Among 8,000 pupils, 10 per cent of all are the very best, and about 10 per cent are backward. Tonsils are slightly more preva- lent in the best pupils. The best singers have 50 per cent more tonsils than the poorest. I have yet to see the backward pupil who became pro- ficient after removal of tonsils, provided other factors were not ameliorated. Six hundred backward pupils who had their diet and mode of life changed, and of whom only two per cent had corrected physical defects gave good results, namely: 98 per cent did good work after six months." William L. Bodine, president of the National League of Compulsory Education, in his annual ADENOIDS 103 address to that body, said: "The underfed child means the backward pupil at school, and the backward pupil means truancy, or delinquency. Poverty is the great cause of truancy and irregu- lar attendance. The higher the cost of living the lower the chances of the children of the poor to complete the eighth grade." Being under-fed is a good reason for a pupil being backward. No one should expect a hun- gry child to make a bright pupil. But, at the same time that a charitable public furnishes milk and sandwiches to under-fed children upon their arrival at school in the morning, it is not consis- tent for the school doctor, when he arrives, to take out their tonsils and "adenoids" upon the ground that they are backward pupils. Remarkable improvement has been noted in mentally and physically backward children fol- lowing the administration of thyroid extract. The operation for "adenoids" should never be undertaken without serious consideration. It is often very difficult. It is always bloody; always painfid and often fatal. The operation shoidd never be perforined in cases that cause no symp- toms; never in patients who are known as bleed- ers. The results of operation will always be dis- appointing in cases that accompany nasal ca- tarrh; with thickening of the lining of the nasal passages; in cases of iiarrow nostrils, and mis- shaped nose; in cases of irregular teeth; in de- formity of the upper jaw; in deformity of the mouth and palate; in cases of deafness, with in- flammation of the middle ear and with thickening and hardening of the lining's of the ear passages; 104 THE TONSILS AND THE VOICE in affections of the ear drum; and in all children with poor constitutions, improper or insufficient food, and had hygienic surroundings. Normal adenoid tissues should always he pre- served if possible. In the strictest concordance with the very latest teachings of the very latest and best authorities, namety: (1) of Delafieldj Prudden, Adami and others that adenoid bodies of all sizes, whether called nodules, nodes or tonsils, are filters; (2) of Brie- ger, Goerhe, Frdnkel, Metchnikoff, and others that they protect the human system against the invasion of germs; (3) of Groher, Escat, Goerke, Mackenzie, Von Levinstein and others that they cannot he completely removed hy a surgical operation; (4) of Goerke, Brieger, Von Levin- stein, Escat, Wright, Grayson and others that when removed they grow again; (5) of Escat, Bosworth and others that they disappear spon- taneousty; (6) of Mackenzie, Semon and others, that the operation for their removal is greatly ahused hy its ignorant and reckless mis-applica- tion to unsuitable cases; (7) of the fact that the operation is followed by numerous deaths; (8) of the fact that the operation is always bloody, always painftd, and is followed by the most ap- palling list of accidents that ever followed any surgical measure; (9) of the fact that 92 per cent of all cases can he cured without operation, as proved hy Marage and others, I desire to ask. Is it not reasonable to demand that greater re- strictions he imposed upon operations for the re- moval of ''adenoids''; that greater efforts be made to improve the hygienic, pthysiologic and ADENOIDS - 105 sanitary conditions of the patient; to better the ventilation of the sleeping apartments; to better the quality and quantity of food and to regulate outdoor eocercise; to thoroughly cleanse and keep sterilized the nasal passages; and to adopt the newer lines of treatment, safer and more in ac- cord with the modern research of Lendrt and Poli and the therapy of Von Levinstein, Frdnkel, Brieger, Goerke, Chiari, Marage, Escat, Moure, Jacobi and other high authorities? CHAPTER VII THE TONSILS AND THE TEETH. The functional relationship between the teeth and tonsils is interesting. George H. Wright, in an elaborate article in the Boston Medical and Surgical Journal, May 20, 1909, gives a detailed account of his views regarding this relationship, and draws "attention to four periods in the de- velopment of an individual from two to eighteen years, when the tonsils become slightly enlarged without inflammation and without obstruction or evidence of suppuration, and these four periods are represented practically at the time when four groups of molars are in the process of eruption. That is, the periods with slight variation are from two years for the first group; six years of age, the second group; twelve years, the third group; and from seventeen, the fourth group. "I propose to show that these enlargements of tonsils coincide definitely with these particular periods of tooth eruption. I hope to show, too, that when there is no infection of the tonsil, by keeping the patient under observation and giv- ing, if necessary, simple prophylactic treatment to the tonsil and waiting for the normal eruption of the tooth, even the slight hyperaemia of the tonsil, which is its expression of function, will entirely disappear and the tonsil will return to its normal condition. "We offer for consideration nineteen patients, and in each case the enlargement coincided with 106 THE TONSILS AND THE TEETH 107 the second, third or fourth periods of tooth erup- tion. In no instance did we find excessive en- largement or suppuration. Yet all these pa- tients were sent to us by physicians and social seiTice workers, or they came on their own initia- tive for treatment and operation. None have been operated on for removal of the tonsils. In two patients under observation since last May, the tonsils have returned to normal and the teeth are fully erupted. "Another aspect of the problem is illustrated by a boy, age eleven, who had his tonsils extir- pated three years ago; he came to us for treat- ment for glandular enlargements in the neck. The tonsillar gland is markedly enlarged and other glands enlarged and distributed down to the border of the clavicle. No history of tuber- culosis in family." "We exhibited another patient, girl, age seven- teen. Tonsil slightly enlarged on right. Left tonsil normal. Right tonsil later removed. Three months later patient returned and shows enlarged tonsillar gland the size of a hen's egg. Examination of mouth reveals lower third molar cutting through the gums — the fourth period. Also remnant of root of lower six year molar. The root was extracted and operation on glands deferred. One month later patient reported. We found the gland reduced to normal, no pain or swelling of any kind and , tooth erupted. (Since reporting these cases, January 30, 1909, we now have a record of forty-nine patients where operations on tonsils have been deferred, 108 THE TONSILS AND THE VOICE awaiting eruption of the molars in the several periods. ) "With the enormous structural upbuilding where nature is elaborating the materials for forty-eight teeth, and the jaws, there is much waste tissue to be disposed of. Sometimes there will be a swelling in the region of the submaxil- lary and lymphoid enlargements, intense pain, excessive salivation, followed by a hot and fever- ish condition of the oral mucous membrane, and occasionally a slight cough. The disturbance may continue until we find a slightly enlarged tonsil, or even acute otitis media with a sinus and profuse suppuration discharge through the ex- ternal ear. Usually within a few hours or days, at least, the offending molar will make its ap- pearance through the gum, disturbance will cease, and tonsil return to its normal condition. So, too, in the adjacent region of the upper first and second temporary molars, we may find lym- phatic enlargements involving the parotid gland, lachrymal gland and tonsil. The faucial tonsil and normal adenoid upon the side nearest to the erupting tooth may become considerably en- larged through the influence of the lymphatically absorbed waste. "Some years ago we made experiments by seal- ing a coloring of Prussian blue into teeth pulps of dogs, to determine the lymphatic drainage, and it was shown conclusively that the blue par- ticles passed directly through the pulp to the lymphatic glands and endothelial spaces. ''Wood states: 'Clinically the gland which be- comes enlarged during tonsillar infection appears THE TONSILS AND THE TEETH IQQ to be superficial and has led to the belief that the posterior gland of the submaxillary groups is in- fected through the tonsils.' This may be rightly so under some conditions, yet I incline to the be- lief that this particular gland which may become enlarged at the periodic time of teeth eruption and coincident enlargement of the tonsil is en- larged not because of infection through the tonsil per se^ but through normal waste or combined with bacteria from the diseased membranes adja- cent to erupting teeth, and that the enlargement of the gland is due to this latter process, and the tonsillar enlargement without infection is a nor- mal expression of the active function of the ton- sillar gland, and when the tonsil becomes in- fected, it does so because of its lack of power of resistance to the invasion of micro-organisms. ''Jonathan Wright has made a careful study of normal tonsils in relation to behavior of the epi- thelial cell in the crypts toward bacteria and their relation toward dust, with conclusions which demonstrate that pathogenic bacteria inhabit the tonsillar crypts in great numbers, and do not en- ter the tonsillar tissue proper so long as the ton- sils are in a normal and healthy condition." The author of the latest text-book on the "Diseases of the Nose, Throat and Ear," has "at- tempted the complete removal" of 2,000 tonsils! What per cent, were examined in connection with carious teeth? What per cent came in the four periods of tooth development? What per cent, would have been unnecessary when function of tooth eruption had ceased? What per cent, were slightly enlarged with no mechanical obstruction 110 THE TONSILS AND THE VOICE or abscess? What per cent, might have re- sponded to prophylactic treatment and given no subsequent trouble? What per cent, have or will develop deeper troubles beyond these bar- riers of the lymphoid ring of Waldeyer because it is presumable that the adenoid tissue was re- moved at the same time from the vault of the pharynx ? What per cent, of cases of temporary paresis of the palato-pharyngeus muscles, cervi- cal cellulitis and hemorrhages? What per cent, of lymphoid enlargements, both superficial and deep, will occur later in life? George H. Wright: "As to what the tonsil may yield as a by-product after the metamor- phoses of this normal waste, and what influence the by-product as a secretion through the crypts to the digestive canal may have upon the body as a whole, is a question for the future to determine. "In conclusion, we offer these six observations: (1) When a tonsil is normal, infection from the external surface is rare. (2) Secondary infection through the lymph channels is the usual source. (3) There are four periods of molar erup- tions, with some variations in time when the ton- sils may enlarge without infection or inflamma- tion, at two years, six, twelve and seventeen. (4) Tonsils, when slightly enlarged and not infected, return to normal with complete erup- tion of the teeth. (5) Diseased teeth are a prolific source of en- largement of the glands, through proximity of membranes, either directly, by infection, or by toxins. THE TONSILS AND THE TEETH m (6) In the treatment of the tonsil by the specialist, may we not include as a routine the observation as to carious teeth and a recognition of these four periods of eruption coincident with slight enlargement?" C. F. Cobb: "For years no one has imder- stood the importance of the tonsil, and, being considered useless, it has been removed freely. "The tonsil lies between the pillars attached to the fascia of the superior pharyngeal muscle pro- tected in front and rear by the pillars to one-half or more of its extent. From the pillars anterior and posterior a reflexion of mucous membrane comes to the tonsil, making it, when at rest, re- semble a telescope one-half closed. Were it not for this reflexion of mucous membrane, the con- traction and expansion of the organ would be checked by the mucous membrane about it and great pain would result on any enlargement of the gland. This arrangement seems to show that nature intended the tonsil to be free to change its shape in accordance with alterations in size due to some functional activity. And this agrees with clinical facts, for we find tonsils now large, now small, at one time recommended for opera- tion, and a few weeks later, when the date ar- rives, of such reasonable proportions that no operation seemed wise. "Of late years, theories of absorption from ton- sils have come in and tonsils have been con- demned on slight evidence and removed. "Let us take two hypotheses: First, that the tonsil is an organ for infection or absorption; second, that it is a protective organ. First then, 112 THE TONSILS AND THE VOICE acute tonsillitis affects the tonsil and gives rise to toxic symptoms. Tuberculosis enters by the tonsil at times and tubercle bacilli have been found in the follicles of the tonsil. Rheumatism is said to be a result of tonsillar absorption. "Of course, it is claimed by many advocates of this theory that the tonsils causing such troubles are diseased tonsils, but practically, as disease can only be determined in most cases by removal of the tonsils and examination under the micro- scope, the result has been the removal of healthy tonsils, the working theory being that the tonsil might form the source of infection; and in any case no harm could be done. "Now let us discuss the probabilities, as seen from an anatomical and pathological standpoint, of the question whether the tonsil is an absorp- tive or protective organ. "If the tonsil were intended to absorb poison- ous substances, why should nature give them to young and tender children and allow them to atrophy as the person grows older? "Why should nature surround the tonsil with chains of lymphatic glands which resist infection into the general System? "How is it that millions of staphylococci, the poison of which to a mild extent reaches the gen- eral system, causing a fever for a day or two, can be cared for by this maligned organ, when a very, very few, in a wound, may result fatally ? "But it will be said. Does not tuberculosis sometimes get in in this way ? "It is true, probably, that it does, but it is also true that because a sentinel is sometimes over- THE TONSILS AND THE TEETH II3 powered by an enemy a wise commander does not abolish all sentinels. There are other channels for tuberculosis. We find them in Peyer's patches in the intestine and in the glands which drain the bronchi of the lung. Who suggests the wisdom of destroying such organs because they have failed in their efforts to protect us ? "Now, Dr. Wright tells us that the tonsil serves as a sentinel for the protection of the sys- tem from the products of dental infection, and this idea is borne out by common sense, by clinical experience and by theory. "I have myself watched the improvement in size of tonsils after the removal of bad, rotting teeth. This function is, perhaps, one and not the only function, but it is enough to justify the ton- sil's presence ; and our gratitude is due to him for clearing up this point. Do not misunderstand these remarks. Removal of obstructing tonsils when breathing, swallowing, or disease is present, is justifiable and wise, but radical extirpation should only be done where disease of the tonsils, chronic tonsillitis or peritonsilar abscess make it necessary, and this rule is especially true in early youth." {Boston Medical and Surgical Jour- nal May 20, 1909.) A. Coolidge, Jr.: "A considerable variation in the size of the pharyngeal or faucial tonsil must be looked upon as within normal limits. The lymphoid tissue may become increased in amount to an extent to be considered pathologi- cal, either as a whole or in one or more of the tonsillar masses. This increase over the normal amount takes place almost exclusively in chil- 9 114 THE TONSILS AND THE VOICE dren, although once estabUshed, it may persist into later life. It is of especial importance in the naso-pharyngeal space, where it is commonly called 'adenoids' and in the faucial tonsils, when the patient is said to have enlarged or hypertro- phied tonsils. "Among the causes to which we must look for tonsillar enlargement, Dr. Wright now adds cer- tain conditions of the teeth." {Boston Medical and Surgical Journal^ May 20, 1909.) G. Hxidson-Makuen: "The Faucial Tonsils and the Teeth," June, 1909: "Diseased faucial tonsils affect the teeth in three ways. First, they interfere with the general health of the patient and thus with the proper nourishment of the teeth. Second, they contribute very largely to the local invasion of the teeth by the numerous bacteria which emanate from their crypts. And third, they interfere by pressure with the align- ment of the teeth and with the normal develop- ment of the maxillarj^ bones. "AVe cannot cure mouth-breathing and its re- sultant disastrous effects, in all cases, merely by the removal of tonsils and adenoids. When there are dental irregularities which make it im- possible, difficult or even a little inconvenient to close the mouth, something more than tonsillec- tomj^ and adenoidectomy must be done." After removal of the wisdom teeth the back part of the roof of the mouth will sometimes sink or drop down to the extent of fully a quarter of an inch. The removal of tonsils, also, according to Von Chiari, will cause the roof to fall down in THE TONSILS AND THE TEETH II5 a similar manner — the tonsils act as a prop or support to the back part of the roof of the mouth. A high, narrow palatal arch is often associated with a deflected septum and irregular teeth. Sturmann {Berliner Klinische W ochenschrift , June, 1912) employed a brace for two and a half months and made the palate and septum practi- cally normal. William S. Flower, an able, experienced and conscientious dentist, has suggested that "in new- born babes it is a good practice to make a habit of pressing the thumb firmly against the roof of the mouth; that this practice spreads the upper jaw, and widens the roof, preventing a saddle- back formation of the jaw; and later facilitates the ease in eruption of the molar teeth and helps to prevent the development of irregularities; by widening the jaw it causes the roof to fall to an extent, creating thereby a more roomy, better drained and better ventilated post nares." Flower states that "the tonsils are more often af- fected from disease of the gums about the necks than the roots of the teeth." The habit of the Indians in tying up the mouth of their new-born babes, so as to force them to breathe through the nose, is an excellent practice, and may help to account for the fine nasal respiration and the absence of "adenoids" in this race. Recently, a young lady applied to me, with the statement that: "I have a severe pain in the left side of my face, so severe that I have had no sleep for fourteen days and nights. My physi- cian says that I have disease in the antrum and 116 THE TONSILS AND THE VOICE that I must be operated upon, and has directed me to see a speciaUst on the nose." I examined her carefully, found no disease in the antrum, but that her teeth were causing the pain. She said, "I have seen my dentist and he has assured me that my teeth are all right and that they have nothing to do with the pain, but that the antrum is diseased." I answered that if she had no objection, we would consult my dentist. We did so, and he discovered that the pain in her face was caused b}^ a tooth that was pressing hard againfft its neighbor. Pressure was at once removed and the pain of fourteen days ceased instantly. A gentleman applied to me, saying: "I have been to a specialist who has told me that the bones in my right cheek are dead, and that I must go to the hospital and have them removed to relieve the severe pain in my right cheek." After careful examination, I said to him: "The bones in your right antrum are not at all diseased, but your trouble comes from your eye tooth." We con- sulted Flower, who confirmed my diagnosis, and by attending to the tooth, the trouble in the face quickly disappeared. In another case a young lady suffered from severe pain in her ear. She was told by a special- ist that she had mastoid disease, and that the mas- toid operation was imperative at once to relieve the pain. The mastoid operation was per- formed, but the pain did not abate. In several days after the operation, she cut a wisdom tooth and the pain disappeared immediately. CHAPTER VIII SIX MEDICAL QUESTIONS. Question Number One. Have the normal faucial tonsils any function: physiologic, biologic, chemical, phonetic or other ? By normal faucial tonsils, I mean the ton- sils situated in the fauces, between the anterior and posterior palatine arches, in healthy condi- tion, and of such size as not to project beyond the line of the palatine arches, nor press upon surrounding tissues, of a size so small as not to interfere with the perfect anatomical outlines of the walls of the pharynx. Answers : H. Holhrooh Curtis: "In my opinion — no." Eugene H. Hodenpyl: "The function of the tonsil is unknown." G. Hudson-Makuen: "The question in my mind is still sub judice." A. Coolidge, Jr.: "I do not believe that any one knows. The fact that they are there should be presumptive evidence that they have." Edwin Pynchon: "If the tonsils have any function at all, it must be only in babyhood or the early years of life, as Nature's apparent effort is to diminish them in size — so-called atrophy. I claim this atrophy is more apparent than real, being largely a transition from protrusion to sub- mersion. In the change the lymphoid element is 117 118 THE TONSILS AND THE VOICE absorbed or destroyed and the glandular element relatively increased. The disadvantageous fea- ture of it is that this change is produced by and through a low grade of inflammatory action, re- sulting in an increase of tonsillar secretion of bad character which increases troubles in both the pulmonary and gastro-intestinal tracts. While when submerged it may be claimed that thej^- do not interfere with the outline of the walls of the pharynx, they at any rate fill a space which should be concave like an inverted trough. In- wardly they ma}^ also exert pressure as on the Eustachian tube, etc." A. Barth: "About the importance and func- tion of the faucial tonsils I have my ideas formed from the literature and our own observations. But I think that in a collective research, to have scientific value, only personal researches should be considered. These are not considered in this question." George B. Wood: "I cannot accept your defi- nition of what is a normal faucial tonsil, as I be- lieve that large tonsils may be a personal idiosyn- cracy and not the result of disease, just as in the nose — sometimes big and sometimes small. As to their function they undoubtedly form lym- phocytes in the germinating follicles, and, ac- cording to my belief, also form a metamorphosis of the epithelial cells of the crypts. Further than this they have not been proven to havie any function." . , j , J. Maclntyre: "With regard to the first two questions, I really cannot pretend to say more than is recorded in our text-books." SIX MEDICAL QUESTIONS 119 J, E. Newcomh: "Have made no special studies in this direction," E. M. Holmes: "I have made no original re- search, and therefore my opinion is without weight." E. W. Scripture: "No phonetic use known. Enlarged tonsils change the timbre of the voice." C. H. Knight: "I presume they have." Sir Felice Seiiion: "In reply to your inquiry, I beg to say that I do not know enough of the physiological role of the f aucial tonsils to give an apodictic opinion in a few lines. In my lectures, 'Some Thoughts on the Principles of Treatment in Diseases of the Upper- Air Passages' (British Medical Journal, November 2 and 9, 1901), I have energetically protested against operative in- temperance in my specialty and need not say that I should consider removal of normal tonsils an absolutely inadmissible proceeding, which could not be condemned severely enough. In Volume XIII of the Reports of St. Thomas's Hospital (London) J, you will find under the heading, '^The Throat Department of St. Thomas's Hospital in 1883/ quite a lengthy arti- cle from me on 'The Indications for, and Meth- ods of. Removal of the Tonsils/ which will give you full particulars on several of the questions concerning which you wish my opinion. What seems to me most important is : to keep the happy medium between operative intemperance and the happy-go-lucky operative inactivity." Lubet-Barbon: "I do not know the function of normal tonsils." 120 THE TONSILS AND THE VOICE Luc: "No personal experience nor views on the subject." Beverly Robinson: "I believe so." John N. Mackenzie: "I can add nothing defi- nite to our imperfect knowledge of the subject. I believe that the tonsils were put into the throat of man with good, and not evil, intents to serve a physiological rather than a pathological pur- pose and that if they were originally intended as easy and natural avenues of infection, then na- ture made a poorer job of it than she did in the case of other portals of germ entrance, such, for example, as the respiratory passages." St. Clair Thomson: "I think they must serve some function in quite early life." Wesley Mills: "I believe they have, though I do not feel justified in teaching that to my stu- dents. I think their function is so slight that they can in their work be readily compensated for by other organs. I am inclined to think that they are related to the glandular system in some Avay." E. B. Gleason: "I believe they have other func- tions beside those in common with other portions of the lymphatic system." George L. Ross: "Undoubtedly. Especially physiological and chemical, but I have never fol- lowed this question in the physiological labora- try and therefore am not prepared to furnish facts." George B. Rice: "Yes." J. W. Gleitsniann: "The normal faucial tonsil has in my opinion a physiological function." SIX MEDICAL QUESTIONS X2I William E. Casselberry: "Yes; to the best of my knowledge and belief." Frank E. Miller: "Lubricates principally. Remove tonsil with capsules and atrophic pharyngitis ensues, also adhesion of pillars. Regulators of pillar action and secretions. They are indices of intestinal changes, hence assist chemistry of the stomach and intestines princi- pally on account of response to alkaline applica- tions. As lubrication and regulation of phonetic muscles are involved in the working of a normal tonsil to such an extent is voice impaired. A healthy tonsil in some throats is never seen, ex- cept by means of pulling out of the way the ante- rior palatine wall, otherwise the arrangement of the parts are abnormal." Von Chiari: "Most probably the tonsils serve for the purpose of formation of leucocytes." Massei: "I believe the tonsils (the faucial nor- mal ) have a biologic function similar to the lym- phatic tissue which forms the so-called Waldeyer ring." Escat: "I am of the opinion that the faucial tonsils have not for their only function that of phagocytosis studied by Metchnikojf, but also a physiological and biological function, due to an internal secretion, like all the secretory internal glands (thymus, thyroid, liver, etc.)." Moure: "I consider that the normal tonsils have physiologic, biologic, chemical and phonetic functions. There is no doubt that they are the advanced sentinels of the rear throat, defending the entrance of the air passages, upper and lower. They do not appear to play an important phago- 122 THE TONSILS AND THE VOICE cytic role, from a biological point of view. From a phonetic point of view their normal role must evidently be to prevent in a certain measure the nasality (nasonnement) by maintaining the pil- lars in the midst of which they are placed." Schmiegelow: "I look upon the tonsils as a part of the protecting system which is repre- sented by all the lymphoid tissue to be found everywhere in the mucous membrane of the pharynx and nasopharynx." Van Bag gen: "The faucial tonsils have cer- tainly a phonetic function. Their situation in the mouth at a place where the voice receives an essential part of its specific qualities allows us to admit this assertion. The muscles of the anterior and posterior pillars of the fauces between which the tonsils rest, are in constant movement, when we are speaking or singing. Their action com- bined with the movements of the muscles of the soft palate changes the shape of the voice passage at the back of the mouth when we are forming the different vocals or producing tones of differ- ent pitch. The position of the tonsils, situated as they are between the pillars of the fauces, are of great importance with regard to the exactitude and perfectness of those movements. Also for the resonance the tonsils are of great interest for the voice. With their spongy tissue, they can be compared to the felt in the piano which softens the tone and regulates the resonance." SIX MEDICAL QUESTIONS 123 ADDENDA TO QUESTION NUMBER ONE FROM ORIGINAL SOURCES. Elaborate researches have been made into the anatomy and physiology of the faucial tonsils, and many minute anatomical data have been posi- tively ascertained and repeatedly verified and authenticated by trained and able investigators. Retterer, Journal de V Anatomic, 1888, "The Origin and Evolution of the Tonsils" : "Proved the existence of clear germinating centers in the follicle of the tonsils. Proved the existence of lymphatic vessels occupying the whole follicular mass of the tonsils, and forming a system of closed lymphatic canals which do not open into the connective tissue reticulum by stomata or by their extremities. He proved that the periphery of the lobules is more vascular than the center." Marcel Labbe and Ch. Levi-Sirugue: ''Re- searches on the Structure and Physiology of the Tonsils" Work done in the laboratory of Pro- fessor Landouzy, at the Laennec Hospital, Re- port published in the Bulletin of the Anatomical Society of Paris, July, 1899. "What we have chiefly sought to do is to defi- nitel}^ determine the nature and distribution of the cellular forms which are met with in the inte- rior of the tonsil, the constitution of the follicles and their relation to the lymphatic passages, and thus deduct as far as possible, their physiology. The tonsil was considered in times past as an organ designed to secrete mucus to lubricate the alim.entarv bolus, but this function does not be- 124 THE TONSILS AND THE VOICE long to the tonsil, but really to the glands in groups which are outside of it." "The phenomena of absorption^ at the level of the tonsils has been studied experimentally. The epithelium prevents absorj)tion which only be- comes possible if it is destroyed, or if the sub- stances are introduced under the epithelial bed, and even under these conditions the absorption is very slow." The most exhaustive and valuable laboratory research investigations on the tonsils have been made by Retterer, Labhe and Sirugue. Labora- tory investigations of Stohr, Von Lendrt^ Poli and Frederici, Krause, Briegei^ Goerke, Westen- hoefer, Merkel, Most, Groher, Hodenpyl, Flem- ming and Von Levinstein are important. So are the clinical observations of Jacohi and Frdnkel. The works of Gulland, Fox, Spicer, Menzer, Lexer, Heridelssohn, Kilmmel, Lindt, Kayser, Allen, Masini, Pugnat, Pluder, Schoenemann, Broeckhaert, Wright, Asliurst, Lichtwitz and Sahrages and Hicguet are valuable. The works of Goodale, Bosworth, Wood and a few others are interesting. And beyond these are more than one thousand monographs that burden the subject. Labbe and Sirugue: "From the absolute anal- ogy of the internal structure of the tonsil, with that of the ganglions (lymphatic) , the spleen and the closed follicles of the intestines, we have a right to conclude, contrary to the opinion of Bet- terer, that the tonsils are assimilable to the gan- glions. Like them, they have a role in the hema- topsis. The germinative centers of the tonsil SIX MEDICAL QUESTIONS 125 have certainly the same functions as those of the gangHons which are, as Flemming has shown, the locaHties for the production of leucocytes." "There is also in the germinative centers of the tonsil, as in those organs of which the struc- ture is analogous, an incessant cellular renova- tion. Stohr admits the passage of leucocytes through the epithelium of the tonsil into the buc- cal cavity. The epithelium has the same protec- tive role at the level of the tonsils as at the level of the rest of the buccal mucosa. The crypts augment its extent. Even in the normal state the epithelium is always more or less irritated, and above all at the bottom of the crypts, and we have seen that it is the seat of the incessant phe- nomena of cellular renovation. This epithelial irritation is due to the presence of dust, of small foreign bodies, which penetrate into the crypts; it is due, above all, to the existence at the surface of the tonsil of pathogenic microbes, which are found constantly in the normal state. Netter, Bezanson and Griff en have observed the constant presence of pneumococci at the surface of the tonsil, generally associated with streptococci. Cornil had already seen that tubercle bacilli meet at the surface of the crypts in normal individuals, in the same way as Strauss has observed on the surface of the nasal mucosa. These microbes, although in the crypts, are on the eooterior of the tonsil, and it is the defense reaction of the epithe- lium which prevents their penetration. It is only when the epithelium has been destroyed that the microbes penetrate, and in such case they rarely pass beyond the conjunctive bed; it is only in the 126 THE TONSILS AND THE VOICE case of the complete destruction of the tonsil that they may be found in the follicles/' Hodenpyl "confirmed the observation of Ret- terer that the Ij^mph net occupies the whole fol- hcular mass of the tonsils and forms a system of closed canals which do not open into the reticu- lum. Hodenpyl tried, but could not procure any absorption by the tonsil from its surface." Groher: "The Tonsils as a Port of Entry for tubercle-bacilli" : "The microbes having entered the tonsil, are mostly destroyed because the serum kills them ; the power of the leucocytes as phago- cytes kills them also. It is also possible that the microbes enter the sj^stem through the blood-ves- sels. The tonsils seem to be a less favorite set- tling place for tubercle-bacilli than the lymph glands, for we find scrofulous glands oftener than infections of the tonsils. JNIany authors have considered diseased tonsils as more liable to mi- crobial infection than healthy ones. If that is true it has not been proven." Metchnikoff: "Some years ago Stohr demon- strated that the walls of the tonsils, and especially the tonsils and other lymphoid organs, are tra- versed b}^ an enormous number of leucocj^tes, which execute a kind of immigration towards the cavities containing micro-organisms. This con- tinual and normal condition is often termed Stohr' s phenomenon, and when we remove a par- ticle of mucus from the surface of the tonsils of a person in good health we always find that it contains leucocytes, especially microphages, filled with micro-organisms of all kinds." Von Levinstein: "As we find in normal tonsils SIX MEDICAL QUESTIONS 127 always follicles with cell-producing centers, we can claim with surety that in the normal tonsil young lymphocytes are produced, and that in the hyperplastic tonsils the number of newly formed lymphocytes is always considerably larger than in the normal tonsil. In the atrophic tonsil young lymphocytes are not found. What be- comes of these young lymphocytes is not decided. That they are put into the circulation has to be considered doubtful, so long as it is not proved that the vasa efferentia of the tonsils contain a larger amount of lymphocytes than the vasa af- ferentia. So far this has not been proved and it will be difficult to prove because it is impossible to say which are the afferentia and which the ef- ferentia. We have also to mention the fact that not a small number leave the tonsil by wandering through the epithelium to the surface of the organ, or into the lumen of the fossula. I have proved in my work that a considerably larger number of lymphocytes leave the hyperplastic organ than the normal tonsils. We know the fact that young lymphocytes are in the tonsils." Frdnkel: "The Infectious Diseases of the Pharynx." "The ideas about the function of the tonsils have materially changed within the last thirty years, through the discovery of Stohr, that an interrupted immigration of, Stohr believes, leuco- cytes takes place from the follicles and the adenoid substances of the tissue surrounding the fossula. One sees the leucocytes passing through the epithelium. This immigration at certain 128 THE TONSILS AND THE VOICE places is so strong that it is difficult to find the epithelium." Jacohi (Archives of Pediatrics, July, 1906) : "Cases of membranous throat diseases behave dif- ferently according to their location. Now, when- ever the membrane is limited to the tonsil there is very little, or no, glandular swelling in the neighborhood. On the other hand, if a mem- brane extends from a tonsil to its neighborhood, or starts at a distance from the tonsil, neigh- boring lymph bodies swell at once. Again, the treatment of this neighborhood shows itself almost immediately on the swelled glands. That is mostly evident when the seat of the membrane is anywhere in the posterior nares which excel by an immense network of lymphatics. On the other hand, when it covers the vocal cords, and Morgagni's fossa, both of which have a scanty network of lymphatics, there \& no adenitis, nor any constitutional symptoms. These clinical ob- servations have stood the test of time and must be reckoned with." "One of the tonsil's functions is surely that of either preparing or storing leucocytes. "It has not been possible, thus far, to verify the existence of afferent or efferent ducts of their own. The practical deduction from this is, that the tonsils have little or no connection with the lymphatic system. The number of blood vessels in the normal tonsils is not large, and it becomes greatly diminished when that organ has become the seat of repeated chronic inflammation." Jacohi {Medical Record, August 19, 1911) : "Does not believe the removal of tonsils should SIX MEDICAL QUESTIONS 129 be done as often as some gentlemen seem to think. It was probable that the infection of rheumatism and scarlet fever through the capsule was not so frequent ; it more likely took place through the soft lymphodes of the Waldeyer ring." He em- phasized the desirability of keeping the nares clear, both before and after operation. "If there were greater care exercised in this respect, so many operations on the tonsils would probably not be necessary." Sir Felice Semon (St. Thomas's Hospital Re- port): "I recommend that the tonsils be reduced in size: (1) If they interfere with respiration and lead to insufficient oxygenation of the blood. (2) If they lead to change in the character of the voice and to defective articulation. (3) If they lead to defective development of the face and chest. (4) If the chronic enlargement be attended by frequent attacks of inflammation of the ton- sils themselves, by tumefaction of the cervical lymphatic glands, or by catarrhal conditions of the neighboring mucous membranes, notably of the Eustachian tubes. The common characteris- tics of these indications are, it will be observed, that all of them are conditional, not absolute. In other words, I recommend a surgical interfer- ence with enlarged tonsils only when they cause any of the serious symptoms above enumerated, and not merely on account of the enlargement per se." "The term, 'large tonsils' is one that can only xo 130 THE TONSILS AND THE VOICE be used relatively. Comparatively large tonsils in a roomy pharynx are no doubt much less mis- chievous per se, than much smaller ones in a nat- urally very narrow throat. ''Supposing that the former do not interfere with any of the functions of the part nor lead to inflammation, etc., there is in my opinion not the slightest reason to interfere with them." "It is by no means rare for children to be brought to me simply because it has been acci- dentally discovered that their tonsils are large. If in such cases I cannot satisfy myself that any of the graver consequences are present, I never interfere. It is only when I find that any or several of the symptoms mentioned in my list are present that I strongly insist on the undesira- bility of either leaving matters alone or losing precious time by having recourse to inefficient measures. I wish to emphasize the distinction thus made, lest it should he inferred from the tone of my foregoing remarks, that I am a fanat- ical advocate of surgical interference as soon as an enlargement of the glands is discovered. Nothing, indeed, could be more alien to my inten- tions.'' "I have no doubt that tonsils can be equally well removed by very different methods. I con- sider total enucleation not only dangerous, but also generally superfluous. The tonsil project- ing under normal conditions nearly or quite up to, or even a little beyond, the palatine arches, it ought to be the aim of the operator to reduce them, in cases of hyperplasia, to their normal size." SIX MEDICAL QUESTIONS 131 Adami and Nicholls (Principles of Pathology, Vol. 2, 1909) say: "The tonsils appear to have an important function. While the lymphoid cells are themselves, to a limited degree, phagocytic, polymorphonuclear leucocytes in considerable numbers make their way from the blood vessels to the surface through the epithelial covering. These leucocytes are strongly phagocytic and their activity suggests that the tonsils form one of the barriers against the invasion of the system by pathogenic micro-organisms." 132 THE TONSILS AND THE VOICE ADDENDA INTRODUCED ESPE- CIALLY FOR THE PURPOSE OF SHOWING THE WIDE DIVERSITY OF MEDICAL VIEWS AND CONJEC- TURES REGARDING THE FAUCI AL TONSIL. Meeting of the American Laryngological As- sociation, IslSiY 31, 1909, reported in Medical Record, September 25, 1909. J. S. Gibh (Philadelphia), Paper on ''Some Observations upon the Co7nplete Extirpation of Diseased Tonsils,^' and Discussions hy the Asso- ciation. Gibh spoke particularly with reference to the method followed with the boys who entered Girard College. "If it is necessary to remove a tonsil at all, it should be done completely. The wire snare was far more efficient than the tonsillotome in bring- ing about the described condition, viz.: removal of all diseased crypts. In ninety cases there is a fever between 99° and 101.5°. In nine cases in which the friable nature of the tonsillar tissue was very pronounced, and in which there was much dissection and the use of punch forceps called for, the fever rose to 102° and over. In two cases there was regurgitation of fluids through the nose. The fauces were indurated and there was sloughing over the area of the ton- sillar wound." E. L. Shurly (Detroit) "commended the views of Dr. Gibb but said that while we were all familiar with the results of tonsillotomy, we did not know so much about the remote results. SIX MEDICAL QUESTIONS I33 We must remember that the tonsil has an inter- nal secretion^ and that we do not know the pos- sible results on the pharynx, stomach and con- tiguous or neighboring organs following the re- moval of all the tonsillar tissue. Disagreeable atrophy might ensue. We should indeed re- move all diseased crypts, but have we done enough by so doing? Should we not leave enough tissue to perform the functions of the tonsils?'' Casselherry {Chicago) "did not agree with Shurly. We should always remove the tonsil- lar tissue completely. We should be sure to remove the tissue included within the velum, which he had named the 'velar' lobe." Freer (Chicago) "used sharp instruments in freeing the tonsil from its adhesions." Barnhill (Indianapolis) said that "whatever function the tonsil might have, there was plenty of other tissue in the throat which would take care of that function, especially since the tonsil was diseased. The tonsil pits often filled up after removal with granulation tissue, but some- times adhesions formed between the anterior and posterior pillars, and these might pile up on the tongue and hind it down/' C. G. Coakley (New York) said that "there had been in his cases anywhere from two to four weeks after operation a small mass of granula- tion tissue, which he removed by either the punch or nitrate of silver. There was often left an irregularity of the lower edge of the velum on the two sides, and he wofidered what effect^ if any, followed in professional voice users/' 134 THE TONSILS AND THE VOICE G. Hudson-Mahuen {Philadelphia) "thought that one great element of value in GibVs paper was that he had been able to watch his cases so closely and report on their condition some time after operation. He would as soon think of leaving a decayed tooth root in the mouth as to leave a portion of a tonsil." R. C. Myles (New York) "called attention to the basi-lateral tonsils he had described some fif- teen years before. He had seen them extending at least three-quarters of an inch into the palate, and when the entire capsule had been removed there had been a cellulitis extending into the zygomatic fossa. Sections of the superior con- strictor muscles were too often removed along with the tonsils."^ J. Price Brown (Toronto) "had been told by a music teacher of that city that several pupils had their singing voices practically destroyed by the removal of the tonsils." W. K. Simpson (New York) "thought that we were too apt to base our opinion on the imme- diate sequel following removal of the tonsils, and that we might get from the filling-up of the ton- sillar fossa with cicatricial and connective tissue an interference with the muscular action of the velum which would he just as harmful as the leaving behind of a small poj'tion of the tonsil." J. O. Roe (Rochester) said "that patients sometimes complained more of septic trouble around the neck and of glandular swellings after the tonsil operation than before it. When a ton- sil was diseased it was diseased all the way through, for the crypts went all the way to the SIX MEDICAL QUESTIONS ^ 135 bottom of the tonsil, and If one left a portion be- hind one had increased absorption of the septic material in the region." E7nil Mayer (New York) "deprecated the use of the finger. Modern surgery called for the use of rubber gloves. He uses a blunt dissector. He thought that too much emphasis had been laid on the amount of blood in these regions." Meeting of the Societe Beige d'Otologie, de Rhinologie et de Laryngologie. Reported in La Presse Oto-Laryngologie Beige, No. 7 of 1910. A review and discussion of paper presented by Hicguet on ''The Func- tions and Utility of the Palatine. Tonsils. Study of the Physio- pathology of that Organ." Hicguet, "in presenting his paper, ran over in a rapid resume the diverse theories held on this subject since those days of Kolliher, who does not attribute to the tonsil any physiological role, down to the quite recent opinion of Frederici, who considers that organ as the agent of elimina- tion of harmful and infectious substances, a function in which the tonsil comes to the defense of the organism. Hicguet remarks that we must accord much more credit to the work of the physiologists than to that of specialists, when these latter constitute themselves improvised laboratory operators. He reviews the work of Stohr and Flemming and also the article of Bickel, in which those authors affirm that the gland itself has, in total, little importance. "The leucocytes, which form in the tonsil, di- rect themselves in part toward the surface of the organ: the others, in a more notable proportion, 136 THE TONSILS AND THE VOICE pass by the vasa eff erentia into the general lym- phatic circulation, and thereon into the blood. It is, so to speak, assigning to the tonsil a role of defense. Goerhe, inspired by the works of Brie- ger, has set forth that latest theory, so much in opposition to American authors, who see in the tonsil a mischievous organ and even dangerous to the organism by reason of the infections which may be carried in by that path. Brieger's views need to be confirmed," said Hicguet, "and," he concludes, that "in the actual state of our knowl- edge, it is very difficult to say whether the normal tonsil is useful or harmful. Two theories remain before us: the one considers the tonsil as an auxiliary to the organic defense, and the other as a source of infection. Both appear to him as exaggerated^ for it seems evident to him that the hypertrophied and diseased tonsil coidd not come to the defense of the organism, while the normal tonsil could not be a source of infection/^ Discussion. Cheval "regrets his inability to come to the support of his conclusions. He put in parallel the last three paragraphs with the conclusion of the first paragraph. The author says, 'The one of the two theories considers the tonsil as an or- gan of defense,' and 'That theory seems to apply to the normal tonsil'; and 'On the other part, it is not possible to afiirm that the normal tonsil is useful or harmful.' It seemed to him that Hic- guet had been able to conclude in the afiirmative. The normal tonsil is a usefid organ, because in the actual state of our knowledge, it is demon- SIX MEDICAL QUESTIONS 137 strated that it comes to the defense of the or- ganism. In his conclusion, Hicguet says further: 'While the normal tonsil could not be a source of infection.' Eveii co7iditionally , that phrase is too absolute. In fact, aside from cer- tain humors which have a bactericidal power, the defense of the organism against infection, which watches it at every instant, is exercised principal- ly by the phagocytes. For the 7nechanism of infection does not sensibly differ from the mech- anism of defense: there is not between these two mechanisms but one difference, if more or less. In effect: (a) That the virulence of the germ augments the chimiotaxism of the leucocytes, an- nounces to them the presence of a germ with its infectious qualities: there is hypopolynucleose ; the polynuclei desert the field of battle and take refuge in the smaller circulation and in the deeper organs ( spleen, etc. ) . There is, in conse- quence, infection more or less profound : a single failure of the phagocycloses may then provoke an infection. To this hypopolynucleosis suc- ceeds a hyperpolynucleosis which may phagocy- tose the germs and avoid the diffusion of the infection; (b) the phagocyte itself may lose cer- tain of its properties, following a weakening of the general condition; for example, sometimes also from some entirely different local cause (traumatism, surgical intervention, etc.) and the germ then triumphs, "In other terms, the leucocyte triumphs over the microbe in the defense of the organism: the microbe triumphs over the leucocyte in infection. 138 iHE TONSILS AND THE VOICE and these alternatives may succeed each other many times in the course of an existence. "But at the precise moment of this weakening or failure, more or less prolonged, of our white corpuscles, the tonsil may appear normal. It will be at least in an ante-pathologic condition, and even normal in certain cases where the germ is not phagocytosed, or only slightly so. From this, can we write that the normal tonsil cannot be a source of infection? "I thus approach the opinion of Broeckaert. It is evident that the pathologic tonsil may be a source of infection and has no longer the power of coming to the defense of the organism; per contra, in a state of perfect health and under ordi- nary conditions, the physiological tonsil has for its function the assisting in that defense. But sometimes, also, its state of defense weakens, and it may become a source of infection." Tretrop "desired to make some remarks in de- tail: Infection through the tonsil, taught as an hj^pothesis, is for Tretrop a realitj^ It is not astonishing that the tonsil, a lymphoid organ in relation with the sub-adjacent lymphatic ways, may become infected, and transmit farther on this infection, without even necessarily becoming diseased on its own account." Escat "addressed his compliments to Hicguet and Broeckaert for their papers, so supported by documents and so precise. He is in accord on the majority of points with these gentlemen, but nevertheless, makes some remarks." Escat "attaches a certain value to the theory oi Allen as to the hypothesis of a tonsillar func- SIX MEDICAL QUESTIONS 139 tion beginning and ending with the skeletonic growth. The fact that the tonsils normallj'' atro- phy from the time that this growth terminates, justifies, to a certain point, this hypothesis. Re- searches made by Lichtwitz and Sabrages on the modification of the hemotologic formula verified before and after the surgical ablation of ade- noids, seems to justify the hypothesis of a dys- trophic condition connected with the alteration of the internal secretion of the ring of Wald- eyer." C apart, Jr.: "Not only the palatine and pharyngeal tonsils atrophy normally at a certain age, but it is the same with the lymphatic tissues of the digestive tube, and of the organism in general. Also, it is by an evident error that we see the anatomists describe in an adult a palatine tonsil of an appreciable dimension. It is follow- ing interior infections that this organ loses the possibility of self- absorption at a certain age. We may recall in favor of the hypothesis of an internal secretion of an unfavorable influence, the remarks made recently by Lermoyez. 'Chron- ically inflamed adenoids appear to lead to differ- ent troubles from those observed following nasal obstructions due, for example, to atresiae or to fibrous polypi. On the other hand, the ablation of adenoids even reduced, often leads to an amelioration not in accord with the respiratory troubles which it could bring on." Poli (Genoa) spoke on "the theory of the elim- ination of microbes by the tonsil," and was supported by his associate, Frederici. In sup- port of that view, he showed microscopic prepara- 140 THE TONSILS AND THE VOICE tions of the tonsil taken from a dog in which Frederici had injected into the pleura a culture of the bacillus of Koch. The presence of bacilli were perceived in the tonsillar crypts." Schiffers (Liege) : "When we speak of the function of an organ, it is necessary to consider above all, its texture. That of the tonsil corre- sponds to the texture of the lymphatic ganglions. It acts, then, as they do. It must be added that the tonsils being placed at the entrance of the superior respiratory and digestive tracts, and dis- posed all on the surface, must also have another function. This is, according to the author, a function of defense. The tonsils are leucocytic organs. Histological examinations show that the leucocytes are derived from the epithelium of the tonsillar crypts." Hicguet responds that "the diversity of theo- ries which he has met in his work has put him to much pains to form the conclusions at the end of this report and explains why he is not enthusias- tic about any of them. He supports in part the observations of Cheval, but puts them in opposi- tion to the opinion of Escat, who does not seem to be a partisan of the phagocyte theory, and who, on the contrary, accords a more particular attention to the theory of Allen." To Tretrop, who "recalls that the tonsil is of- ten the port of entry of infection, Hicguet re- sponds that in his paper he does not consider this fact hypothetic, except in the sense of the Amer- ican authors, who consider the tonsils as a dan- ger." "As to the analysis of the blood, it could not SIX MEDICAL QUESTIONS 141 give serious results, except in the case of 'hos- pitalized' patients." At the same meeting of the Societe dfOtolo^e, de Rhinologie et Laryngologie, also reported in the La Presse Oto-Laryngologie Beige, there was a paper presented by Broeckaert, entitled, ''Ad- vantages and Disadvantages of the Ablation of the Palatine Tonsils." Broeckaert (Gand), at the beginning of his paper, "declares that the theories proposed so far do not satisfy him, and that, as Levinstein has very justly remarked, 'The question of the true role of the tonsils is yet to be solved.' In the first chapter the author examines the arguments that may be of value in favor of the suppression of the tonsils; he then studies the various infec- tions to which the palatine tonsils appear to serve as a port of entry; he then describes the remote troubles to which these infections give rise. "The second part of the work is devoted to an examination of the disadvantages resulting from the ablation of the tonsils, and the measures to be taken to avoid the complications following that operation." Discussion. Escat (Toulouse) is "completely in accord with the writer concerning the technic of the abla- tion of the palatine tonsils. The adenoid tissue is not neoplastic tissue: why then be so bent upon . extirpating it as radically as if it were a cancer^ It is to be feared that if tonsillectomy following the American method becomes very common, the cases of operatory hemorrhage will 142 THE TONSILS AND THE VOICE multiply and that the good reputation of tonsil- lectomy will suffer from it." M. Delsaux (Brussels) "has paid attention to two types of tonsils, very distinct : the simple hy- pertrophic and the 'enchatoneed lacunary. t^Hiile the former are rarely accompanied by a ganglionic invasion of the neck, the others, pro- foundly infected, have transmitted their infec- tion to the IjTuphatic cervical barriers. Thus, when we remove the tonsils of the first variety, we almost never perceive a febrile reaction. It is not the same with the ' enchatoneed' tonsils, accom- panied by cervical ganglionic swelling. And this may be conceived, since the infection is locahsed in the tonsil, on the one part, and that on the other it has passed the limits of the organ in view. The traumatism of the tonsillectomy exalts the microbian virulence, and the fever appears. Del- sauoc is supported by the statistics of about fifty cases." ScMffers (Liege) : "When it concerns the set- ting forth of therapeutic, and above all, of oper- atory conditions, it is necessary to consider the normal and pathologic state of an organ. Evi- dently, if the tonsil is inflamed, its function is prejudiced by it. We must distinguish the true from these false hypertrophies. The tonsil of- ten retrocedes because there is no true hyper- trophy. The volume of a tonsil does not consti- tute an absolute indication for an operation. The speaker has remarked this with reason. Accord- ing to ScMffers, the tonsillectomy is an operation to be completel}'- advised when it concerns solely the avoidance of new inflammations. It is not SIX MEDICAL QUESTIONS 143 imposed, and is not justified except in cases of malign tumors of the tonsil. The tonsil itself, is, however, very rarely attacked by suppuration : there exist certainly, suppurative follicles, hut the instertitial tissue itself does not suppurate. When we speak of tonsillitis with suppuration, it concerns, in the immense majority of cases, the peritonsillitis. It is the peritonsillar tissue which forms the abscess, and most frequently it is at the superior pole of the tonsillar loge where the pus must he sought. In many cases of relapse it is necessary, first of all, to liberate the tonsil, principally in front and rear, which suffices to definitely cure the patient." Broeckaert (Gand) : "Thanks Escat, Delsauoc and Schiffers for the important part they have taken in the discussion of his paper and partakes completely of their opinion. In spite of the elo- quent pleading of Jacques in favor of tonsillec- tomy with the hot instrument, Broeckaert could not come to the support of this mode of interven- tion, which, as Tretrop has said, is painful and in no way avoids hemorrhages and infections. '"One question to which it would be difficult to respond is that of knowing what is to be under- stood by a normal tonsil. When does it become hypertrophied, and when is it pathologic? We must not forget that, even normal, the tonsil pre- sents an irregular form with innumerable crypts which are true microbian receptacles. Two points stand out from this discussion: "1st. We are in accord in admitting that there are infectious ' enchatoneed' tonsils, which are the most dangerous and claim our intervention. 144 THE TONSILS AND THE VOICE "2nd. Such intervention, in these cases, must be radical, without falling into excesses." At the same meeting of the Societe d'Otologie, Jacques {Nancy) presented a paper on the "Considerations on the Ablation of the Tonsils" "Among the multiple lymphoid agglomera- tions which are arranged along the paths of the air and of the aliments, the palatine tonsils par- take, with the pharyngeal tonsils, an unfortunate fragility, which translates itself by a remarkable receptivity in regard to pathogenic germs and a consecutive aptitude for hyperplastic degenera- tion. Also we should relegate to the ranks of the Utopias, the seductive theory which makes of these organs intangible citadels of the digestive and respiratory passages, though they do not constitute, in reality, in the greater number of cases, more than a double hearth of infection, with continual menace of the lymphatic passages. Every tonsil recognized as chronically inflamed should be radically suppressed." "The different methods of partial amputation are inoffensive or dangerous. The section with the hot instrument, after pediculisation of the gland, assures a rapid and complete excision. It is exempt from danger, if it is practised with a wire moderately heated, applied to the exact lim- it of the tonsil and the pillars." Tretrop {Antwerp) : "Tonsillectomy, the In- dications, the Results." "The tonsil is the seat of local inflammations, and the port of entry of general infection. The author has observed it in tuberculosis, etc. The chronic inflammations, bringing on close ad- SIX MEDICAL QUESTIONS 145 hesions with the pillars, create a pseudo-tubercu- losis. Tonsillectomy is the chosen method in the adult to cure the old inflammations and the pseu- do-inflammations. Tretrop passes in review the methods most employed and shows the advan- tages of each of them. He insists on the neces- sity of treatment preparatory to the interven- tion." Meeting of the British Medical Association, Section of Larynology, July 29, 1910, reported in the Journal of Laryngology, Rhinology and Otology, of October, 1910. A paper presented by Dan MacKenzie, on ''Enucleation of the Ton- sil" ; and the discussion by members of the Asso- ciation. "Complete and entire removal of the hpyer- trophied tonsil by dissecting it out of its bed in the pharynx has come to be the operation de rigueur in America. Those who advocate enu- cleation as the routine operation summon logic to their aid. "If, they say, it is improper in the surgical sense not to remove the whole of a lymph node or nodes when they are diseased, in the neck or elsewhere, then surely it is equally improper to treat an enlarged tonsil — which is, after all, a lymph node — by partial excision, seeing that in doing so we leave behind undisturbed a certain amount of diseased gland tissue. At first sight this argument looks unassailable, but it rests upon an assumption — namely, that an enlarged tonsil is invariably a diseased tonsil. Compari- son of the enlarged tonsil with the enlarged lym- phatic gland of chronic tuberculosis is not quite 11 146 THE TONSILS AND THE VOICE accurate. For, as it is well known, no patholo- gist has so far succeeded in proving to the satis- faction of all that ordinary hypertrophy of the tonsils is general^, or frequently, or ever at all, due to tuberculous infection such as that which so often induces chronic cervical adenitis. In op- position to the opinion which would lead us to take up enucleation as the routine operation for hypertrophy of the tonsil, we can point to the fact that the ordinary tonsillotomy efficiently performed is seldom followed by a recurrence of the hypertrophy. "There is no doubt whatever that enucleation is the more severe operation; it takes longer to perform; it inflicts a deeper and more extensive wound. "Is there a class of cases in which enucleation is to be preferred to tonsillotomy or the typical operation? I think there is. Enucleation should always he performed when the tonsil is diseased and not merely hypertrophied. Second- ly, the tonsils should be enucleated in patients who are suffering from tuberculous disease of the cervical lymphatic gland. There is another variety which should be dealt with by complete removal. I refer to what is known as the 'buried' tonsil. One would be very cautious of recommending enucleation to a professional singer, for obvious reasons." Discussion. St. Clair Thomson said: "The operation de- scribed hy Dan McKenzie was no new depar- tiu-e. It was as old as Celsus, and he himself SIX MEDICAL QUESTIONS 147 had published a method of enucleating the tonsil many years ago." Dundas Grant said that "he exercised a cer- tain amount of eclecticism in the choice of opera- tion. He considered that the leaving of a portion of tonsil tissue, as such, was not a serious matter and indeed possibly a beneficial one so long as the crypts were cleared away. Moreover, the protective character of the capsule had already been pointed out, and its complete removal was open to question." Luc said: "The wire snare was a troublesome instrument to use, and recommended in its stead the so-called 'rigid cold snare' of Vachez." Watson Williams asked: "What definite in- formation did we possess regarding the physiol- ogy of the tonsils? In rheumatism, which had been ascribed to tonsillitis, he had frequently found the tonsils atrophied or absent. He did not think, therefore, that enucleation was the best operation, but the question was one which re- quired thrashing out." Lambert Jack held that "enucleation should never be the routine operation. Removal of the tonsils by the guillotine in the hands of a skilled operator gave results as good as any other opera- tion. The need of getting every crypt away was exaggerated. The throat has many crypts and to remove them all would be impossible. Mr. Hetfs statistics, referring as they did to hospital cases, were fallacious, because at hospitals the operation was most incompletely performed." Syme said that "Enucleation was not neces- sary in every case." 148 THE TONSILS AND THE VOICE TV. Stuart-Low thought that ''Enucleation was best suited for adults with large tonsils and not for children. He feared that Hett removed muscle as well as tonsil in operating." Seccomhe Hett said that "If Stuart-Low charged him with removing muscle, his reply was that Stuart-Low left the capsule behind." Dan McKenzie in reply said that "The discus- sion had revealed considerable discrepancy of opinion with regard to the best way to operate. It also showed that the principles laid down in his paper with regard to enucleation in disease and recurrent hypertrophy had received a gen- eral assent." The president, H. Tilley, said that "the trend of opinion seemed to be that the cases should be selected for each operation." Seccomhe Hett {Meeting of British Medical Association, July 29, 1910. Reports in Journal of Laryngology, Rhinology and Otology, Octo- ber, 1910) . "The Anatomy of the Capsule of the Tonsil and Its Significance in the Treatment of Diseases of the Tonsil" Describing the anatomy of the tonsillar cap- sule, Hett "observed that the upper portion is surrounded by a loose areolar tissue space, the peritonsillar space, which is limited below by the insertion of muscular fibres from the superior pharyngeal constrictor into the capsule. In the act of swallowing, the upper part of the tonsil is pressed downward and inwards between the pil- lars in such a way as to encourage the discharge of secretions from the supra-tonsillar fossa." Meeting of the American Laryngological As- SIX MEDICAL QUESTIONS 149 sociation. May 30, 1911, reported in the New York Medical Record of September 16, 1911. Report of paper presented by Henry L. Swain {New Haven) on ''Are Tonsils a Menace or a Protection?"^ and the discussion by members of the Association. Swain discussed the question as answered, "First, in the practice of throat surgeons all over the country. As they almost universally were adopting the operation of tonsillectomy when- ever they attacked the tonsils, the inference was that the latter were surely of account and always a menace. Answering the question from the anatomical and physiological standpoint, the evi- dence adduced was such that it could be readily proved that the tonsil was to all intents and pur- poses a lymph node and was of just as much im- portance, no more, no less, as any other node. He called attention to the fact that the tonsils (faucial) had lymphatic trunks leading into theiUj, which drained from the nose and palate, so they had a very definite office in caring for this lymphj, a very different viewpoint from the usual one' of being a mere retentive area for matter soaking into them from the mouth. Being thus, when in health, an active agent of protection to the system, the tonsil must, like the whole lym- phatic system, be of relatively greater importance to the very young child than to the adult. These two facts were strengthened by the additional observation that as the healthy normal individual always had such tissue, which began to function- ate early in life in the adenoid tissue in the naso- pharynx, in the faucial tonsils, in childhood, and 150 THE TONSILS AND THE VOICE in the lingual tonsil in later adult life, it would seem absolutely jjroved that the body required some such physiological action of some such tis- sue for its proper development or in its economy, i.e.: a definite function for lymphoid tissue. Taking this as true, it would be absolutely illogi- cal to remove any of it except for just cause, and this led Swain to deplore tonsillectomy, complete removal of the tonsils, as an indiscriminate rou- tine procedure in young children, especially when this was accompanied by complete adenoidec- tomy. The adenoidectomy was to be com- mended — too thorough an operation was rarely possible — but in early childhood a portion of the healthy f aucial tonsil tissue could be well allowed to remain. The system might have need of it. When diseased, any of the good operations for tonsillectomy could be used, but he felt that the teaching should be that, even in adults, there were other methods of bringing about a satisfac- tory and safe condition of the tonsils. These latter he almost universally employed by prefer- ence and such patients had, at least, the benefit of Avhatever protection the saved tissue could be to them." Discussion. George B. Wood (Philadelphia) "objected to the views held by the essayist, and stated that he had proved the lymph flow in the tonsil an effer- ent current. He did not believe it to be possible to tell macroscopically a diseased tonsil. He ad- vocated in all diseased conditions the complete removal of the tonsil." SIX MEDICAL QUESTIONS 151 J. G. Wilson (Chicago) "agreed with Dr. Swain that the physiological activity of the tonsil was principally confined to fetal and infant life, but did not consider it as a pure lymphatic gland." W. E. Casselherry {Chicago) said "he had never seen a particle of detriment to either the child or adult resulting from the total excision of the tonsil, but explained this on the basis that there were supplementary tissues to continue its functions. He agreed with Swain that during childhood the tonsils should never be removed unless definitely diseased, but advocated their absolute removal if operated upon at all." John N. Mackenzie (Baltimore) "emphat- ically voiced his disapproval of the indiscriminate removal of tonsils so largely practiced at the present time, and considered it the duty of every laryngologist to make the conditions warranting tonsillectomy plain to the general practitioner." C. G. Coakley (New York) "called attention to the fact, also referred to by Swain, that the tonsils in children and in adults were entirely dif- ferent in function; in adult life it was classed more as a pathological than as a physiological organ. He mentioned the fact that frequently in adults with rheumatic diathesis the removal of the tonsil which has caused quinsy, etc., would show an abeyance of these peculiar manifesta- tions. It was his opinion that tonsils should be enucleated and not cut off, and his experience had been that the children in whom this pro- cedure had been carried out because of disease of 152 THE TONSILS AND THE VOICE the tonsils, as a general rule became markedly improved in health following the operation," A. Coolidge, Jr. (Boston) "discussed the etiol- ogy of acute tonsillitis, referring to the recent epidemic in Boston, which was at first traced to the milk supply, but later became general throughout the city. He considered, in view of the mode of onset, that the condition in the tonsil pointed rather to an efferent than to an afferent flow of the septic micro-organisms or their toxins." B. R. Shurly {Detroit) "deprecated the re- moval of tonsils unless proved to be diseased. In many hundreds of tonsillectomies he had seen nothing but favorable results." Bliss {Philadelphia) "considered the stumps of tonsils remaining after partial removal to be a great menace to the health of the individual." SIX MEDICAL QUESTIONS 153 LETTER OF MOURE. Translation. Question 1. I consider that the normal tonsils have physiologic, biologic, chemical and pho- netic functions. There is no doubt that they are the advanced sentinels of the rear throat defending the en- trance of the upper and lower air passages. They do not appear to play an important pha- gocytic role, from a biological point of view. From a phonetic point of view, their normal role must evidently be to prevent in a certain measure the nasality by maintaining the pillars, in the midst of which they are placed. Question 2. What I have said above contains the response to the second question. Question 3. It is difficult to say what are the effects of allowing the ablation of the tonsils in view of the fact above all, that, at least in our country, the complete ablation is never per- formed, but only a removal more or less complete and that in consequence there always remains enough follicles to fulfill the role devolving on that gland, which, like the greater part of the lymphatic organs, atrophies little by little with age. Question 4. After the ablation of the tonsils a change of the voice is above all observed when the subject has already been accustomed to singing and that in consequence he has habituated himself to emit the voice with the two tonsils situated be- tween the pillars. If the forms of certain hypertrophied tonsils 154 THE TONSILS AND THE VOICE embarrass the speaking voice (phonation), there is no doubt that there is then, after their removal, a very appreciable modification in the emission of the speaking voice among young persons. Question 5. I believe that in a general way, one should not remove the tonsils when they are not of excessive size, or are not inflamed; in a word, that they are not the point of departure of local infection, frequent or distant (caseous, sup- purative tonsilitis). They are organs as useful as the ganglions when these latter are not degen- erated. (Signed) Moure. Bordeaux, January 28, 1910. SIX MEDICAL QUESTIONS 155 Question Number Two. What are the functions of the f aucial tonsils ? Answers : Eugene Hodenpyl: "Unknown." A. Coolidge, Jr.: "I do not know." G. Hudson-Makuen: ''I do not know/' H. Holhrook Curtis: "To prevent the am- nionic fluid entering the respiratory tract by pre- natal coalescence with the pharyngeal and lingual tissues constituting the ring of Waldeyer." Edwin Pynchon: "I am disposed to think that they have no function except to cause trouble, evidenced by the invariable improvement in one way or another after their complete and correct removal. If they have any function, nature evi- dently supplies other means to fully and easily take their place, therefore the system sufl*ers no disadvantage from their loss." William E. Casselherry: "The adoption of tonsillectomy as the ideal operation, even though the ideal be not always exactly fulfilled, lends more importance to the inquiry with respect to the protective and other functions of the tonsils. The tonsillar crypts always contain pathogenic germs against which nature seeks to provide by phagocytosis, the engaging polynuclear neutro- philes, however, coming not from the lymphoid tissue, per se, but from the blood, so that this is a protection only against the evil of the tonsils themselves. More stress is now laid upon the bactericidal properties of the juice of lymphoid glands and upon the vaso-tonic effects of an in- 156 THE TONSILS AND THE VOICE ternal secretion, but it will be remembered that aside from the tonsils there are other lymphoid tissues which seemingly are quite adequate to care for these functions. Certain it is that no functional ill effects are discernible from tonsil- lectomy." George B. Wood: "See answer to question one." Charles H. Knight: "1 do not know." J. E. Newcomb: "I believe that the normal tonsil is the origin of cells, phagocytes, to take care of deleterious substances introduced into the mouth." Joseph W. Gleitsmann: "I believe the tonsils to be an organ for defense (Goerhe, Archiv. fiir Laryngologie XIX, 1907, page 244), {Jonathan Wright, New York Medical News, March 4, 1905), {Brieger, Archiv. fiir Laryngologie, XII, 1902, page 2500)." George B. Rice: "I beheve that the lymphoid ring in a normal state, including, of course, the faucial tonsils, has a protective function. The conclusions of many observations would seem to warrant this belief." E. B. Gleason: "They are lymphatic glands. Aside from the functions of similar structure, I am not prepared to give an unqualified endorse- ment to any of the somewhat numerous theories as to the functions of the tonsils." Wesley Mills :''l think likely: (1) absorption, (2) possibly they furnish an internal secretion, (3) they may act as elaborators of white blood cells." SIX MEDICAL QUESTIONS 157 George L. Ross: "This is covered by question number one." St. Clair Thomson: "I think this function is a protective one in early childhood, possibly only up to the completion of the first dentition. The tonsils may defend the organism from the risks attendant on a small child's omniverous tastes." J. Maclntyre: "See answer to question num- ber one." E. M. Holmes: "I am of the opinion that one important function of the tonsil (faucial) is that of a very active lymphatic gland, acting (as a fort and battlefield) against infection arising in upper air tracts. We have all seen many attacks of marked activity in the tonsils after injury to nose (operative or other) and I am at present study- ing the frequent cervical adenitis following these causes where there is no faucial tonsil. The re- sults of my studies thus far are really very marked." John Mackenzie: "I do not know." William G. MacCallum: "Probably to act as guards against infection — to abort and destroy infectious agents. Obviously little is known as to the exact function of the tonsils, but they ap- parently form part of the lymphoid apparatus distributed throughout the digestive tract, and are comparable to the Peyer's patches, etc." Frank E. Miller: "Lubrication principally. If tonsils are entirely cut out with capsule and adjacent glands, there will be glandular secre- tions from the pharynx, base of the tongue or back of pharynx." A. Barth: "Secretory and resorptive action. 158 THE TONSILS AND THE VOICE The latter action is germicide ( protective against infection) but under circumstances leads to local and general infection." Luc: "Same answer as to question number one." Castex: "The palatine tonsils have not ap- peared to me to have any other function than that of the other superior vascular glands of the body (lymphatic ganglions, etc.)." Moure: "What I have said in response to the preceding question contains the answer to ques- tion number two." Escat: "I am of the opinion in accord with Allen, that the tonsils (palatine, lingual, tu- baire) secrete a principle, the nature of which it has been unable as yet to determine, but which should be useful in the development and to the growth of the subject, and probably to the growth of the skeleton. I have found a reason for this in the fact that the normal tonsils atro- phy normally about the age of eighteen to twenty j^ears, from the time that the subject has become fully an adult. This normal atrophy is manifest and striking for the pharyngeal, tub aire and lin- gual tonsils ; it is more defaced and more dissimu- lated in the faucial tonsils by reason of their globate form ; this is why, in spite of the atrophy, there always persists a small nut or nucleus, but this atrophied tonsil is nothing but a stump of a tonsil ; when that atrophied tonsil has conserved in the adult, a certain grandeur (groneur), it is because it is sick : it is because the chronic inflam- mation has counteracted the physiologic atrophic involution." SIX MEDICAL QUESTIONS 159 M asset: "I do not give great importance to the opinion according to which the faucial tonsils may render easier deglutition, nor I think suf- ficiently demonstrates that they are glands of internal secretion." Van Bag gen: "For my answer to this ques- tion see the first answer." Von Chiari: "Formation of leucocytes, es- pecially in children." 160 THE TONSILS AND THE VOICE Question Number Three. What effects have you observed as being di- rectly due to the removal of the faucial tonsils? Answers : H. Holhrook Curtis: "Only good effects." G. Hudson-Makuen: "Only good effects." A. Coolidgej, Jr.: "No serious injurious ef- fects." George B. Wood: "I have never seen any bad effects from the removal of the faucial tonsils." Edwin Pynchon: "After twenty years' expe- rience, covering at least 3,000 cases, I have never observed any other than favorable effects, aside from temporary inconvenience after the opera- tion.- The general health has always been im- proved, only exceptions are question four." William E, Casselherry: "No evil effects, only good. Total tonsillectomy has been my practice for a period of j^ears long antedating our present more technical method, and I have recorded statistically the immediate and ultimate results from a total of 600 double operations upon private patients, among whom are relatives, friends and acquaintances, together with other patients re-examined years aftenvard, for a con- siderable number whom I have been able to ascer- tain the last state of the patient. In none has any harm resulted, in many inestimable good. In none did I have any reason to regret having made total tonsillectomy, my sole regret having been on account of those cases in which a remnant of tonsil had escaped removal." SIX MEDICAL QUESTIONS 161 Charles H. Knight: "Improvement in general and local conditions, voice resonance and breath- ing, subsidence of glandular swellings, etc." Beverly Robinson: "When advisedly done — many and good." George B. Rice: "The enucleation of patho- logic tonsils in my experience is followed by less frequent sore throats, improvement in the speak- ing and singing voice, and a change for the better in the general health." J, E. Newcomh: "Improved breathing and lessened liability to sore throats." Joseph E. Gleitsmann: "No deleterious, only beneficial ones." E. B. Gleason: "From the removal of hyper- trophied or diseased tonsils improvement in the voice and hearing when there was middle ear ca- tarrh, usually also improvement in the general health." Eugene Hodenpyl: "In pathological tonsils the usual well-known improvement ensues." Wesley Mills: "None that were unfavorable." George L. Ross: "Healthy and unimpaired action of the oro-pharynx, freedom from the pre- vious mechanical impediment of hypertrophy and in atrophic cases relief from suffering (though this is not invariable) ." John N. Mackenzie: "I cannot recall a high fatality or serious complication after tonsil- lotomy in all the years of my experience ; in suit- able cases it is always productive of good, and 'when properly done is practically just as effec- tive as tonsillectomy *. neither can ever be absolute- ly complete; but the risks of tonsillotomy are as 12 162 THE TONSILS AND THE VOICE nothing compared with the accidents which fol- low tonsillectomy, to say nothing of its long roll of death." J. Maclntyre: "Question three is an exceed- ingly difficult one for me to answer because you refer to faucial tonsils without any reference to naso-pharynx, lingual tonsils or, indeed, to the adenoid tissue in the nose and throat. I would find it very hard to make any observations upon the faucial tonsils alone. The same remark ap- plies to question four." St. Clair Thomson: "The usually noted and well-recognized improvement in health." E. M. Holmes: "A much larger percentage of cervical adenitis following nasal and naso- pharyngeal infection." Massei: "Improvement of voice (when en- larged) ; improvement of general health (when representing the mechanical impairment to the free respiration) ; less occasion to sore throat or infections which may originate from that point." Luhet-Barbon: "I have never observed any troubles from the removal of the tonsils." Luc: "I generally observed diminution or sup- pression of the symptoms due to the hypertrophy of the glands." Moure: "It is difficult to say what are the ef- fects following the ablation of the tonsils in view of the fact above all, that at least in our country, the complete 'amygdalectomie' (extirpation) is never performed, but only a removal more or less complete, and that in consequence there always remains enough follicles to fulfill the role devolv- ing on that gland, which, like the greater part of SIX MEDICAL QUESTIONS 163 the lymphatic organs, atrophies little by little with age." Casteoc: "I have never observed any but good results to the condition. I do not interfere with the anterior or posterior pillars." Escat: "I have observed nothing but good ef- fects — amelioration of the general condition, exaggeration of development in the child. I attribute the good result as much to the cessation of physiologic troubles resulting from the vicious internal tonsillary secretion from the chronic in- flammation, as to the cessation of the mechanical interference brought on by the hypertrophy — no cacheocia tonsilliprive has been observed because, even in the most radical ablation of the tonsils, there is always left a little adenoid tissue." A. Barth: "Rarely any, always a bleeding easily subdued. Once a necrosis progressive, which yielded to antiseptic washings. Often weak children recover quickly. Scrofulus habi- tus disappears. Same thing in removing pharyn- geal tonsils." Frank E. Miller: "All effects due to abnor- mal mucous membrane thus affected." Schmiegelow: "When I remove faucial tonsils it is always because they are diseased or inclined to be affected with tonsillar angina; and the re- moval has always prevented new attacks; other effects I have not seen." Van Baggen: "Only in two cases during my experience of eight years the removal of the fau- cial tonsils was necessary. In both cases the ton- sils were of abnormal size. In one of those two cases there was no regular movement of the soft 164 THE TONSILS AND THE VOICE palate and of the pillars of the fauces ; especially when forming" the initial vocals a spasmodic con- traction of those parts took place, whereby the swollen tonsils were strongly protruded. Every attempt to correct the action of the muscles of the soft palate and the pillars of the fauces re- mained without any results because of this pro- jection of the tonsils. After their removal, the desired effect was obtained by carefully applied exercises." Von Chiari: "The pharynx will be more roomy," SIX MEDICAL QUESTIONS 165 LETTER OF VON CHIARI. Translation. (1) The tonsils most probably serve the pur- pose of forming leucocytes. (2) Formation of leucocytes, especially in children. (3) The pharynx will be more roomy. (4) If in older mammals very large tonsils which have very much stretched the palatine arches have been removed to the bottom of the sinus-tonsillaris, the arches then lose their prop and on account of the relaxing of the muscles of the arches they cannot thereafter contract ef- ficiently. Therefore, the resonance of the throat gets flabby walls, so that the strength and fulness of the tones suffer. (5) No. (6) You will find a new detailed summary of my remarks in the book called: Die Krankheiten des Rachens, Von O. Chiari Leipzig und Wien, Franz Denticke, 1903. Yours truly, (Signed) O. Chiari. Vienna, 18th October, 1910. 166 THE TONSILS AND THE VOICE Question Number Four. Have you noted phonetic changes after the re- moval of the faucial tonsils? Answers : H. Holbrook Curtis: "Always improves the clearness of tone and lessens vocal fatigue." G. Hudson-Makuen: "Yes, changes for the better." A. Coolidge„ Jr.: "No important ones, except in adult singers, who in one or two cases partially lost delicate control. This would have been un- important to anyone else." Edwin Pynchon: "When properly done with proper after treatments to prevent growth of exuberant granulation tissue, the effect has always been favorable, increasing the vocal range of singers and correcting former tendency to hoarseness when such existed either in singers or speakers, as lawyers, etc. When proper after treatments are neglected a new growth of tissue may interfere with free motion of the pillars and soft palate, though this has occurred rarely and the effect on the voice has been slight." William E. Casselherry: "In no instance has any ultimate harm resulted from the operation; nothing but good. Lambert Lack reports a case of loss of singing voice. My series includes but eight prominent vocalists and perhaps an equal number of public speakers, in all of whom the voice was improved, but the number would be larger were it not that in singers I have limited the operation to those in whom the tonsillar dis- SIX MEDICAL QUESTIONS 167 ease itself seemed about to destroy the voice, so that I believe that vocalists form no exception to the rule, that wherever the tonsillectomy is really indicated, enhanced general vigor and vocal sturdiness may be expected to result from the operation." George B. Wood: "Personally, no, except to clear the voice." George B. Rice: "Yes." J. E. Newcomh: "No." Charles H. Knight: "Often very marked. In- crease in volume and metallic quality, the latter diminishing as the palatal muscles adapt them- selves." Joseph W. Gleitsmann: "Consider carefully removal of hypertrophied (not otherwise dis- eased) tonsils in professional singers. If re- moved, influence on voice is easily and quickly relieved by vocal studies, with benefit to patient." E. B. Gleason: "Generally a great improve- ment in the voice after the removal of hyper- trophied tonsils. Great impairment of the sing- ing voice of a professional female singer from a tonsillectomy done in New York probably result of great change in size of pharynx or possibly cicatrical contractions." Wesley Mills: "None unfavorable — often good results both on the general health and the voice, i.e.: when enlarged." George L. Ross: "No, but would not say they do not occur, for of the many cases done yearly (150) I have rarely seen the case more than twice, oftener only once, about a week after operation. Have not had a case of secondary hemorrhage in 168 THE TONSILS AND THE VOICE twenty years, but in every ease I think of its pos- sibilities." J. Maclntyre: "The same remark applies to question number four that was made to answer question number three." St. Clair Thomson: "None but changes for the better." E. M. Holmes: "Yes." E. W. Scripture: "Removal of enlarged ton- sils improves the timbre of the voice." John N. Mackenzie: "The voice is often im- proved after tonsillotomy and some of the great singers of the world have profited from it. I know of several cases in which the singing voice has been ruined after complete enucleation. In two cases, teachers of singing operated on by a skilful surgeon, the voices in same were destroyed and the life work of the patients was gone. The tonsils in connection with the other structures of the pharynx unquestionably have to do with the character — the timbre — of the voice. It is im- possible to foretell exactlj^ the amount and char- acter of the changes in anatomical relations after the so-called 'complete' operation, no matter how skilful the surgeon may be or what new theoreti- cal hues in surgery along which he works. It is therefore of urgent importance to proceed with great caution in those who make professional use of their voices ; if I were a great singer I should never consent to a tonsillectomy except as a very last resort." Massei: "Never." Luc: "The singers generally stated an im- provement of their vocal powers. I never came SIX MEDICAL QUESTIONS 169 across any who complained of any bad conse- quence." Casteoc: "I have observed to my satisfaction the voice gains in facility and sonority." Moure: "After the ablation of the tonsils a change of the voice is above all observed when the subject has already been accustomed to singing, and that in consequence, he has habituated him- self to emit the voice with the two tonsils situated between the pillars. If the forms of certain hypertrophied tonsils embarrass the speaking (phonation) there is no doubt that there is then, after their removal, a very appreciable modifica- tion in the emission of the speaking voice among young persons." Escat: "I have only observed a modification of the timbre and the volume of the voice, but rather for good than bad. Among professional singers the result obliges them to modify the vocal emis- sion (to bear upon the sound) differently; an artist may be obliged to reconstruct somewhat his vocal education, and to modify his pharyngeal gymnastics; but he will do this rapidly and his voice will rather gain by the operation." A. Earth: "Voice improves after removal of hypertrophic tonsils, but can also get worse, never the consequence of anatomical conditions." Eugene Hodenpyl: "No." Schmiegelow: "None, if the tonsils were not hypertrophied." Frank E. Miller: "Yes. High range, more timbre, better resonance if by removal of abnor- mal tonsils sometimes through dry catarrh and irritating compensatory glandular or other ele- 170 THE TONSILS AND THE VOICE merits of mucous membrane or swellings of glands extending down the sides of the palate." Van Baggen: "The other case, where the ton- sils were removed, was a singer. Here also the removal of the swollen tonsils appeared unavoid- able because of the impossibility to correct a nervous contraction of the pillars of the fauces. As a result of the removal entire success followed. It did not affect the timbre of the voice; an in- crease of resonance was observed and she sang with far more ease and less fatigue." Von Chiari: "If in older mammals (or in- fants) very large tonsils which have stretched the palatine arches very much, if they have been removed to the bottom of the sinus tonsillarus, then these arches lose their props (supports) , and on account of relaxing of their muscles (the muscles of the arches) they cannot contract themselves thoroughly any more. Therefore, the resonance of the throat gets flabby walls, so that the strength and fulness of the tones suffer." SIX MEDICAL QUESTIONS 171 LETTER OF ESCAT. Translation. Doctor Escat, 2, Rue Cantegril, 2, Toulouse. REPLY OF DR. ESCAT, TOULOUSE, TO TONSIL REFERENDUM. Answer to Question 1. I am of the opinion that the faucial tonsils have not for their only function that of phagocytosis studied by Metch- nikofF, but also a physiological and biological function due to an internal secretion, like all the secretory internal glands (thymus, thyroid, liver, etc.). Answer to Question 2. I am of the opinion, in accord with Allen, that the tonsils (palatine, pharyngeal, lingual, tubaire) secrete a principle, the nature of which it has been unable as yet t3 determine but which should be useful in the de- velopment and to the growth of the subject, and probably to the growth of the skeleton. I have found a reason for this in the fact that the normal tonsils atrophy normally about the age of eighteen to twenty years, from the time that the subject has become fully an adult. This normal atrophy is manifest and striking for the pharyngeal, tubaire and lingual tonsils; it is more defaced and more dissimulated in the faucial tonsils by reason of their globate form ; this is why, in spite of the atrophy, there always persists a small nut or nucleus, but this atrophied tonsil is nothing 172 THE TOXSILS AKD THE VOICE but a stump of a tonsil ; when that atrophied ton- sil has conserved in the adult, a certain " gro- neur" (grandeur) , it is because it is sick; it is be- cause the chronic inflammation has counteracted the physiologic atrophic involution. Answer to Question 3. I have observed noth- ing but good effects — amelioration of the general condition, exaggeration of the development in the child. I attribute the good result as much to the cessation of physiologic troubles resulting from the vicious internal tonsillary secretion from the chronic inflammation, as to the cessation of the mechanical interference brought on by the hypertrophy — no cachexia tonsilliprive has been observed because, even in the most radical abla- tion of the tonsils, there is alwaj^s left a little ade- noid tissue. Answer to Question 4. I have only observed a modification of the timbre and the volume of the voice — but rather for good than bad. Among professional singers the result obliges them to modify the vocal emission ("to bear upon the sound") differently: an artist may be obliged to reconstruct somewhat his vocal education, and to modify his pharj^ngeal gymnastics; but he will do this rapidly, and his voice will rather gain by the operation. Answer to Question 5. I am not a partisan of systematic ablation; I am not a partisan except of the ablation of hypertrophied tomils or those suffering from chronic inflammations causing re- peated tonsillitis, or peritonsillitis, etc., etc. I am of the opinion that we need not seek to leave tonsillitic tissue (for one always leaves SIX MEDICAL QUESTIONS 173 some in spite of himself) sufficient that (with children) the function of internal secretion of the tonsils continues to be assured. But on the other part, it is not necessary, in my opinion, to set one's heart upon completely ex- tracting all the tonsillar tissue, as various Ameri- can confreres proposed. The tonsil is not an epithelioma! Further, a radical enucleation is very difficult with certain subjects, by reason of the almost constant exis- tence of an intra-v clique portion of the tonsil, which it is necessary to dissect with the bistoury, in the thickness of the veil. Thus, one such dissection will be very dan- gerous from the point of view of the possible hemorrhage (see on the subject of the intra- velique portion of the tonsil, in my "Technique O. R. L.," pages 83 and 84, second edition, Paris, Maloine publisher, lately published). Consult also my argument on the report of Hicguet and Broeckaert to the Belgian O. R. L. Society, June 12, 1910 (in "Presse O. R. L. Beige," Number 7, 1910). 174 'IHE TONSILS AND THE VOICE Question Number Five. Would you, as a rule, advise the removal of normal tonsils ? Answers : Von Chiari: "No." Von Schrotter: "No." Van Baggen: "No." Schmiegelow: "No." Castex: "No." Beverly Robinson: "No." Charles H. Knight: "No." Joseph W. Gleitsmann: "No." E. B. Gleason: "No." George B. Rice: "No." E. M. Holmes: "No." John N. Mackenzie: "No." Eugene Hodenpyl: "No." William G. MacCallum: "No." A. Coolidge, Jr.: "No." G. Hudson-Makuen : "No." William E. Casselherry : "No." Edwin Pynchon: "The tonsil which might ap- pear 'normal' to one, might appear abnormal in some way to another with a greater experience in the study of the tonsil question. Generally we do not advise operation if there is no trouble sub- jective or objective. In fact, such patients do not call for treatment. Many years ago Bos- worth said, 'The less tonsil the nearer normal,' and my experience causes me to agree with him. The fact that a tonsil has never become inflamed is no proof that it is not causing or may not cause SIX MEDICAL QUESTIONS 175 trouble. I frequently remove tonsils which have been passed upon by other specialists as being 'normal' because I saw a relationship which they did not see between the tonsils and other parts, as the nose, the ears, the pharynx, the larynx, the pulmonary and gastro-intestinal tracts, and the results we think as particularly, and differing in different cases, deafness, tinnitus, hoarseness (re- current) catarrh, bronchitis, cough and indiges- tion, and therefore more or less impairment of the general health in one way or another." J. Maclntyre: "Question five is rather a puz- zle to me because it is hard to say under what circumstances one may be called to remove normal faucial tonsils." St. Clair Thomson: "It is impossible to define what is a 'normal tonsil.' I should never remove a tonsil at any age, unless convinced that there are disorders of health or hindrances to develop- ment which are directly attributable to it." Frank E. Miller: "Never, if as described in question number one." H. Holbrook Curtis: "Not unless they gave trouble." Wesley Mills: "No. Only in exceptional cases if at all." George L. Ross: "No. Have always avoided doing so." J. E. Newcomb: "If not impeding function by their size in adults and patient is not subject to sore throat, do not consider removal necessary. Would remove all enlargements in patients, say below sixteen years." George B. Wood: "I certainly would not ad- 176 THE TONSILS AND THE VOICE vise the removal of tonsils unless there is some rea- son for doing so." Massei: "No — I advise removal only when (although not much enlarged) they are the cause of frequent sore throat or when with the pharyn- geal tonsil they are concurrent to insufficient breathing." BartJi: "I do not remove normal or slightly hypertrophic tonsils (which do not cause patho- logical disturbances). If one wanted to do that one would have to perform in any normal man a number of prophylactic operations." Lermoyez: "I consider that the normal tonsils are organs that must he respected. One should never remove the human organs; not more a nor- mal tonsil than a healthy tooth or a healthy eye!" LiUC: "No. Unless patients are subject to frequent pharyngitis, and we may hope that the suppression of their tonsils will make the attacks less painful." Moure: "I believe that in a general way, one should not remove the tonsils when they are not of excessive size, or are not inflamed ; in a word, that they are not the 'point of departure' of local infection frequent or distant (caseous suppura- tive tonsillitis). They are organs as useful as the ganglions when these latter are not degen- erated." JLubet-Barhon: "I think there is never an in- dication to remove a normal organ, and for my- self, I never remove tonsils responding to the type you call normal, like volume and like condi- tion of the gland ; without chronic inflammation, without crypts, without adherence to the pillars, and elsewhere. How will you examine the tonsils SIX MEDICAL QUESTIONS 177 if the patient does not complain of something in regard to them, and then why remove them or touch them any more than the 'corner' of the nose or the uvula. I add that there are very few nor- mal tonsils, because of the multitude of inflam- mations of which that organ is the seat from years of infanc}^ and results of these inflammations — crypts, adhesions, hypertrophies." Esc at: "I am not a partisan of systematic ablation ; I am not a partisan except of the abla- tion of hypertrophied tonsils or those suffering from chronic inflammation causing repeated ton- sillitis, peritonsillitis, etc., etc. I am of the opinion that we need not seek to leave tonsillitic tissue (for one always leaves some in spite of him- self) sufficient that (with children) the function of internal secretion of the tonsils continues to be assured. But on the other hand it is not neces- sary in my opinion, to set one's heart upon com- pletely extracting all the tonsillar tissue as vari- ous American confreres proposed. The tonsil is not an epithelioma! Further, a radical enuclea- tion is very difficult with certain subjects, by rea- son of the almost constant existence of an intra- velique portion of the tonsil, which it is necessary to dissect with the bistouiy, in the thickness of the veil. Thus, one such dissection will be very dangerous from the point of view of possible hemorrhage (see on the subject of the intra- velique portion of the tonsil, in my 'Technique, O. R. L.', pages 83 and 84, second edition, Paris, Maloine, publisher. Consult also my argument on the report of Hicguet and Broeckaert to the Belgian O. R. L. Society^ June 12, 1910, in 'Presse O, R. L. Beige/ Number 7, 1910.)" 13 178 THE TONSILS AND THE VOICE Question Number Six. Remarks ? Answers : Charles H. Knight: "I hope you may be able to throw some light on the ever new, old question of function. I anticipate you will find a fair degree of agreement on other points. Wish you success in your quest." E. M. Holmes: "I do not wish to be under- stood as opposed to removing badly diseased ton- sils, for I believe they may be the cause of much trouble." George B. Rice: "After removal of the diseased faucial tonsil the relations of the reso- nant cavities is changed; therefore the voice of r trained singer does not at once respond in the same manner as previously. This difficulty in tone production is in my experience soon over- come by training and readjustment of method, conforming to the new conditions. After this has been accomplished the voice is I believe im- proved m quality, in carrying power, and in ease of use." E. B. Gleason: "The answers above refer to tonsillectomies properly done ; and not to cases in which portions of the anterior and posterior pillars or other muscular portions of the pharynx were inadvertently removed with the tonsil, nor to ton- sillotomies." Wesley Mills: "I think somewhat enlarged tonsils may have for a speaker or singer, i.e.: cause him the expenditure of greater energy to do his work well, even when they do not embarrass V SIX MEDICAL QUESTIONS I79 as greatly enlarged tonsils do. In doubtful cases, I would remove them, especially in singers." St. Clair Thomson: "I am afraid the enclosed answers to your inquiries are not very satisfac- tory. I have few facts to offer you." Frank E. Miller: "The usual cause of the singer's node is tonsillitis, which causes a weaken- ing of muscular action over the side affected, then a sense of no power, then a relaxation, of cord on side affected, then bulging of the cord, akinesis, then node with hyperplasia, etc. A clean enuclea- tion of tonsil in such a case cures nodule and its consequences in reversion. But never remove capsule in a singer." "Since your visit and report of several cases of death from hemorrhage from ablated tonsils, I have developed a system of aeroelectrotomy for diseased tonsils, by means of suction and wash- ings. Am very sorry I cannot go further into the matter for you just now. Be sure, however, that I have not forgotten your skill, care and kindness, and wish to praise and thank you for your great effort in behalf of tonsillar hygiene." Massei: "I have operated by tonsillotomy in 2881 cases ; I have not taken note of cases in which I removed the faucial tonsils with punch and in several sittings. The modest answers I have given are in relaton with the experience of these cases." Schmiegelow: "I have never had serious at- tacks of bleeding after operation." Luc: "I have adopted the practice of remov- ing the tonsils ordinarily with the cold snare, after liberating them by means of curved scissors 180 THE TONSILS AND THE VOICE and drawing them well out of their cavity by- means of a special forceps passed through the loop." - Von Chiari: "You will find a new detailed summary of my remarks in the book called ^Die Kranhheiten des Rachens von O. Chiari, Leipzig und Wien/ " Van Bag gen: "As I am exclusively a special- ist — expert for voice and speech afflictions, I considered the questions but from the phonetic point of view." The vowel siren and buccal resonators. — Marat CHAPTER IX THE SCIENCE OF THE VOCAL ART. The science of voice mechanism, and the mas- [ tery of voice production, do not belong to the , physician's art. Medical science reaches its 1 limits at the science of the vocal art. The study of voice mechanism presents many difficult problems. The mechanism is marvel- ously delicate, extremely complicated, with ad- justments and re-adjustments easily deranged. The finest art is the art of song. It is the divine art. To teach this art requires intelligence, apti- tude, high ideals, and specialized education. Teachers of this art must he trained to teach, and they must he credited with skill and experience in the attainment of artistic results. The voice profession may point with pride to the scientific contributions to the mechanism of speech, of such singing teachers as Bennati, Garcia, John Howard, and Charles Lunn; and to the perpetuation of the vocal art, by such masters as Porpora, Tosi, Gahrielli, Trivuhi, the Lam- perti's, Mme. Cappiani, Mme Mott, Mme. Leh-^ mann, Shakespeare, De Reszke, Sehastiani, the Marchesis, and many others. Marage, Scripture and other voice mechan- icians of our day have made wonderful strides in acquiring scientific knowledge concerning the mechanism of speech and voice, and have thus contributed to the greater security in the preser- 181 182 THE TONSILS AND THE VOICE vation of our inheritance of the art of song, as handed down by the great song masters. The purpose of a vocal method is to produce a perfect co-ordination of all parts of the human voice-producing mechanism. The Italians, like Tosi, Porpora, Trivulzi, the JLampertis, and Mme. Cappiani, were teachers of great practical experience and they understood how to adapt method to individual needs. Con- sciously or unconsciousl}^ their method was physiological, and the fundamental principles of the physiology of voice production were there. Salvatore Marchesi {''A Vademecum") says: ''Manuel Garcia, when tr^ang to investigate the mechanism of the vocal organ, aimed ex- clusively at establishing a physiological sj^stem for the production and development of the voice in connection with the art of song, and proposed putting an end, if possible, to the dangerous in- terference of dabblers." "On the contrary, the new scientific path he had opened to the cultivation of the human voice fell a prey to empiricism; thousands of undesir- able meddlers seized upon the subject and brought about confusion." "A conscientious laryngologist must indeed study and investigate the anatomical structure and physiological w^orking of the human vocal apparatus, but he should remain on pathological ground. Laryngologists who publish books on 'Voice Production' betraj^ their mission. The publication of their books complicated with scienti- fic quotations and dilemmas, and consequently out of proportion to the general standard of in- THE SCIENCE OF THE VOCAL ART 183 struction, create unconsciously a number of physical disorders and diseases among singing people, and thus contribute to the dedine of the art of song." "In view of the abuse that modern laryngolo- gists, physiologists, and teachers have" made of anatomical engravings, illustrating some scienti- fic parts of their works, I wish to avoid any theoretical example of the sort." "It would certainly be unjust to deny that modern physiological and acoustical investiga- tion has furnished a broader basis for studying the phenomena of the human voice. But the ma- terial furnished by new scientific discoveries must he subjected to servere criticism, and compared by the practical teachers with such real facts as are positively demonstrated by long experience, accredited traditions and approved results" "We cannot and must not throw away all that constitutes the inheritance of the ages, all that has furnished evidence of practical value; but must use the new ideas to complete and perfect the old ones. The teacher may utilize all the precious discoveries made by modern science, but on condition that he understands them, and pro- vided he knows where, when and how they are to be employed." Mme. Lilli Lehmann {"'How to Sing," 1909) says: "Singers should seek to acquire accurate knowledge of their own organs, as well as of their functions, that they may not let themselves be burnt, cut and cauterized by unscrupulous physicians. Leave the laryncc and all connected with it alone. I give warning of unprincipled 184 THE TONSILS AND THE VOICE physicians who daub around in the larynx, hum it, cut it, and make everything worse instead of better. I cannot comprehend why singers do not unite to brand such people publicly and put an end to their doings once for all." Manuel Garcia, singing teacher, laid the foun- dation for the practice of scientific laryngology. Without his invention, the laryngoscoj)e, there would be no laryngologists, and very incomplete knowledge of diseases of the larynx. The dis- covery of the laryngoscope is not all, however, that the world owes to the voice profession. John Howard's classic work on the "Physi- ology of Artistic Singing," including his great eccpose of the j^^iy^iology of artistic breathing, are contributions of the highest value to the science of the vocal art. And the scientific observations of Charles Lunn are impoj'tant. The elaborate scientific investigations of Scrip- ture and Mar age have revolutionized scientific thought regarding the mechanism of speech and voice. And they state that their great work is in its incipiency. The genius of Garcia grows greater! Scrip- ture and Marage have proved the trutli of Gar- cia s SECOND great achievement, that of his dis- covery of the PUFE ACTION of the vocal cords. But his second observation was fifty years ahead of his time; so far ahead that no one under- stood or accepted it. This second great discov- ery has waited over fifty years for Scripture, Marage and others to prove its truth, the truth THE SCIENCE OF THE VOCAL ART 185 that Garcia persistently taught for over fifty years, as follows: "What is sound?" "Answer: "The sensation made in the ear by vibrating" air." "How does the glottis produce sounds?" "Answer: The two lips of the glottis, which are separated in the act of breathing, meet when preparing to produce a sound, and close the pas- sage with the degree of energy demanded by the nature of the sound and the power with which it is to be emitted. Then, being pushed upwards by the air, they give way and allow a portion of air to escape, but immediately return to their original contact, and recommence the action. These intermittent emissions or explosions of air, when regular and rapid enough, form a sound." "Can you name any action which is an illus- tration of this?" "Answer: The action of the lips of a horn player." "Are the sounds obtained always of the same character?" "Answer: No. They may be bright and ringing' or veiled." "How do you obtain these bright and veiled sounds?" "Answer: If, after every explosion the glot- tis closes Completely, each impinges sharply on the tympanic membrane, and the sound heard is bright and ringing. But if the glottis is imper- fectly closed, and a slight escape of air unites the explosions, the impressions upon the tympanum are. blunted, the sound being then veiled." : 186 THE TONSILS AND THE VOICE "Has this observation any importance?" "Answer: Coupled with the theory of timbres and that of the breath, it puts the singer in posses- sion of all the 'tints' of the voice, and indeed initi- ates him into all the secrets of voice production." "What produces pitch?" "Answer: The number of explosions that occur in a given time." "What causes intensity of sound?" "Answer: Intensity of sound is not due to the amplitude of movement of the glottic lips, but to the quantity of air which makes one vivid explo- sion. The resistance offered b}^ the lips to the pressure of the lungs determines this quantity. The amplitude is therefore a result, not a cause. After each explosion the glottis must be re- closed; for if the air found a constant issue, the greater the expenditure of air, the weaker the sound would be." "How is volume of sound obtained?" "Answer: The volume of sound depends on the expansion of the pharynx and of the vesti- bule of the larynx." Garcia s theory was fully set forth in 1855 and published in the Proceedings of the Royal So- ciety of Great Britain, Vol. 77, 1856. He has ever since reiterated his views. The vocal cords do not throw off vibrations of sound, like a snapped cord or the string of a violin, but it is well illustrated by Professor George M. Sleeth, who states that : "As the column of air coming from the lungs meets the resistance of the closed glottis, it is forced against the vocal cords, which by their re- THE SCIENCE OF THE VOCAL ART Igy sistant flexibility chop or clip it into a series of instantaneous and continuous puffs or explosions of compressed air, which shock the surrounding air, and the reports are heard as continuous tone." The puff theory of Garcia has been accepted by Hermann, Scripture and Marage. Scripture, in "Researches in Eocperimental Phonetics'' says: "The two essentials of the theory, as stated by Willis and Hermann, namely: 'That the glottis emits puffs of greater or less sharpness, and that the vocal tones are generally inharmonic to the glottal tone, can he considered as definitely estab- lished. The reason for the puff character of the glottal action has been found by Professor Ewald (Strassburg) in the fact that the glottal lips are masses of muscle which yield by compression and do not vibrate like membranes. These facts have remained largely unknown, and we still find in the text-books the totally false theory that the vowels are produced by membrane-like vibrations in the larynx." "I have adopted the puff theory and have taken into consideration some further elements also, namely: friction in the vocal cavities and associative formation of the vowel at the glottis." "According to the puff theory, the glottis emits a series of more or less sharp puffs; each puff, striking a vocal cavity, produces a vibration whose period is that of the cavity; a single wave group shows the sum of these vibrations from all the cavities. The glottal lip bears no resem- blance to a membrane or string. These puffs act on the vocal cavity, that is, on a complicated sys- 188 THE TONSILS AND THE VOICE tern of cavities (trachea, larynx, pharynx, mouth, nose) with variable shapes, sizes and openings." "The entire intellectual and emotional impres- sion conveyed by the voice from the speaker to the hearer is contained in the speech vibration and registered in the speech curve. Hardly any problem of greater interest could be proposed than that of discovering the manner of getting from a voice curve the data concerning the action of the vocal organs in such an exact and minute form that conclusions can be drawn concerning the variations in the voice as depending on every emotion, on every condition of health, on every step in voice culture, on every difference in vow- els and consonants, on each change in dialect, etc. The problem, however, is too vast for solution in a short time." "The experimental analysis of the action of the vocal organs in speech is already well developed and forms almost a science by itself. A first at- tempt at something different, namely : an experi- mental analysis of the sounds heard by the ear, will here be described." "An element of speech may be 'physically' de- fined hy the properties of the vibrations trans- mitted through the air. It may be 'physiologi- cally' defined by a description of the action of the vocal organs producing it, or of the ear re- ceiving it. Or, finally, it may be 'psychologi- cally' defined by a description of the hearer's or speaker's perception of the sound as heard or spoken." "A vowel analysis maj^ be physical, physiologi- cal or psychological." THE SCIENCE OF THE VOCAL ART Igg "Krause reports the case of a tenor whose glot- tal lips looked like two ridges of red flesh and whose tones appeared nevertheless unusually sweet and soft. Imhofer observed a singer with hypertrophy of one of the ventricular bands so that the glottal lip appeared as only a small edge beneath the heavy mass of the ventricular band resting upon it ; with this apparently unavailable organ he is a successful tenor on one of the largest German stages." "^Both these cases can be understood on the pufF theory, according to which the glottal lips in most cases come together at each vibration and open only to emit the puff* of air." "According to the puff theory of Willis and Hermann, the glottis emits a series of more or less sharp puffs ; each puff, striking a vocal cav- ity, produces a vibration whose period is that of the cavity ; a single wave-group shows the sum of these vibrations from all the cavities ; the periods of these vibrations may stand in any relation to the interval at which the puffs come; that is, to the fundamental." "This theory is certainly correct in asserting that the glottal tone (the fundamental) consists of a series of more or less sharp puffs. The puff action of the vocal lips has, moreover, been directly observed for male bass voices by the laryngostroboscope. ' ' "The pitch of a cavity tone is to a great extent independent of the interval of the puffs. A sharp puff acting on a cavity will arouse a vibra- tion whose period is that natural to the cavity," "Each glottal lip consists mainly of a mass of 190 THE TONSILS AND THE VOICE muscle supported at the ends and along the lat- eral side. It bears no resemblance to a mem- brane or string. The two lips come together at their front ends, but diverge at the rear. The rear ends are attached to the arytenoid cartilages. When the ends are brought together by rotation of these cartilages, the medial surfaces touch. At the same time they are stretched by the action of the cricothyroid muscles, which pull apart the points of support at the ends." "In this way the two masses of muscle close the air passage. To produce a vowel such a rela- tion of air-pressure and glottal tension is ar- ranged that the air from the trachea bursts the muscles apart for a moment, after which they close again ; the release of the puff of air reduces the pressure in the trachea and they remain closed until the pressure is again sufficient to burst them apart. With appropriate adjustments of the laryngeal muscles and air pressure, this is kept up indefinitely, and a series of puffs from the larynx is produced. The glottal lips open partly by yielding sidewise — that is, they are compressed — and partly by being shoved upward and out- ward. The form of puff — sharp or smooth — is determined by the way in which the glottal lips yield; the mode of yielding depends on the way in which the separate fibers of the muscles are contracted. When contracted along the medial edge, the action may approach that of a stretched string loaded with a soft mass along its middle portion or along its entire length. When con- tracted more laterally, the action may approach that of a soft mass flapping in a current of air, THE SCIENCE OF THE VOCAL ART 19 1 or of two soft cushions striking together. These two forms of contraction correspond to separate action of the M. vocahs and the M. thyreoaryte- noides (externus). When the slant fibers which insert along the medial edge of the glottal lips are contracted, there will be nodal points similar to those of stretched strings." "These diiFerences produce differences in the forms of the puffs. We can thus explain the forms of puffs in the different types of vowels by differences in the action of the muscles of the glottal lips." "Physically stated, a vowel consists of a series of explosive puffs of air from the glottis acting on a complicated cavity with considerable fric- tion. The puffs of air may be very brief and may be separated by comparatively long inter- vals of rest, or they may be of smoother form, even resembling a tuning-fork vibration. The period from one puff to the next determines the pitch of the voice; the form of the puff deter- mines the musical timbre." "These puffs act on the vocal cavity; that is, on a complicated system of cavities (trachea, larynx, pharynx, mouth, nose) with variable shapes, sizes and openings. The effect of the puff on each element of the vocal cavity is double ; first, to arouse in it a vibration with a period de- pending on the cavity; second, to force on it a vibration of the same period as that of the set of puffs. The prevalence of one of the factors over the other depends on the form of the puff, the walls of the cavities, etc. Some vowels include the puff element as an important component, 192 THE TONSILS AND THE VOICE others consist almost entirely of the cavity vibra- tions." "The vowel curve, according to this theory, contains the record of the glottal puffs and of the set of cavity tones aroused by it. In a single wave there is not only a record of one glottal puff and of the cavity tones for one vibration, but also of what is left over from the fading vibrations of the preceding wave." "In speech the pitch of the glottal tone changes continual^. As the pitch of the tone from the glottis rises, the group of cavity vibra- tions come closer and finally overlap. This pro- duces veiy complicated forms, but when the pe- riod of the puff becomes an even multiple of that of the cavity, the waves sum up in like phases and strong, smooth vibrations result." "For the ear the succession of puffs produces the tone of the voice; that is, the pitch of the sound heard depends on the interval at which the puff comes. The form of the wave impresses the ear with the effect of timbre, that is, with its character as more or less musical and also with its vowel character." "A frietional analysis is required by the only theorj^ of vocal action which we can accept. The simple harmonic analysis can lead only to false conclusions." "In speech vibrations the friction cannot be neglected. For small movements, the friction may be considered as proportional to the velocity and opposed to the movement." "It is evident that the complete analysis of a Vowel wave is not a light undertaking. We can- No. 1 No. 2 Photographs of the voice in singring the same exercise.— AfaraffC. 1. French method. 2. Italian method. Both numbers represent the same exercise well sung, and indicate that in th/s case, the Italian method has produced the more agreeable im- pression on the ear. THE SCIENCE OF THE VOCAL ART 193 not escape from it, if the work is to have scientific value. A single trustworthy analysis is an achievement. When many such analyses have been accumulated, we can hope for correct views of the physical and physiological nature of the vowels and reliable data concerning the vowels of a language; we can ultimately expect in this way to have accurate knowledge with which to replace the vagueness and error prevalent at the present day." Mar age. (''Etude des Vibrations de la Voice") Vibrations of the Voice. "As to the special timbre of each voice, it de- pends probably upon the size of the opening of the glottis, on the tension of the vocal cords, on their size, on the volume of the ventricles of Mor- gagni, on the position of the teeth, quantities es- sentially variable not only with each individual, but also with the actual state of the mucosae." "The vowels are due to an intermittent aero- laryngeal vibration, reinforced by the buccal cavity and producing ou, o, a, e, i, when these are put in unison with the sum of the vibrations, transformed by them, and giving birth to other vowels when that unison no longer exists: the number of the intermittances gives the funda- mental note on which the vowel is emitted." "If the buccal cavity alone operates ^ we have the whispered vowel." "If the laryncc operates alone^ we have the sung vowel." "If both operate at the same time we have the spoken vowel" 14 X94 J^^HE TONSILS AND THE VOICE Mar age. {''Les Voyelles Laryngiennes" 1909.) The laryngian vowels. "The vowel is an intermittent aero-laryngian vibration. The buccal cavity only serves to re- inforce or to transform it (Report made Novem- ber, 1908), and as there are not two mouths ex- actly the same, we obtain for the same vowel, as many traces as there are different singers, if we inscribe all the vibrations giving the special tim- bre of each voice." "It now remains to determine experimentally the place in the larynx where that intermittent vibration is produced." Mar age. (''Differents Traces d'Une Meme Voyelle Chant ee.") Different Traces of the Same Vowel as Sung. "The fundamental vowels, ou, o, a, e, i, are formed in the larynx. These laryngeal vowels are either reinforced or transformed by the buc- cal cavity." "In that which is about to be said, no account is taken of the accessory harmonics which give the special timbre to each voice." "Then, to each laryngeal vowel well emitted, corresponds one form, and one only, of the buc- cal cavity, for a determined subject. If that condition does not exist, the vowel is badly emit- ted; that is to saj% transformed, and the charac- teristic curve no longer exists." "We can comprehend why it is so rare to en- counter singers having a good diction (fine pro- nunciation) ; a beautiful voice depends solely on the larynx and the ear ; that is to say, on anatomic conditions ; a good diction necessitates a series of Molds of the buccal cavity pronouncing the vowels. — Maragcm THE SCIENCE OF THE VOCAL ART 195 long and difficult studies, which few singers have the courage to make completely." Marage. ("Etude des Vibrations Lar- yngiennes," November 22, 1909.) Study of the Laryngian Vibrations. "I have studied, until now, by the processes of biological physics, the vibrations of speech; ana- lytical and sj^nthetical experiments have led me to admit that the voice is an intermittent aero- laryngian vibration reinforced or transformed by the supra-laryngian resonators, and in particular by the mouth ; but it is necessary to directly prove that the larynx alone is capable of producing these vibrations." "I have been able, with the living subject, to completely annul the role of the buccal cavity, by filling it with stents, the substance which dentists use for taking impressions; an unbending cylin- drical tube traverses the stents and conducts the vibrations to the exterior ; there is then no longer any buccal vocable, since there is no longer any resonator; however, the larynx produces per- fectly the five vowels, ou, o, a, e, i ; these are then laryngeal vowels; furthermore, their traces are characteristic." "It is necessary to push the experiment further, completely isolate a larynx and cause it to render sounds analogous to those which it pro- duces during life. This is why I have again taken up these experiments on the larynx of dogs." "Technic. — Three hours after having been in- jected with morphine, the animal is put to sleep with chloroform and during the sleep, the larynx 196 THE TONSILS AND THE VOICE is removed with the hyoid bone and the five or six rings of the trachea ; a tube of caoutchouc of the same diameter as the trachea is fitted to it by a tube of thin glass, in such a manner as to permit a current of air to pass, the pressure of which is measured with metalhc manometer extra sensitive, graduated in miUimeters of water. This air can be taken from a reservoir of about 37 degrees." "The IsLTyngeal muscles are submitted to an in- duction current produced by a small 'hohine a chariof; the primary current is produced b}^ one accumulator only. The larynx is photographed with magnesium on plates sensitive to red, and the vibrations are inscribed on a phonograph." "Results. — (1) If the larynx has been re- moved during the chloroform sleep, the muscles can contract during three to ten minutes at the most." " (2) To produce the vibrations, the current of air must have a varying pressure, as in man dur- ing phonation, between 150 and 200 millimeters of water." " ( 3 ) If the excitor is placed on a level with the crico-arytenoid posterior muscles, the glottis opens wide, the vocal cords separate to the maxi- mum and there is no sound." " (4) If the excitor is placed at the level of the ary-arytenoids, the arytenoids approach each other and we obtain a fine low note recalling to such an extent as to be easily mistaken for the barking of a dog on a continuous note of the oc- tave 1." " (5) If the excitor is disposed in such a man- ner as not only to contract the ary-arytenoids, but THE SCIENCE OF THE VOCAL ART 197 also the thyro-arytenoids (vocal cords), we ob- tain a note very pure and very high, belonging to octave 5; it is a kind of whistle on u, corre- sponding to the howling of dogs, who at night, bay the moon." "This note, very high and sharp, has been ob- tained from a dog of medium height; in the photograph we see that the arytenoids have almost ridden one over the other, the glottis has become very slender and very short." "(6) The height of the note does not seem to depend either on the current, nor on the pressure of the air, but solely from the position of the excitor; that is to say, of the muscles which contract." " (7) In any case, the laws of the vibrations of cords have not appeared to me to be applicable to vibrations of the vocal cords ; these latter have no sound by themselves; it is the air which vibrates." "Conclusions. — ( 1 ) In taking the precautions which I have indicated, these experiments are very easy to repeat." " ( 2 ) The photographs show that, at each note, the entire larynx, including the epiglottis, changes in form." "(3) To each note corresponds a special form of the entire organ, and the larynx is an instru- ment of music which changes its form at each note." "(4) If to this is added the influence of the supra-laryngial resonators, we comprehend the diversity of the tracings which are obtained for the same vowel. If the apparatus inscribed every- 198 THE TONSILS AND THE VOICE thing, it is safe to say that there are no two tracings alike, for there are no two sounds ab- solutely the same." "(5) The vocal cords do not act at all like membranous reeds in caoutchouc, and there is not any resemblance between the sounds rendered by reeds in caoutchouc and the sounds rendered by the isolated larynx." "(6) Do these vibrations produce themselves at the level of the glottis; that is to say, at the moment when the air passes between the vocal cords, or have the ventricles of Morgagni, as Savart supposes, a preponderating influence ? It is a question which, for the moment, it is im- possible to determine." " (7) We comprehend that the voice may sud- denly disappear without apparent lesions of the vocal cords, for all the adductor muscles and all the articulations of the laryngeal cartilages are subject to rheumatic lesions, which may occur in a very short time." John Howard C"^ Physiology of Artistic Sing- ing." 1886) says: "The vocal cords are, in the main, two shelves of flesh more tender than the flesh of the softest fingers, and more easily squeezed or pressed into different shapes. They are about as soft as the flesh on the inside of the cheeks." "The usual pictures of the vocal organs are misleading." "The false cords are also small fleshy masses, similar to the vocal shelves (true cords) below in material, and quite as capable of producing THE SCIENCE OF THE VOCAL ART 199 sounds of definite pitch as the fleshy parts of the fingers or the true vocal shelves (true cords)." Liskovius in 1814, in his experiments upon the dead larynx did make them produce a succession of musical sounds by bringing them together with pincers and blowing between them. Alexander Graharn Bell {''Mechanism of Speech, Third Edition, 1908") says: "Every change in the shape of the passage waj^ through which the voice is passed, occasions a corresponding change in the quality of the voice." "The ventricles also, the spaces between the true and false vocal cords on either side, should, theoretically, exert an influence on the quality of the voice, for they constitute two small reson- ance chambers, situated close to the source of sound." John Howard {''Physiology of Artistic Sing- ing'') says: "The truth is, that very powerful contractions must be made to support even a soft and mild tone of artistic quality." "Likewise, the true delivery, though it excites no sensation of palatal effort, so flrmly tenses the palate that it must be pushed very strongly before it will give way. These and many other tests establish the indubitable fact that all powerful tones are the result of powerful muscular effort." "The surest test of feeble throat action is pressure of the finger against the sternohyoid muscle just above the breast bone. If the finger detects no apparent swelling (virtual straighten- 200 THE TONSILS AND THE VOICE ing) very little extrinsic effort, either right or wrong, is being made." "The writer has yet to learn a single fact valu- able in artistic singing which has been revealed by the laryngoscope." "To the anatomist or physiologist, the sm^geon or even the general practitioner, no smallest part of the whole throat can seem unimportant." "To quote the words of Baron Cuvier, in intro- ducing Bennati's 'Recherches sur le mecanisme de la voix humaine/ to the Royal Academy of Sciences^ that not only the muscles of the larynx serve to modulate the voice, but also those of the hyoid bone, those of the tongue and those of the veil of the palate, without which one could not at- tain the degree of modulation necessary for sing- ing." "That the upper part of the voice channel has great influence upon the nature of the tone and principally upon the formation of the mouth-tone is proved." "Furthermore, the greater size of the tongue is noted when the voice is especially full and re- sonant. The renowned Catalini, Lablache and Santini furnished examples." "Bennati found that the soft palate was less decidedly lowered for high notes ; but the positive contraction of the palate-larynx muscles ( palato- laryngei) is shown by the narrowed forms of the palatine arches." "The inferior constrictor, between the cricoid cartilage and the spine, forms the main boundary of the lower end of the purse-like pharynx. Whate /er is swallowed must come into direct con- THE SCIENCE OF THE VOCAL ART 201 tact with this muscle, and in this fact is found the reason why different habits affect the voice so differently and seriously. Many sing better after eating, because the descending food and drink have cleared away all thickened mucus or re- dundant moisture. More commonly the excessive flow of the secretions impairs the tone by making the layer between larynx and spine too thick to check the backward cricoid movement as fully as before, and too thick, also, to communicate the laryngeal vibration to the spine." "Spiritous liquors inflame all mucous mem- branes and their influence upon tone is unmistak- able. Malt liquors appear to be most harmful." Escat. {Maladies of the Pharynx.) Role of the Pharynx in Phonation and Articulation. "The veil of the palate by its movements of rising and lowering contribute in a large part to the formation of certain vowels and consonants." " ( 1 ) The paralysis of the veil of the palate pro- duces a phonetic trouble; rhinolalie ouverte, or, true nasality of tone, characterized by its exag- geration of the nasal resonance;" " (2) The immobilization of the veil, provoked by the enormous hypertrophy of the palatine (faucial) tonsils, or, by a tonsillitis phlegmon, prevents the emission of the gutturals, g, r, hard g, r; that is to say, the tonsillitic voice;" "(3) The obstruction of the nasopharynx di- minishes and suppresses even the nasal resonance, creating a third phonetic trouble, the rhinolalie ferniee, or stoniatolalie, characterized by the im- possibility of emitting the nasal an, en, on; this last trouble is above all charged to adenoid 202 THE TONSILS AND THE VOICE growths and tumors of the nasopharynx; finally the pharynx in its entirety plays in the emission of the singing voice, the role of a powerful res- onating box, and thus all the lesions of that organ bring with singers, various troubles of which the princij)al are the alterations of the timbre and the diminution of the volume of the voice." Frank E. Miller saj^s: "It is especially the structural differences between the resonant cavities of individual singers that determine dif- ferences of timbre or quality. There are innum- erable timbres for the human voice, as manj^ as there are voices, and all due to the pliability of the vocal tract. The walls of the pharynx are permeated by a network of muscles, susceptible of numerous adjustments and re-adjustments in size and shape. So numerous are the adjustments in shape of the voice tract that Mara could make one hundred changes in pitch between any ttvo notes in her voice, and as she had a compass of twenty-one notes, she could produce no less than twenty-one hundred changes in pitch within a range of twenty-one notes. It is b^^ timbre that we distinguish voices as we distinguish features." "There are not such minute and individual differences between instruments of the same kind as there are between voices of the same range, be- cause there are no such minute and individual structural differences in instruments as in the vocal organs of individuals — differences that each individual can multiply ad infinitum by the subtle and delicate play of muscles acting in response to mental suggestion, art sense, inspiration, tern- THE SCIENCE OF THE VOCAL ART 203 perament, psychic impulse or whatever cognate term one may choose to call it." G. Hudson-Makuen, in The Transactions of the American Laryngological Association, 1911 states: ''There is no absolute standard of vocal excellence. The voice that sounds good to one person may sound different to another. Whether a voice is good or bad depends, not actually but practically, upon the ear of the listener. This fact may account, perhaps, for the great differ- ence of opinion now prevailing as to the effect of tonsil operations upon the voice." Are these statements the truth? Is it a fact that "A good or bad voice depends upon the ear of the listener?" and that " the great difference of opinion as to the effect of tonsil operations on the voice depends upon the differences in ears?" Or is the alleged fact only an assumption? Is it the mere faculty of hearing, the simple ear, that enables one to judge the quality of tone; that justifies the price put upon the patrons of grand opera; that moves the audience to raptur- ous applause of famous singers ; or, is it not rather the educated ear that reigns as an umpire in the art of song ; is it not the cultured critic alone, who is capable of perceiving, analyzing and appre- ciating the very rudiments of a standard tone ? Is there no standard in vocal excellence, no criterion, no aim? There is no doubt that the old Italiaii singing masters aimed for a standard tone, and taught strictly according to correct physiological prin- ciples. The old teachers insisted on a course of voice training which took years to give the stu- 204 THE TONSILS AND THE VOICE dent complete ease and perfect control of techni- que. The voice mechanism is delicate and finely- poised. Slight physical disturbance, or wrong use of the mechanism, promptly and seriously affects the quality of the voice. Artistic singing depends upon a correct method in voice production. A correct method consists of a perfect co-ordination of all parts of the voice-producing mechanism, an intricate and complicated apparatus. Frank E. Miller says that "in every voice cer- tain notes are better than others, and a correct method of voice production, while it may not be able to make every note in the range of the voice of equal quality, brings the whole voice up to a more even standard of excellence. It leaves the best notes as good as ever and brings the notes which naturally are not so satisfactory nearer the standard of the best. There are certain fundamental lyrinciples in a correct meth- od of voice production, based upon study and knowledge of the organs concerned." "Every vocal tone is, in fact, a mental concept reproduced as voice by the physical organs of voice production. That is why an inaccurate ear for pitch results in a vocalist singing off pitch.'' "In 1891 I stated the necessity for a standard for tone, and had the idea of constructing a voice measure. It was to consist of a combination of a phonograph, photograph, and a mechanical re- production of registration of the vocal sounds, the combination so arranged as to form a stand- ard for vocal tones to measure and compare for all time every voice in the world." THE SCIENCE OF THE VOCAL ART 205 "A standard pitch for orchestras was found to be absolutely necessary, in order that every com- bination of musical instruments might render music intelligently, and with greater harmony and without discord. The standard should be as nearly perfect as possible." ''It is of equal or greater importance that a standard vocal tone should be recognized, and a system formulated which will enable singers to acquire it. Recognizing that the vocal tone of Caruso and Melba each represent in the male and female voice the highest and best- example of tone, and approach perfection nearer than any others, definitely to ascertain and fix the method of producing these tones, making it possible for students and singers to adopt these methods and produce tones of precisely the same character, is a prime desideratum. The waves of sound upon a disc or cylinder as they come from the throats of Caruso or Melba, furnish an exact template or model for waves that should be made by the vocal utterances of the pupil in order to produce this perfect tone. The waves of sound as taken by a record from a student will at once disclose marked variations from these pattern records, and with the knowledge of the point at which these variations occur, opportunity is had for modification or enlargement at these special lo- calities. When this is done, further records will show a nearer approach to the pattern, and by successive corrections, the pupil should be able to produce sound waves as nearly identical with those of Caruso and Melba as is possible." "Phenomenal voices always have been rare, and 206 THE TONSILS AND THE VOICE doubtless are no rarer now than at any other period. At any time any opera house would have been proud of two such tenors as Caruso and Bond, and of two such sopranos as Melha and Tetrazzini, while there is no period in which a Semhrich would not have been a i^ara avis." "What is tone production? The very name implies that it is sound produced by a mechanism of some kind. Therefore, the first thing to be gathered from this deduction is that if the mech- anism is correctly operated, of course, a correct result will be obtained, or, in other words, the tone produced will be a normal one." ''From the inception of the vocal art, the world has had its Carusos and Melhas to establish the STANDARD FOR TOXE^ but Until recently, the phy- siological process of producing this tone has been unknown." "Now, as tone is the foundation of all singing, and as this tone is the thing of all others for which our artists have ever been criticised, does it not seem reasonable that there should be and is a tangible as well as scientific means of voice building, whereby all these difficulties can be overcome, and the beauty of each voice developed to its highest possible degree?" "The time is rapidly coming, if not already here, when not only singers and musical people, but the general public, will see the truth of these statements. It is not enough for the teacher to be able to sing a correct tone; he must be able to show minutely in every stage of development from the beginning to the most advanced stages, the points of study to be taken up" THM SCIENCE OF THE VOCAL ART 207 Scripture {''Researches in Experimental Pho- netics,'' 1906) says: "The ear will hear what it expects to hear. The scientific man of to-day de- mands that work with the unaided senses he fol- lowed up by the methods of recording and measuring. Automatic records, experimental analysis and careful measurement must he the foundation of phonetics as a natural science J" A. Zund-Burguet (''Experimental Researches on the Timbre of the Nasal French Vowels'") says: "Beyond the physiological method, re- searches into the timbre of the nasalized vowels could be made by the purely physical method. In fact, in place of judging the color of sounds ac- cording to the position of the phonator organs, we may, by the aid of certain methods, produce an inscription of the vowels, and devote ourselves thereafter to the analysis of the tracings thus ob- tained. The celebrated and regretted acous- tician, Rudolph Koenig, had inaugurated, thirty years ago, the inscription, and following it, the decomposition of the vowels by means of mano- metric flames. M. M. Hermann and Marichelle have devoted themselves to the same researches according to the tracings of the phonograph." "Helmholtz and others, notably the Abbe Roussolot, have extolled the study of the timbre of the vowels from tracings obtained by the ap- plication of the graphic method of M. Marey." Mar age ("^ Audition and Phonationf 1907) : "The ear can hear three kinds of vibrations: noises, music and speech/' Marage ("Photographing Vibrations of the Voice") : "I have had an apparatus constructed 208 THE TONSILS AND THE VOICE which permits of photographing, developing and fixing immediately, the vibrations of the voice." "I think that this apparatus will be of service to professors of singing and of elocution in en- abling them to not only permit their pupils to hear J but to seei, the qualities and the defects of their voices, and to recognize their progress: philologists have with this instrument a method which permits them to easily inscribe exact tracings of the voice spoken or sung in different languages : finally, physicians have, with a photo- graph of the voice, an indisputable means of con- trolling and causing to be controlled the state of the larynx of their patients before and after a treatment." Mar age {Photographing the Voice in Medical Practice) : "Photographing the laryngeal vibra- tions permits us to see in a very clear manner, the state of the voice at the beginning and at the end of a treatment." The foregoing observations prove conclusively that the faucial tonsils are factors in voice mech- anism ; they show definitely the degree of perfec- tion attained in the scientific notation by sight and sound of the action of the mechanism, and they exhibit the value of this registration in voice culture, as well as in the practice of medicine; they suggest the difficulties and show the great necessity of care in the diagnosis of tonsillar affec- tions that bear upon the mechanism of the voice. Robert and Sven Berglund, Stockholm^ have invented a new apparatus, the photo graphone, which reproduces simultaneously both sound and action. ' '-'"^•fi^^/Vr i»eif 1 .'.^VJ4^,j,j^,<: ^'^^;i' .., ^^^^'^&'iMtx'!r^ B:-?5S'^54j -««.^,^^^^ ''**^-'^^^-;.- «tes-i, **»»*«» Photographs of the voice in singing and speaking. — Marage. 1. Speaking. 2. Singing. THE SCIENCE OF THE VOCAL ART 209 Thomas A. Edison has invented a talking ma- chine that operates in harmony and unison with motion pictures, called the Kinetephone, Escat. ''Role of the Pharynx in Audition f* "The auditive function has for an essential condition the integrity of the naso-pharyngeal cavity, and the free functioning of the muscles of the veil and of the pharynx." Marage. ('' Photo graphie des Vibrations de la Voiai") "Photographing the Vibrations of the Voice." "(3) By photographing the vibrations of the voice, a professor of elocution can recognize from the foregoing: "(a) The duration of each vowel." "(b) The note on which it is emitted." "(c) The constituent parts of each syllable." "For foreigners and deaf mutes, we have thus a method of permitting them to see their de- fects." "(4) A professor of singing can immediately cause a pupil to see a scale which he has just sung." "(a) If he has sung in time, for each note must have the same duration and each rest, repre- sented by a straight line, the same length." "(b) If he sings true, for it suffices to count the number of vibrations per line and multiply it by n if each second line lasts 1/n of a second." "(c) // his voice is good, for the vibrations must have a constant amplitude, and be regular, having no traces in spindles, which indicates that the voice trembles." . "(d) If he h^.s an insufficient vital capacity, 15 210 THE TONSILS AND THE A'OICE for if the singer is obliged to breathe too often, we find the periods of rest too long and too fre- quent." "(e) If he has good diction (declamation) : in fact, if his diction is bad, there is no proper grouping." "(f) If his diction is good, each vowel should have its characteristic grouping and the conso- nants should be marked in the places which they should occupy." "(g) What the compass of the voice is: we can recognize it in finding the lowest and the highest note that a singer can give." "(h) If he has 'holes' in his voice: then the corresponding notes are short or trembling, or without diction or even nil." "Conclusion. — I think then that this apparatus will be of service to professors of singing and of elocution in enabling them to not only permit their pupils to hear, but to see, the qualities and the defects of their voices, and to recognize their progress; philologists have with this instrument a method which permits them to easily inscribe exact tracings of the voice spoken or sung in dif- ferent languages ; finally, physicians have, with a photograph of the voice an indisputable means of controlling and causing to be controlled the state of the larynx of their patients before and after a treatment : in many cases this control will not be useless either to the physician or the patient." Mar age. (La Photographic de la Voice dans la Pratique Medicate.) Photographing the Voice in Medical Practice. "If in the course of a treatment it is indis- No. 1 No. 2 Photographs of the voice in medical practice. — Marage. No. 1. The note " la " sung by a larynx affected with the singer's nodule, photo- graphed at different periods of the treatment. No. 2. The same note photographed at the beginning and at the end of treatment for pharyngeal catarrh. THE SCIENCE OF THE VOCAL ART 211 pensable to measure in a precise manner, the vari- ations of the auditive acuity, it is also equally im- portant, in the same conditions, to inscribe the notes which a diseased larynx can sing." "In a work presented to the Academy of Sci- ences, March 23, 1908, I have described an ap- paratus which permits photographing the vibra- tion of the voice on a strip of paper 25 meters in length." "I have thought that this method might be use- ful to physicians in permitting them to recognize, and to allow their patients to recognize, the state of their voice before and after a treatment." "I have had occasion to photograph a large number of voices." ^'^Conclusions. The photographing of the lar- yngeal vibrations permits us to see in a very clear manner, the state of the voice at the beginning and at the end of a treatment; this proceeding is a guide for the practitioner in the progress of the case to be given and in certain cases these tracings would not be useless to the patient and to the phy- sician." U.S. Consul-general, Edward D. Winslow, Stockholm, has courteously furnished me the names of Robert and Sven Berglund (Stock- holm), inventors of a new instrument called the photo graphone. This instrument reproduces si- multaneously both action and sound. In this in- strument, the human voice and all other sounds are perfectly reproduced without any disturbing secondary sounds. So perfect is the reproduction of sounds with the photographone that the in- ventor can distinguish between and actually read 212 THE TONSILS AND THE VOICE on the curve the different letters of the alphabet, and the photographic plate is so sensitive that the smallest variations in the voice can be studied. The same words uttered in the same language, but by another individual, appear diiFerent in the photographone script. The great importance of this method for obtain- ing linguistical and musical records is evident. With the photographone it is possible at one time to photograph the action as well as the music and song and to reproduce the same at one time. If the original music or song should not be strong enough to fill a large concert hall the sound can be increased as desired. An immense volume of magnified sound can be reproduced. And it has been suggested that this apparatus will be of great value at sea in calling out the names of lighthouses. And I believe that it would also prove a valuable equipment in various ways for ocean steamships. Marage. ( Voix de Poitrine et Voioo de Tete.) Chest Voice and Head Voice: "A subject determined may emit a certain number of notes which constitute the tessiture of his voice •} to the lower notes of that tessiture cor- responds what is called the chest register ; to high notes, the head register ; between these two regis- ters there exists a passage more or less marked ; it is the mechanism of this passage that I wish stud- ied to-day." "(1) Anatomical Fact. All the intrinsic mus- cles of the larynx are innervated by the recur- rent; the two crico-thyroidians are alone inner- vated by the external laryngeal; they have then THE SCIENCE OF THE VOCAL ART 213 a special independence; these two muscles make the thyroid cartilage see-saw on the cricoid in bringing together the two cartilages forward; they are then the tensors of the vocal cords." "(2) Experimental Fact. If, at the moment of passing from the chest voice to the head voice, there is a sudden contraction of the crico-thyroid- ian, the space comprised in front between these two cartilages must diminish in size, and we can then recognize that diminution by means of the cardiagraph of Marey, modified by Zund-Burg- uet." "This instrument is placed on each side of the neck in the space limited by the thyroid, the cri- coid and the crico-thyroidian muscle; these two drums communicate with an inscriptor drum by means of a tube having a y-shape." ''First case. — There is a very marked differ- ence between the two registers ; there is then pro- duced a sudden contraction of the two crico-thy- roidian muscles." ''Second case. — The passing of the chest voice to the head voice is less marked, then the curve rises little by little, and with certain artists, it is almost continuous without a union. The crico- thyroidian muscle may then either suddenly con- tract, or contract little by little in such a manner as to produce the progressive tension of the vocal cords. If, at the same time, we photograph the vibrations of the voice, not only may we know the notes which belong to the chest register and to the head register, but further may determine the missing notes, that is to say, the holes in the voice. "The professors have then well observed this 214 THE TONSILS AND THE VOICE phenomenon of the transition due to the contrac- tion of the crico-thyroidian muscle, but the names chest voice and head voice seem to be quite badly chosen, for they may lead their pupils into error : there is only in fact one voice to the aero-laryn- gian vibration produced at the level of the glottis ; it would be better to employ the term low regis- ter and high register." "The contraction of the crico-thyroidian muscle is perhaps not the only phenomenon which is pro- duced at the moment of passage, but it is always produced and it is easy to put in evidence." ^'Conclusions. When the passage between the two registers, low or high, is very marked, the tracing of the vibrations shows that the voice is tremulous and that certain notes are in default. The professors of singing have then reason for employing the methods which they believe to be useful to cause this passing or transition to dis- appear." Mar age. (La Respiration chez les Chanteurs.) The Breathing of Singers: "As Marey said a long time ago, there is no such thing as masculine respiration and feminine respiration; there are good respirations and bad respirations." "(1) Good Respiration. In order that the respiratory act be well done, it is necessary that the thoracic cage be dilated nearly equally fol- lowing all its dimensions. It is further necessary that the respiration be sufficient, that is to say that the vital capacity be in accord with the age and the height of the subject." "(2) Bad Respiration. Bad respiration oc- THE SCIENCE OF THE VOCAL ART 215 curs, when one of the perimeters, inferior, or su- perior, augments much more than the others." ''Exaggerated augmentation of the inferior perimeter. Occurs in men and women of a seden- tary life; the muscles of the abominal wall have no longer the tonicity sufficient; the diaphragm in contracting, repels the intestinal mass; these subjects breathe with the abdomen, according to the vulgar expression." "Exaggerated augmentation of the superior thoracic perimeter. Occurs, chiefly, in certain subjects much given to sport and in women who wear corsets, even if not tight; the slightest ob- stacle suffices in effect to change the type of res- piration. The muscles of the abdominal wall have no longer any work to perform since they are replaced by the corset, and allow themselves to be repelled too easily by the diaphragm when that obstacle has disappeared." ''Conclusions. (1) For a respiration to be good, it is necessary that the thoracic cage be dilated following all its dimensions." "(2) In order that it be sufficient, it is neces- sary that it dilates enough and in such a manner, as to obtain a vital capacity in accord with the age, the height and the weight of the subject." " ( 3 ) Each pupil of singing or elocution should have a respiratory card giving not only his height, his weight, his thoracic perimeter and his vital capacity, but also the curve represent- ing his class of respiration." " (4) It is useless to learn to sing or to speak if one does not know how to breathe, and the ma- 216 THE TONSILS AND THE VOICE jority of voices are lost not so much through a bad general method as by bad respiration." John Howard, Harry Campbell, Marage, and Koffler, are four great authorities on breathing and thej^ all agree. Marage. (La Ported de Certaines Voice et le Travail develojjpe Pendant la Phonation.) The reach of certain voices and the energy developed during phonation: "An orator is often embarrassed, when he speaks in a room of which he does not know the acoustic qualities, to know what energy he must give to his voice to make himself heard by all his auditors." "The problem is quite complex; we have, in effect, three factors which may intervene: the room itself, the auditors and the orator." "A room is good if there is no echo and if the resonant sound has a sufficient duration to rein- force the sound which produces it without en- croaching upon the sound which follows." "Further, the ears of the auditors are not equally sensitive to all the sounds : to the physio- logical state and in the open air, low tones are heard much less easily than high tones." "We have then remaining, the influence of the orator." "We say generally that certain voices carry bet- ter than others: is this assertion true; what ex- actly does it signify?" "We are therefore going to seek, in a deter- mined room, what energy must be given to his voice to make himself heard, an orator, accord- THE SCIENCE OF THE VOCAL ART 217 ing to whether he has a register of basso, barytone or tenor." "The energy of the sound being given by the product VH of the Volume V of air which es- capes from the lungs under a pressure H, the question is to determine these two quantities." "The numerous experiments on the measuring of the auditive acuity, have proved to me that the synthetic vowels ou, o, a, emitted on the same note, fa, for example, common to the registers of basso, barytone and tenor, produce the same im- pression on the ear as one of these three voices : it will be sufficient then for us to employ successive- ly these three vowels." "We will then seek the smallest amount of en- ergy necessary to cause one of these sounds to be heard by a listener placed successively in differ- ent parts of the room." "In the experiments made in rooms of the Trocadero, Chapel of the Sorbonne, Academy of Medicine, and Richelieu Amphitheatre, it is at once seen that in all these rooms bass voices have a great disadvantage, since they must employ an energy 7 to 16 times greater than a tenor voice: the barytone voices are intermediate, while ap- proaching much closer the tenor voice." "If we consider the different rooms, a tenor must expend four times more energy in the Troc- adero than in the Richelieu Amphitheatre ; on the contrary, a bass voice is obliged, according to the room, to give sometimes an energy nine times greater." ''Conclusions. Equality of Diction. • " ( 1 ) It is right to say that certain voices carry 218 THE TONSILS AND THE VOICE better than others; this expression simply signi- fies that certain voices require less effort to make themselves heard." " (2) An orator should develop V and H, that is to say, augment V in increasing his vital ca- pacity by exercise appropriate for the inspirator muscles; augment H in learning to exercise his expirator muscles;' and at the same time not al- low the air to. be uselessly lost by the opening of the glottis." " (3) In practice, to make himself heard by an audience in an unknown room, it is necessary to augment little by little the energy of the voice until he commences to perceive himself the sound of the resonants; this diminishes a little the en- ergy of the sound and will thus obtain the best results." "Remarks. (1) The pressure of the air main- tains itself whether it is an affair of the natural or of an artificial larynx between 100 and 200 millimeters." "(2) That which causes the energy of phona- tion to vary enormously is the delivery of the air, which oscillates from 300 litres per hour ( natural larynx, conversation) to 2,070 litres per hour (artificial larynx, conversation.)" "(3) The vocal cords not having the same length in men (20 to 24 millimeters) as in women (16 to 18 millimeters), I have made experiments in changing the length of the vibrating part of the membranous reeds." "For the long reeds (24 mm.) the minimum energy* to make them vibrate is 57 kilogrammet- ers per hour; for the short reeds (18 mm.) 14 THE SCIENCE OF THE VOCAL ART 219 kgm., 400. One may then foresee that woman fatigue themselves much less in talking than the men; we know also that children, in whom the larynx is still much smaller, can talk all day with- out having the air of being in the least tired." ^'^Conclusions. ( 1 ) An orator must, before all, learn to breathe, since it is V which varies the most." " (2) He must not lose air uselessly; that is to say, the vocal cords must join on the median line." "(3) Men, and in particular, basses, fatigue themselves much more in speaking than women and children." ''Resume. During phonation, there escapes from the lungs a certain volume of air under a certain pressure; the product of these two quan- tities, the volume and the pressure, give the work developed." "It is a question then to determine them." "The volume of air which escapes is obtained * quite easily, but it is more difficult to measure the pressure, for it is necessary to take it directly in the trachea." "These difficulties have been surmounted in taking the measures on two subjects; one was furnished with an artificial larynx and the other wore a tracheal canula and a normal larynx. During ordinary conversation, there is developed, in one hour, an energy of about 48 kilogram- meters; that is to say, that to speak during one hour is not more fatiguing than to lift at each second a weight of 13 grammes, one meter high: a lady in trifling with her fan, or a professor ges- 220 THE TONSILS AND THE VOICE ticulating with a piece of chalk, exerts an energy much greater." "To pronounce a discourse in a large room, the. energy is more considerable, but it is not enor- mous; it is, on an average of 200 kilogrammet- ers per hour; an employee of a railroad per- forms a greater work in lifting from the ground on to his shoulder, four packages of 50 kilo- grammes." "We have compared subsequently the energy developed in conversing by the voice of a man and that of a woman, and have found that women are fatigued, in talking, four times less than a man. We can then comprehend how children who have a larynx narrower than their mothers, can talk for several hours without taking a rest." "The practical conclusions of these experiments is as follows: The energy developed depends, above all, on the volume of air expirated ; an ora- tor must then learn to accumulate the air in his lungs and to not allow it to escape uselessly." In the science of the vocal art, there are many lights and side lights, of exceeding interest, which the bounds of this book must of necessity exclude : such, for example, as the consideration of what well-informed teachers of voice, artists, and stu- dents, should know of the anatomy and physiolo- gy of the vocal organs ; the measure for increasing the volume of the voice, its power, intensity and endurance, the means for improving the purity of tone ; consideration of variations in resonance, compass, timbre and quality, advanced views re- garding pitch, and the sensations of audition ; ex- periments in phonetics; the production of vowel THE SCIENCE OF THE VOCAL ART 221 sounds by manikins; speech without a larynx, etc. Charles A. Rice: "Vibration is tone production. Tone production is vibration. Vibration is the cause of sensation. Perception of pitch is oc- casioned by the sensation acting directly on audi- tion by mediate contact, and not by listening with the outer ear. Perception of pitch is due to medi- ate contact with the nerve of hearing, or direct contact with the sounding board. Listening by the external ear is only confusion in tone produc- tion." Mar age [Audition et Phonation chez les Sourds-muets) : "The ear can hear three kinds of vibrations: noises, music and speech." Mar age (Theorie Elementaire de V Audi- tion) : "The middle ear is filled with air which com- municates with the atmosphere by a tube, the Eustachian tube, opening into the pharynx: the pressure is thus always equal on the two faces of the tympanum." "The vibrations of the tympanum are traversed to the round window by the intermediary of the air, and to the oval window by the intermediary of the chain of ossicles." "The internal ear is filled with a first liquid, the peri-lymph, which communicates with the cepha- lorrhachidian liquid by a canal, the peri lymphatic canal; a membranous sack, the endo-lymphatic sack, is completely immersed in the peri-lymph and filled by a second liquid, the endo-lymph liquid. It is in the midst of this liquid where are 222 THE TONSILS AND THE VOICE found the nerve terminations of the auditory- nerve ; the volume of the endo-lymph is very near- ly the third of that of the peri-lymph. We see then that the exterior vibrations, before impressing this nerve, must traverse the tympanum, the chain of ossicles, the peri-lymph, and the endo-lymph, and that everything is disposed in the ear, not to augment the intensity of the vibrations, but, on the contrary, to diminish them as much as pos- sible." "When, for any reason whatever, the chain of ossicles is immobilized, the chain of vibrations can pass directly from the tympanum to the round window by the intermediary of the air of the mid- dle ear, and if the tympanum itself is too much thickened to vibrate, it suffices to pierce a hole in order that the vibrations may pass directly to the ound window and that the sound be perceived." How does a sound impress itself upon the nerve terminations ? There are two theories : ( 1 ) By Helmholtz. Each nerve termination of the cochlea is influenced, and could not be influenced except by one sole sound of determined pitch; ( 2 ) by other authors. All the neiwe threads will be equally impressed, and it will be the different nerve centers situated in the brain which will re- act differently." "The results of 1,500 measurements of auditory acuity, the observation of 800 cases of deafness of different kinds, lead me to suppose that this second hypothesis must be admitted." Marage, presented by M. Yves Delage {Con- tribution a VEtude de V Audition, October 12, 1908) : THE SCIENCE OF THE VOCAL ART 223 " ( 1 ) Anatomic Facts. The internal ear is not composed only, as is taught in many classic works, of vestibule, of semi-circular canals, and of the cochlea with its nerve terminals, as found therein ; in this term internal ear must be comprehended the real terminations in the brain, of the two branches, vestibular and cochlear, which constitute the auditory nerve; the vestibular nerve which corresponds to the anterior root, terminates in the nucleus of Deiters and in the vestibular nucleus ; the posterior root, or cochlear nei've is much more complex, and joins, by divers branches, to eight different nuclei. Bechterew has divided these different branches into centripetal auditory ways of first and second order, which communicate, either among themselves, or directly with the cochlea, with the different centers ; further, there exist centrifugal or recurrent ways which allow the different cellular nuclei to communicate among themselves." " (2) Pathological Facts. With the apparatus which I have presented here, one may now deter- mine exactl}^ the height, the timbre and the ten- sity of sounds, which the ear may hear." "Results obtained: "(a) Subjects are frequently met with who hear the most feeble noises, but who are com- pletely deaf as to music and speech." "(b) Others are met with who hear noises, mu- sic and speech, even to the musical vibrations pro- duced by the timbre of each voice, but who do not comprehend it." "(c) There exist other subjects, in whom deaf- ness has evolved rapidty, in such a manner as to 224 THE TONSILS AND THE VOICE become absolute in 24 hours ; in one instance, for example, deafness is evolved in the following fashion: the deafness began at 11 o'clock in the evening, by the disappearance from the hearing of certain instiTiments of the orchestra, the vio- lins; 2 hours afterwards, no musical sound could be heard, but speech is very well comprehended; 8 hours after the deafness is complete for all vi- brations, noises, music, speech." "(d) When the auditive acuity is developed by appropriate means, the inverse phenomena are produced; all of the vibrations do not commence to be heard at the same time, and the amelioration is produced as if it concerned different ears which are not sensible to the same sound." "Explanation: These phenomena may be ex- ulained in the following manner: when a vibra- tion of any nature is produced at the exterior, all the nerve terminals are impressed by the inter- mediary of the peri-lymph and the endo-lymph, and, in case it concerns a noise, a musical or speech vibration, it is the nerve centers of the first, second, or third stage which are impressed." ''The degree of perfection of the hearing is then connected, not so much to the ear as an or- gan than to the auditive centers , and in conse- quence to the brain." "Resume. The second theory of the auditory centers is conformable to our most recent ana- tomic and pathologic knowledge. Furthermore, it readily explains the phenomena which we ob- serve." Adolph Zund-Burguet (Controle et Connexion de V Emission Vocale) : "holds that the improper THE SCIENCE OF THE VOCAL ART 225 pronunciation of words is due to the wrong posi- tion of the tongue at the moment of emission, and that by means of the instruments, which he has invented and herein describes, we may now, for the first time in the history of phonetics, observe and control the action of the tongue, and thus lead to a perfect emission and correct pronuncia- tion of not only French, but of any other lan- guage." The article is highly interesting to pho- neticians. A. Zund-Burguet (Recherches Eocperimen- tales sur le Timbre des Voyelles Nasales Fran- ciases) : "It remains for us to determine the tim- bre of the four nasal vowels according to the po- sition of the lips. Here, still, I will be able to employ the graphic method : I have preferred to have recourse to photography." "I have said previously that beyond the physi- ological method, researches into the timbre of the nasalized vowels could be made by the purely physical method. In fact, in place of judging the color of sounds according to the position of the phonator organs, we may, by the aid of cer- tain methods, produce an inscription of the vow- els, and devote ourselves thereafter to the anal- ysis of the tracings thus obtained." Adolph Zund-Burguet. (La Reeducation Au- ditive d'apres la Methode Electro-V ociphon- ique) : "We had no trouble in recognizing that the su- periority of the oral method, over other methods of auditive re-education, resides principally in the physical nature of the sounds of the human voice. In the case of a correct emission, these are char- 16 226 THE TONSILS AND THE VOICE acterized by a great richness in low harmonics, and the absence of all noise." "To create an instrument capable of producing low, medium and high sounds, and possessing the characteristics of the sound of the human voice, was only to solve half of the problem presented. To solve it entirely, it was necessary to find a means of modifying at will their intensity, with- out changing at the same time their musical pitch, and also inversely, to be able to vary the pitch while conserving the intensity. The discovery of a new principle, led to the creation of an instru- ment until now unknown, and with it, the com- plete realization of our dream." "This instrument we call the Electro-Voci- phone. It contains three organs, producers of sounds very rich in harmonics, free from all noises, and so like the sound of the human voice that it is only necessary to pass the sounds through an appropriate resonator, to transform them at once into vowels." "Technic. After having determined in any usu- al way the auditive acuity of each ear to be re- educated, we sound the entire series of tones in passing from the low to the high, or inversely : at the same time insisting on the sounds that the ear perceives the least easily." J.IIelsmoortel (La Surdite d'OrigineSclereuse et la Reeducation Auditive par le Methode voci- pJionique. Deafness of Sclerotic Origin and Auditive Reeducation by the Vociphonic Method) : "In 1903, in the course of the meeting of the Belgian Otological and Larjmgological Society, THE SCIENCE OF THE VOCAL ART 227 Professor Eeman of Gand declared that we know no means of acting on this process. The usual means remain without effect. Local me- chanical means only aggravate the malady and precipitate its progress. Dr. Le?'moyez sub- scribed without reserve to that declaration, and the greater part of the otologists present were of the same opinion. We held that opinion until the beginning of 1909, when happy circumstances permitted or obliged us, to modify totally our opinion. It will not be found extraordinary that we have changed our opinion on the intractibility of sclerotic deafness." "We have presented a number of cases of scle- rotic deafness greatly ameliorated by re-educa- tion, at the meeting of the Society of Otology and Laryngology at Brussels, in 1909, and on two oc- casions to the Medical Society of the Louise- Marie Hospital, at Antwerp." "The apparatus, invented by M. Zund-Burg- uet, called Vociphone, or Electrophone, contains the producing organs of sounds which correspond to the three human registers, low, medium and high. The timbre of the sounds is entirely similar to that of the human voice." "By the sole aid of the electrophone or voci- phone, it becomes extremely easy to fulfill all the conditions exacted and the recital of the clinical observations will permit you to judge of the effi- ciency of this new method, of auditive re-educa- tion in the case of progressive deafness of scle- rotic origin; that is to say, in the precise cases where medico-chirurgical methods are absolutely powerless. The results obtained, to our surprise, 228 THE TONSILS AND THE VOICE have not only been integrally maintained, but, in the majority of cases, have been considerably augmented during the period of repose." A. Raoult. (Reeducation de VOuie par le Procede Electro-Phono'ide. Re-education of the Hearing by the Electro- phonoid Method.) He was at first extremely skeptical of the proc- ess, but has since tried it in some 50 cases with great success, and is now completely in favor of it. After reciting cases, with details, he says : "In conclusion, that which gives an entirely special value to the electro-phonoid process of re- education, is the persistence of the amelioration of the hearing even when the treatments are fin- ished and the patients left in repose. Helsmoor- tel has related several observations of patients seen a year after the re-education, and in whom the amelioration had persisted." "Summary: From the observations of all these facts, we may conclude: "(1) Even in cases of advanced sclerosis in the aged, we may still hope to obtain ameliora- tion." "(2) The amelioration is much more notice- able in the young, and even more when the evolu- tion of the oto-sclerosis is less remote." " (3) The verification in patients of the abnor- mal paracousis of Willis or that of Rinne seems to make it our duty to prognosticate a notable amelioration of deafness." "One great value of the highly important method of auditive re-education of Zund-Burguet and Helsmoortel will be that of enabling the voice THE SCIENCE OF THE VOCAL ART 229 user, especially the singer, to again be able to per- ceive his proper vocal pitch." Marcel Natier {Reeducation Methodique de JL' Oreille par des Exercises Acoustiques) states that he has had great success in the re-education of the ear by acoustic exercises with diapasons (large tuning forks). Marcel Natier {Surdite et Altitude. Re- education Methodique de V Oreille) : Details cases of deafness which were greatly helped by living in the mountains at a height of 625 to 900 yards. He simply records the success of altitude. J. W. Gleitsmann {Ueber Pharynocstimme, 1909) : "The first patient who could phonate after the extirpation of the larynx was presented to the Medical Society of Greifswald, 1888, and to the Medical Society of Berlin, 1893, by Dr. Schmid, B. Frdnkel gave the correct explanation. One year and six months after removal of the larynx, the man could speak with a harsh, monotonous voice. The second case was that of J. Solis- Cohen, in April, 1892. He was presented to the Medical Society of Philadelphia in October, 1893. He could talk well and modulate his voice. Heard 40 feet away." "Two cases reported by Dr. Gottstein (1909). First patient, Gottstein was going to provide with a pharyngeal voice. Was given exercises. Re- turned in four months, with a plain voice. After two other lessons, he could modulate his voice and even sing a song. What Gottstein accomplished with this man in about one year, he did with an- 230 THE TONSILS AND THE VOICE other patient in six weeks. This second one spoke in a hoarse voice, but plain and distinct." "The systematic perfection and scientific de- velopment of the method is due to GutzinannJ" "Such a voice can be acquired on two condi- tions: the first in an air chamber in the hypo- pharynx, generally, created by the free will of the patient, and second, a little narrow space above the air chamber, which must be such that the emis- sion of air into the folds of the mucous membrane may cause vibrations which are able to produce a real tone. Gutzmann says that there cannot be a general rule about the place where the voice is formed ; it depends entirely on the mechanical con- ditions created by the laryngectomy in every case respectively." And I will add to the statement of Von Gutzmann, no vibration^ no voice. Von Gutzmann, in his work, "Stimme und Sprache oJine Kehlkopf" makes the remarkable statement that "if he can teach those who have no larynx to talk and sing," that "he can himself also talk and sing without using his larjmx." He has explained the mechanism by which he accom- plishes this. He states that he can talk and sing and whistle with absolutely no air passing out of his larynx. "Whistling with the closed larynx is not hard at all. I can whistle and speak with the closed larynx; without using my larynx. I am able to speak in a way that my breathing is absolutely suspended." To preserve the voice, composers must write for the voice. Much of the music written for orches- tration effects is ruinous to the voice. Artists THE SCIENCE OF THE VOCAL ART 231 should never attempt to sing music which makes the human voice secondary to orchestral instru- mentation. The human voice is the most sublime instrument^ and should forever demand music written for the voice. Artists w ould soon bring composers to a sense of realization of their fault, if they would refuse to sing music written chiefly for orchestration. And good voices would be saved. The most wonderful singing voices in the world to-day are being produced in America. And there are in America teachers of song as capable as any that live in any country. There are many cogent reasons why the art of song should take on new life and flourish in America. Art must be pur- sued for Art's sake. Mme. Cappianij in her excellent work, "Prac- tical Hints and Helps for Perfection in Sing- ing," asks the question: "Why are so many voices ruined in Europe? If we consider what regiments of students have for the past thirty years been going to Europe, and how few good voices return, we are appalled." Henry W. Savage (Opera and the American Singer.) (Monthly Section, Pittsburgh Dis- patch, July 10, 1910), says: "The transatlantic steamers sailing from American ports during the months of June, July and August bear from our shores many thousands of American girls going to study music in Europe. And only in rare instances is it true that the outward-bound student has exhausted the facilities and the op- portunities for study which are being left behind, at home. We have in this country the finest mu- 232 1HE TONSILS AND THE VOICE sical talent in the world. 'The finest voices in the world come from America, the biggest, the purest, the most dramatic,' said Jean de Reszke to me. 'The very best singers in the world come from America,' said Tito Ricardo, of IMilan, to me. He is regarded as an authority of the high- est rank." "I often wish that I could go into the homes of these girls and talk things over with them and their families. I should like to persuade fathers and mothers of the folly of the idea that it is fashionable to send their daughters to Europe for a musical education, to explain to them that the necessities for this course have long since ceased to exist, and to focus their attention upon the fact that home institutions are offering facil- ities equal to those of Continental schools, and at a much smaller cost." "'Let the American pupil i^emain at home, where the American voice can he better handled than on the Continent, because it is better under- stood. American institutions offer splendid courses in the techfiology of music. The best of vocal training may be received here." Students from abroad now come to New York for musical education. Mme. Mott can verify this statement. In Paris, the American singer is looked upon as a "good thing" to be exploited. A long list of brilliant American trained ar- tists have succeeded in opera, here and abroad, including Putnam Grisxscold, Frances Maclen- nan, Vernon Stiles, Florence Easton, Gertrude Rennyson, William Wegener, William Miller, THE SCIENCE OF THE VOCAL ART 233 Yvonne de Treville, Edward Lanhow, Harriet Behnee, Marion Ivelle, Ellison van Hoose, Clar- ence Whitehill, Alfred Picaver, Robert Kent Parker, Marion Weed, Florence Wickhain, Olive Fremstadj Edith Walker j Bessie Abbot and Geraldine Farrar. Frank E, Miller (The Voice): "There is one great singer, Lillian Nordica, who knows to whom to give credit for that skill in voice-pro- duction which enables her to sing Valentine, Aida and Isolde with equal success. Her voice-pro- duction she acquired not from Madame This or Signor That, but from plain John O'Neill, of Boston, and she took good care not to allow any other teacher, however 'famous' to undo the work of the man who had taught her voice-pro- duction based on correct knowledge of the physi- ology of the voice-producing organs." David Bispham {"Why We Should Sing in English/' Century Magazine, July, 1910), says: "For singing there is nothing difficult about English; it is just as easy as any other language. Are not its vowels the same — its consonants ? Are not its words softer than German, and easier to pronounce and more rotund than French? Is it not as noble as Italian? All the arguments against it emanate from those who do not know it, or how to pronounce it either in song or speech." "Though we formerly imported singers, it is obvious that we need do so no longer. Soon we can — indeed, we do already — export artists." "When will the scales drop from the mana- gerial eyes, and Americans get their chance here 234 THE TONSILS AND THE VOICE in the same minor parts that at first they have to take abroad?" "If they can work and grow famous there, they can do here just the same." Richard Mansfield said, "America has become too great, and its influence abroad too large, for us to afford to have recourse to that ancient and easy method of criticism which decries the Amer- ican and extols the foreign." This is true indeed. Frank E. Miller {The Voice), states: " 'The English language is probably the one that has been described by foreigners as the most unfit for singing. Greater calumny has never been uttered. I contend for just the opposite: that English is the very best language for an ar- tistic singer to use for it contains the greatest variety of vocal and aspirate elements, which af- ford an artistic singer the strongest, most natural and expressive means of dramatic reality. The English language has all the pure vowels and vocal consonants of the Italian ; and besides, it is full of rich elements, mixed vowels, diphthongs and an army of vigorous aspirants.' " Tosi (Italian School of Florid Song, 1743), says : "After having corrected the pronunciation, let him take care that the words be uttered in such a manner, that they be distinctly understood, and no one syllable be lost; for if they are not dis- tinguished, the singer deprives the hearer of the greatest part of that delight which vocal music conveys by means of the words. For, if the THE SCIENCE OF THE VOCAL ART 235 words are not heard so as to be understood, there will be no great difference between a human voice and a hautboy. This defect, though one of the greatest, is nowadays more than common, to the greatest disgrace of the professors and the profession." Salvatore M archest (Vademecum) states that: "It is wholly erroneous to argue that there is a peculiar Italian, French, German or English method of singing. There is only a single aes- thetic style in music throughout the civilized world, as well as a single singing method, and that is the good one, in the pure and artistic conception of the term." Mme. Mathilde Marchesi (Method of Singing) says: "People often speak of the Italian, French or German School or Style of Singing. Having re- sided for many years in the different centers of these three nationalities, I can safely say that, with the exception of national songs of a popular and local character, peculiar to each nation, there are only two vocal schools in the whole world: the good, from which the best results are ob- tained; and the had, in which the reverse is the case. The same may be said with regard to style. It is, therefore, quite a mistake to speak of a Ger- man, English, French or Italian Vocal School or Style." Whether you learn to sing in Italy, France, Germany, or America, the physiology of singing, like the physiology of digestion, is always the same. The process of digestion is the same, no 236 THE TONSILS AND THE VOICE matter where you eat the food. The process of singing is the same, no matter where j^ou learn it. There is no Italian physiology, no German physi- ology, no French physiology — it is all human physiology. ^ Whether you are taught singing in Naples, by Sehastiani, in Milan, by Sabatini, in London, by Shakespeare or Santley, in Berlin, by Mme. Leh- mann, in Paris, by De Reszke, in New York by Mme. Mott, Mme. von Klenner, George Sweet, or Rice, in Boston, by Hubbard, Mme. Everett or Mme. Clara Kathleen Rogers, the physiology of singing is identical. History will probably show that the very best in art and the names of the greatest artists only of all periods have been selected for the preserva- tion of the ages. Thus, by comparison, one is led to think that art and artists of the present time are not so great as those of the past. But I hold no such opinion. Masters of art (in speech and song) have passed away. Masters are passing away. Great masters of the art remain. "The best traditions of the art of singing are, with very few exceptions, nearly lost J" (Salva- tore Marchesi.) Exceptions prove that the art is not lost. It should be remembered that in the old daj^s, from which traditions of phenomenally high voices have come down to us. musical pitch was lower than it is now. Phenomenal voices always have been rare. At no other time in history, of which I have any knowledge, has there been such general. THE SCIENCE OF THE VOCAL ART 237 powerful and international educational co-opera- tion as now. Ambassadors of education, in the form of exchange professors, are now sent from the United States to Germany, Sweden, Den- mark, France and Japan. Never before has there been such a world-wide uplift in the spread of enlightenment in science, art and general cul- ture. Never before has money been so lavishly and universally expended in the pursuit of science, art and education. The establishment of the Kaiser Wilhelm professorship at Columbia University, and the Roosevelt professorship at Berlin Uni- versity, six years ago, was the beginning of this universal uplift. The regents of Oxford Univer- sity, following in the wake of the establishment of these international professorships, made a ruling, in 1909, "that, the students of Columbia Univer- sity in the freshman class shall be admitted to Oxford freshman class: that students at Colum- bia in the sophomore, junior and senior classes, shall be admitted to Oxford's semester classes on a parity." There never was a time when money was more lavishly spent than now to further the ends of education, of science, of art, and of all that con- tributes to the highest and most stable civilization. True art is built on firm foundations ; its mas- tery requires intelligent comprehension, conscien- tious application, and an abundance of hard work long continued. High art is maintained by high ideals. High ideals require strength in the char- acter of the votaries. The first signs of depreciation in any art is per- peptible in the lowering of the ideals. 238 THE TONSILS AND THE VOICE True art is always pure art. Venal considera- tions always disfigure and destroy. England once led the world in music. Italy has passed her zenith. America^ replete with native artists, and with abundant means appar- ently stands upon the threshold of the world's new era in the progress of music. THE SCIENCE OF THE VOCAL ART 239 Letter of Mme. Cappiani. Question 1. Are the normal faucial tonsils of any use to singers ? By the term, normal faucial tonsils^ I mean the tonsils situated in the fauces, between the anterior and posterior palatine arches, in healthy condition, of almond shape, and of such size as not to project beyond the lines of the palatine arches, nor press upon surrounding tissues, upon the superior constrictor, the palato-glossus or palato-pharyngeus muscles, of a size so small as not to interfere with the perfect anatomical out- lines of the walls of the pharynx. Answer. Certainly, they are necessary for the acoustics of the voice, the sounding board of which is in the nasal bridge where from all the fa- cial bones connected with each other are awakened to resound to — which by their different shapes give different tones, forming a kind of accord to the one tone we produce. These vibrations to- gether beautify the voice in sympathy and gran- deur and give the individual ''timbre de la voice/' Question 2. How, or in what manner are they of use to singers, already described? Answer. If tonsils are cut out, it wants con- siderable skill to bring the vibrations of whatever tone up in the nasal bridge, as they come too easily from the larynx through the mouth to the listen- er in a harsh or vulgar tone without that sympa- thy above described, when all the facial bones are awakened to resonance. Question 3. Do you personally know of any 240 THE TONSILS AND THE VOICE instance or instances, in which a singer's voice was improved after removal of normal tonsils? Answer. No! But the voice may be changed to higher or lower pitch by the cicatrization and the Chirurgeon can not know beforehand which way the result may be. Often the compass of the voice may not be changed at all ; only the sound- ing quality made more ordinary. Question 4. Do you personally know of any instance or instances in which a singer's voice was impaired or ruined after the removal of nor- mal tonsils? Answer. A singer's voice cannot be entirely ruined by cutting out the tonsils. It is too great a distance from the tonsils to the vocal-bands in the larynx. Question 5. Would you, as a rule, advise the removal of normal tonsils in singers? Answer. No. Only in cases of diseased and so swollen tonsils that danger of suffocation is near. Then they must be cut out — as it is better to lose one's tonsils than one's life. LuiSA Cappiani. ^ ^ J 5 ,e ^ "=^-^ CHAPTER X SIX VOICE QUESTIONS. Question Number One. Are the normal faucial tonsils of any use to singers ? By the term, normal faucial tonsils, I mean the tonsils situated in the fauces, between the an- terior and posterior palatine arches, in healthy condition, of almond shape, and of such size as not to project beyond the lines of the palatine arches, nor press upon the surrounding tissues, upon the superior constrictor, the palato-glossus, or palato-pharyngeus muscles, of a size so small as not to interfere with the perfect anatomical outlines of the walls of the pharynx. George A. Sweet: "No." Mnie. Marie Olive Fremstad: "No." Vincenzo Sahatini: "I do not know." Bond: "I do not think so." S. S. Curry: "None that I have ever been able to trace." David Bispham: "I do not know from my own experience, as I have never had trouble with my tonsils." Mme. Clara Kathleen Rogers: "Normal fau- cial tonsils have no direct use in singing." Charles A. Rice: "The normal tonsils are of no use to singers in tone production, nor in giv- ing assistance to the quality of the voice." David C. Taylor: "No, not of direct use in the 17 241 242 THE TONSILS AND THE VOICE conduct of the voice. Their functioning is no doubt an item in the general vitaUty, but this is not specifically a matter of voice." Frederick E. Bristol: "I cannot say if the normal tonsils are of any particular use, or in other words, if they have any function, as re- gards the proper emission of the voice. I have never seen that they are an obstacle and have never advised their removal." George Fergusson: "I consider it impossible for singers or teachers to state definitely the use of the tonsils to the singer." Mvie. Irene San Carola: "I hold that one of the most important functions of the singer's art is to produce for the voice a perfectly free pas- sage, through the pharynx, to all resonators. In my opinion, therefore, no part of this passage can be of any use to the singer except in a nega- tive sense, i.e. : in its capability of being kept out of the way. Xormal tonsils can — and should — be rendered nugatory by muscular exercise as exemplified in yawning." Mme. Lillian Nordica: "My tonsils being very small are perfectly healthy. I have never realized that they have played any special part in singing." Charles A. White: "A\nio knows ?" William Shakespeare: "I believe no one knows what the functions of the tonsils really are." Mme. Lilli Lehmann: "I do not believe that anyone can answer this in the right way." Sir Charles Santley: "I am not prepared to say the tonsils are of any use to singers, especiallj'-, SIX VOICE QUESTIONS 243 but that they are of use is certain or they would not exist." Carlo Sebastiani: "Anything belonging to our organism has its function, and its proper reason to exist. Only the excess or the deficiency of any part whatsoever can be of detriment to the or- ganism. As to the first part of this question, the normal tonsils they might perhaps be of utility to the voice, to modify the resonance, and the timbre. Though it is not proven by me." Richard Loewenherg: "To prevent misunder- standing by 'normal' tonsils, I mean tonsils of a healthy color, those not enlarged in length or thickness, and showing no evidences of chronic in- flammatory processes. Such tonsils should, ac- cording to my experience, never be removed by operation, neither on account of the effect upon the general health, nor of the functional activity of the organ itself. Even though the physiologi- cal significance of the tonsil still rests upon a hy- pothesis, this, like any other healthy organ in the body, should be left undisturbed." Mme. Schumann-Heink: "Yes." Mme. Luisa Tetrazzini: "Yes." Miss Cecelia Winter: "Yes." Arthur J. Hubbard: "They are." Mine. Alice Garrigue Mott: "In some cases. They preserve the original structure of the throat on which depends the beauty of the individual voice." Mme. Cappiani: "Certainly, they are neces- sary for the acoustics of the voice, the sounding board of which is in the nasal bridge where from all the facial bones connected with each other are 244 THE TONSILS AND THE VOICE awakened to resound to — which by their different shapes give different tones, forming a kind of accord to the one tone we produce. These vibra- tions together beautify the voice in sympathy and grandeur and give the individual ^'timbre de la voix." Lamperti: "Most decidedly, I consider them of the greatest importance to all singers." Letter of Van Baggen. Question 1. Have the normal faucial tonsils any function: physiologic, biologic, chemical, phonetic, or other? By normal faucial tonsils, I mean the tonsils situated in the fauces, between the anterior and posterior palatine arches, in healthy condition and of such size as not to pro- ject beyond the line of the palatine arches nor press upon surrounding tissues, of a size so small as not to interfere with the perfect anatomical outlines of the walls of the pharynx. Answer. The faucial tonsils have certainly a phonetic function. Their situation in the mouth at a place where the voice receives an essential part of its specific qualities allows us to admit this assertion. The muscles of the anterior and posterior pillars of the fauces between which the tonsils rest, are in constant movement when we are speaking or singing. Their action combined with the movements of the muscles of the soft palate changes the shape of the voice passage at the back of the mouth when we are forming the diff*erent vocals or producing tones of dif- ferent pitch. The position of the tonsils situated as they are between the pillars of the fauces are SIX VOICE QUESTIONS 245 of great importance with regard to the enacti- tude and perf ectness of those movements ! Also for the resonance the tonsils are of great interest for the voice. With their spongy tissue they can be compared to the felt in the piano which softens the tones and regulates the resonance. Question 2. What are the functions of the fau- cial tonsils? Answer. For my answer to this question, see the first answer. Question 3. What effects have you observed as being directly due to removal of the faucial tonsils ? Answer. Only in two cases during my expe- rience of eight years the removal of the faucial tonsils was necessary. In both cases the tonsils were of abnormal size. In one of those two cases there was no regular movement of the soft pal- ate and of the pillars of the fauces; especially when forming the initial vocals, a spasmodic con- traction of those parts took place, whereby the swollen tonsils were strongly protruded. Every attempt to correct the action of the muscles of the soft palate and the pillars of the fauces remained without any result because of this projection of the tonsils. After their removal the desired effect was obtained by carefully applied exercises. Question 4. Have you noted phonetic changes after removal of the faucial tonsils ? Answer. The other case where the tonsils were removed, was a singer. There also the removal of the swollen tonsils appeared unavoidable be- cause of the impossibility to correct a nervous contraction of the pillars of the fauces. As a 246 THE TONSILS AND THE VOICE result of the removal, entire success followed. It did not affect the timbre of the voice; an in- crease of resonance was observed and she sang with far more ease and less fatigue. Question 5. Would you, as a rule, advise the removal of normal tonsils? Answer. No! Remarks. As I am exclusively a specialist- expert for voice and speech afflictions I consid- ered the questions but from the phonetic point of view. N. J. Poock Van Baggen, Plaats 10a, The Hague, Holland. Addenda to Question Number One. Frank E. Miller: "They are regulators of pil- lar action." Moure: "They have phonetic functions. From a phonetic point of view, their normal role must evidently be to prevent in a certain measure the nasality of tone, by maintaining the pillars in the midst of which they are placed." Van Baggen: "The faucial tonsils have cer- tainly a phonetic function. Their situation in the mouth at a place where the voice receives an essential part of its specific qualities allows us to admit this assertion. The muscles of the ante- rior and posterior pillars of the fauces, between which the tonsils rest, are in constant movement when we are speaking or singing. Their action combined with the movements of the muscles of SIX VOICE QUESTIONS 247 the soft palate changes the shape of the voice passage at the back of the mouth when we are forming the different vocals or producing tones of different pitch. The position of the tonsils, situated as they are between the pillars of the fauces, are of great importance with regard to the exactitude and perfectness of those move- ments. Also for the resonance the tonsils are of great interest for the voice. With their spongy tissue they can be compared to the felt in the piano which softens the tone and regulates the resonance." 248 THE TONSILS AND THE VOICE Question Xumber Two. How, or in what manner, are normal tonsils of use to singers? Vincenzo Sabatini: "I do not know." George A. Sweet: "Of no use." David Bispham: "I do not know, and do not think a singer should consider his physical for- mation at all, if it is healthy, and as little as pos- sible j, if it is (or he thinks it is) sick." Richard Loewenberg: "Same answer as to question number one." Frederick E. Bristol: "The answer to question number one is mj^ answer to this question." George Fergusson: "I do not think the state- ment of an early teacher of mine — an Italian tenor — to the effect that the tonsils lent brilliancy to the tone, is of any value whatever." Mme. Lillian Nordica: "I have never been conscious of possessing tonsils — so know of no use — but presume they are there for a purpose." Mme. Irene San Carola: "I consider that they are of no special use to singers as such, though doubtless they are factors both in pharyngeal and general health, or they would not be there." Charles A. White: "Who knows?" Carlo Sebastiani: "As I have said, the utility of the normal tonsils in singers has not been proved or demonstrated, as to what might be their special function in the emission of the voice. I have been able to verify that the larger the development of the tonsils, the more difficult is the resonance and the emission of the tones of the second register or high notes: even the removal SIX VOICE QUESTIONS 249 of the normal tonsils does not facilitate these high tones." Mme. Luisa Tetrazzini: "They protect the vo- cal cords from dust, microbes, etc., also being part of a normal throat cannot be removed with- out doing injury." Mme. Schumann-Heink: "They guard the throat, supply fluid secretion, are a link in the chain. They were put there by nature. We can get along with one leg, one eye, etc., but we can get along better with two." S. S. Curry: "I cannot see any use except as they affect the overtones of the voice; all the chambers of the pharynx and of the head, and even the whole body affect the resonance of the voice. When the tonsils are abnormal, they af- fect it slightly in this way." Mme. Clara Kathleen Rogers: "Only as fac- tors in forming the perfect resonator." Miss Cecelia Winter: "In healthy condition, they round out what would otherwise be an irreg- ular cavity without power of adding resonance. Since the fauces are not firm enough in material to be of any use as added resonators and from the standpoint of tone-quality any distortion of the air wave in passing them would be more detri- mental than advantageous. It is considered well to have a diseased tonsil that protrudes removed for the same reason." Mme. Alice Garrigue Mott: "The normal fau- cial tonsils are of use to the singer, in so far as they preserve the original structure of the throat, on which depends the beauty of the individual voice." 250 THE TONSILS AND THE VOICE Arthur J. Hubbard: "We are not sure how, but we know that their removal causes a difficulty in assuming different shapes of the pharynx necessary in singing, causing a hardness of qual- ity and laborious action." Mme. Cappiani: "Already described. If ton- sils are cut out it wants considerable skill to bring the vibrations of whatever tone up in the nasal bridge, as they come too easily from the larynx through the mouth to the listener in a harsh or vulgar tone, without that sympathy above de- scribed when all the facial bones are awakened to resonance." Lamperti: "The tonsils are most necessary for modulation in singing: without them it is very difficult, sometimes impossible, for the voice to modulate. They assist in expanding and in withdrawing the tones." SIX VOICE QUESTIONS 251 Question Number Three. Do you personally know of any instance, or instances, in which a singer's voice was improved after removal of normal tonsils? Mme. Olive Fremstad: "Yes." Jean de Reszke: "I only know of one case among my pupils of the tonsils having been re- moved. The operation was most successfully performed, and the result excellent. The pupil's voice is now better than ever and she no longer suffers from sore throat, as she did before the operation." Van Baggen: "Only in two cases during my experience of eight years, the removal of the faucial tonsils was necessary. In both cases, the tonsils were of abnormal size. In one of these two cases, there was no regular movement of the soft palate, and of the pillars of the fauces; es- pecially when forming the initial vocals a spas- modic contraction of those places took place, whereby the swollen tonsils were strongly pro- truded. Every attempt to correct the action of the muscles of the soft palate and the pillars of the fauces remained without any results because of this projection of the tonsils. After their re- moval the desired effect was obtained by care- fully applied exercises." Carlo Sehastiani: "I have been able to verify that some time after the excision of the tonsils, the voice has improved, the resonance facilitated and the color of the voice also improved. I here speak of tonsils, not normal but of tonsils hyper- trophic diwd hyperplastic. In this case the ex- 252 THE TONSILS AND THE VOICE cision has been of some good, because they were an impediment to the normal function of the soft palate." Charles A. White: "Never heard of the re- moval of tonsils except for the reason that thej^ were abnormally large or diseased." S. S. Curry: "I have never to my knowledge taught a case that had the normal tonsils re- moved. When abnormal tonsils have been re- moved, there is a slight improvement in reso- nance." Charles A. Rice: "No. To remove any part or portion of a normal tonsil is unnecessarj'- and will in no way aid the singer's voice in tone pro- duction or in quality." Mme. Irene San Carola: "No. And even when tonsils are abnormally large, I always op- pose any proposal to remove them by surgery. I prefer to try every other means of reducing them and I have had considerable success in my methods." 31 me. Alice Gairigue Mott: "I know no case in which the singer's voice was improved by the removal of normal tonsils." Mme. Lillian Nordica: "I do not. If any of ni}'^ comrades have had their normal tonsils taken out, I have never heard of it." Sir Charles Santley: "I do not know of any instance of improvement or injury to a singer's voice after removal of the tonsils." Frederick E. Bristol: "Have never seen any singer w^hose normal tonsils have been removed, so far as I know." Mme. Clara Kathleen Rogers: "I have never SIX VOICE QUESTIONS 253 known of the removal of normal tonsils from the throat of a singer." George A. Sweet: "No." Mme. Schumann-Heink: "No. Decidedly no." M7iie. Luisa Tetrazzini: "No." David Bispham: "No." Bond: "I do not." Stephen Townsend: "No." David C. Taylor: "No." Miss Cecelia Winter: ''^o^ Arthur J. Hubbard: "No. On the contrary, a deterioration in quality of voice and of ease in singing." Richard Loewenberg: "I do not know of any case in which a singer's voice was improved by the removal of normal tonsils. On the contrary," M7ne. Cappiani: "No! But the voice may be changed to higher or lower pitch by the cicatriza- tion, what the chirurgeon cannot know before- hand, which way the result will be. Often the compass of the voice may not be changed at all; only the sounding quality becomes more ordi- nary." Laniperti: ''No. If the tonsils are normal^ they should on no account be removed, as the removal will never improve the voice. If abnormal, only the projecting part should be most carefully removed, never the whole tonsil taken out, but merely the diseased part cut off. / am decidedly op loosed to the growing tendency of having tonsils cut and re- moved" 254 'J^HE TONSILS AND THE VOICE LETTER OF DR. LOEWENBERG. Translation. Berlin W., 62 Keith Street, 22nd March, 1912. Richard B. Faulkner, M.D., 306 Diamond Bank Building, Pittsburgh, Pa. My dear Doctor: — I received your short let- ter of January 9th, and thank you for your expression of confidence in my opinion con- cerning the questions under consideration, and gladly express my opinion as follows: (1) In the first place, to prevent misunder- standing, by "normal" tonsils, I mean tonsils of a healthy color, those not enlarged in length or thickness, and showing no evidences of chronic inflammatory processes. Such tonsils should, according to my experience, never be removed by operation, neither on account of the effect upon the general health, nor of the functional activity of the organ itself. Even though the physiological significance of the tonsil still rests upon a hypothesis, these, like any other healthy organ in the body, should be left undisturbed. (2) These remarks will also answer question Number 1. (3) I do not know of any case in which a singer's voice was improved on the removal of normal tonsils. (4) On the contrary, I know of cases in which the removal of normal tonsils has caused perma- nent detrimental effects to the voice, in conse- SIX VOICE QUESTIONS 255 quence of the unavoidable injury to the arches of the palate ( adhesions, scar tissue, etc. ) . (5) For these reasons, I disapprove of opera- tion upon normal tonsils in all cases. I am always glad to be of service. Sincerely, (Signed) Dr. Richard Loewenberg. 256 THE TONSILS AND THE VOICE Question Number Four. Do you personally know of any instance, or instances, in which a singer's voice was impaired or mined, after the removal of normal tonsils ? Richard Loewenherg: "I know of cases in which the removal of normal tonsils has caused permanent detrimental effects to the voice, in consequence of the unavoidable injury to the arches of the palate (adhesions, scar tissue, etc.) ." David Bispham : "Most persons have constant trouble after such an operation, and though their voices are not "ruined" the healthy operation of the parts that contribute to good singing is inter- fered with." Mme. Alice Garrigue Mott: "I recall no case where a singer's voice was ruined after removal of the tonsils. I know many cases where the re- moval of tonsils has made a change for the worse in qualitj^" Mme. Katherine E. von Klenner: "Yes; many." Mme. S chumann-H eink : "I know of several. The voice became acid, uncertain, weak or rough, or was entirety ruined." Carlo Sehastiani: "Often the voice has been damaged if the operation on the tonsils was not necessary, but simply performed for the desire to increase or to improve the voice, as it has been practiced by some artists whom to deficienc}^ of vocal faculties and the mediocrity of talent, they want to substitute the surgical instruments. In similar cases, the voice has been damaged and sometimes entirely lost: SIX VOICE QUESTIONS 257 "(1) Because the too frequent use and not enough justified to alter with surgical instru- ments so delicate an organ as that of the voice, it is not well for the clearness, the exercise, the color and facility of the voice; "(2) Because the tissues, the nerves, the muscles, always remain depreciated from an operation that was not compulsory to avoid greater damages." 31 me. Luisa Cappiani: "A singer's voice can- not be entirely ruined by cutting out the tonsils. It is too great a distance from tonsils to the vocal bands in the larynx." Mine. Marie L. Everett: "I am fully pre- pared to say — indeed, am convinced — that with the removal of the tonsils, the voice loses much of its personal quality; and much of its frontal focus — or in other words — somethi7ig is missed in the quality after the tonsils have been removed that does not come back. The tone seems dis- persed — not as well forward — and lacks its usual brilliancy of resonance." Arthur J. Hubbard: "Not ruined, but im- paired." David C. Taylor: "I know of two instances, neither one of which was my pupil, of voice im- pairment following some months after the re- moval of tonsils which I was informed, were nor- mal. But I cannot state that this impairment was due to the removal of the tonsils, as several other causes might have operated." Mine. Irene San Carola: "No, not personally — though I have heard of such instances — and such mutilations would, prima facie^ appear to 18 258 THE TONSILS AND THE VOICE me as not only useless but likely to limit poten- tialities." Charles A. White: "Normal, no. Abnormal, yes — improved. ' ' Charles A. Rice: "I have known of cases where loss of voice had been attributed to the re- moval of the tonsils, and the conditions appeared to verify the conclusion, but in several instances where I have had the opportunity of working with the voice after it had been pronoimced ruined, it has developed that the trouble came not from the removal of the tonsils, but from the teachers' lack of knowledge in vocal physiology and tone production. The pain and imaginary troubles of the singer's tonsils are invariably due to wrong tone production (i.e.: placement of the voice). This I have proved many times with students who came to me with the impression that their tonsils would have to be removed, but after a few weeks' study all the throat trouble had dis- appeared without an operation." Mme. Lillian Nordica: "I do not. And I have never heard of removing normal tonsils any more than removing a normal vocal cord." Bonci: "I do not." 3Iiss Cecelia Winter: "I know of no singer who ever had a normal tonsil removed." Sahatini: "Same answer as Number 3." Mme. Clara Kathleen Rogers: "No." Mme. Olive Fremstad: "No." George A. Sweet: "No." Stephen Townsend: "No." S. S. Curry: "No." Frederick E. Bristol: "No." SIX VOICE QUESTIONS 259 Question Number Five. Would you, as a rule, advise the removal of normal tonsils in singers? Lamperti: "Most decidedly not; as long as they are normal, they are far too necessary in singing and only when greatly enlarged should the diseased part be removed, never the entire tonsil." Richard Loewenherg: "I disapprove of opera- tion upon normal tonsils in all cases." Mme. Lilli Lehinann: "No. I never would advise the removal of anything from the throat (of a singer)." Jean de Reszke: "I do not believe in removing the tonsils unless they are abnormally developed, but certainly would recommend the operation being performed in any case where a singer is troubled by unusually large tonsils." Sir Charles Santley: "Certainly, I would not advise the removal of the tonsils under any ordi- nary circumstances, but attack the root of the evil, the ill-treated stomach." Carlo Sehastiani: "No; unless the operation has been deemed necessary in the opinion of the physician, to avoid grave misery and special pathological cases. These cases must be sepa- rately studied in each individual by the physi- cian." Mme. Cappiani: "No. Only in cases of dis- eased and such swollen tonsils that danger of suffocation is near, then they must be cut out, as it is better to lose one's tonsils than one's life." George A. Sweet: "No, I have never advo- 260 THE TONSILS AND THE VOICE cated the removal of a singer's tonsils, except in extreme cases, when chronically enlarged from colds covering periods of many years — or result- ing from organic disease (scrofula)." Charles A. Bice: "Never. The removal of the normal tonsils is an unnecessary operation and accomplishes nothing ; therefore, I would not sanction such an operation." Stephen Townsend: "No." George Fergusson: "I have had no experience with singers who have had the normal tonsils re- moved. Personally I am opposed to their re- moval in a normal state." Arthur J. Hubbard: "No, most decidedly. During twenty odd years of experience, I have encountered many cases of diseased and trouble- some tonsils. My conclusions based on careful observation of the treatment given them are that normal tonsils are useful and should never be re- moved. And also, when diseased ones are re- moved, as should always be done, great care should be exercised not to cut deeply. In fact to leave enough to constitute what would be gener- ally called a normal tonsil. In many cases among my pupils, I have observed nothing but good results from the removal of diseased ton- sils, when done in the manner above indicated. But I have known great harm to be done when the operation has extended too far." Mme. Alice Garrigue Mott: "I never advise removal of normal tonsils." Mme. Clara Kathleen Rogers: "Certainly not." Mme. Katherine E. Von Klenner: "No." SIX VOICE QUESTIONS 261 Mme. Lillian Nordica: "1 certainly deprecate meddling with normal organs. I have never had my throat touched, or sprayed, in my life." Mine. Luisa Tetrazzini: "Never." Mine. Olive Fremstad: "No." Mm Cecelia Winter: "No." Mine. Irene San Carola: "Certainly not. I consider that a perfect control of all parts of the pharynx, as well as of all organs engaged in voice production, can and should be acquired through exercise for the development of the par- ticular muscles employed." Mme. Marie L. Everett: "I thoroughly be- lieve in having tonsils removed that are trouble- some. They often are but a trap for disease. But I certainly have noticed a loss in the person- ality, and in the warmth or coloring of the tone in those pupils who have had the tonsils removed during the period of study with me. I have a case I am studying now — a pupil who had ton- sils removed in the summer — tone larger, clear- er — hut less beauty — the personal charm seems affected." Frederick E. Bristol: "I would not — in fact I am very much opposed to any surgery in con- nection with the throat and nose, except in cases where the tonsils have grown to an abnormal size, or where there are growths on the vocal cords which cannot be removed in any other way. I have known of two instances where enlarged tonsils were removed to the great injury of the voice, and I have had several cases come under my observation where benefit accrued by their remov- al. I have always attributed the former cases to a 262 THE TONSILS AND THE VOICE bungling operation. I am drifting farther and farther away from resorting to surgery, and have been pleased to note that in very many cases the cure of any trouble has been effected through a normal use of the voice, produced upon a cor- rect method. Please observe that I do not say there may not be need in some cases of surgery." A. Bond: "No, unless there is some special reason." David Bispham: "Certainly not!!" Vincenzo Sahatini: "No." S. S. Curry: "I can see no reason for the re- moval of normal tonsils." David C. Taylor: "Not under any condi- tions." Charles A. White: "Never." LETTER OF SEBASTIANI. Translation. Richard B. Faulkner, M.D. (Columbia), 306 Diamond Bank Building, Pittsburgh, Pa. Answer to Question No. 1. Anything belong- ing to our organism has its function and its proper reason to exist. Only the excess or the deficiency of any part whatsoever can be of detri- ment to the organism. As to the first part of this question, the normal tonsils, they might, per- haps, be of utility to the voice, to modify the resonance and the timbre. Though it is not proven by me. Answer to Question No. 2. As I aforesaid, SIX VOICE QUESTIONS 263 the utility of the normal tonsils in singers is not proven or demonstrated, or what might be their special function in the emission of the voice. I have been able to verify that the larger the de- velopment of the tonsils, the more difficult is the resonance and the emission of the tones of the second register or high tones: even the removal of the normal tonsils does not facilitate these high tones. Answer to Question No. 3. I have been able to certify that some time after the excision of the tonsils, the voice has improved, the resonance facilitated and the color of the voice also im- proved. I here speak of tonsils, not normal, but of tonsils hypertrophic and hyperplastic. In this case, the excision of the tonsils has been of some good, because they were an impediment to the normal function of the soft palate. Answer to Question No. 4. Often the voice has been damaged if the operation on the tonsils was not necessary, but simply performed with the desire to increase or to improve the voice, as has been practiced by some artists, when, for deficien- cy of vocal faculties and the mediocrity of talent, they wished to substitute the surgical instrument. In similar cases, the voice has been damaged and sometimes entirely lost: (1) Because the too frequent use and not enough justified to alter with surgical instru- ments so delicate an organ as that of the voice, it is not well for the clearness, the exercise, the color and facility of the voice ; (2) Because the tissues, the nerves, the mus- cles, always remain depreciated from an opera- 264 THE TONSILS AND THE VOICE tion that was not compulsory to avoid greater damage. Answer to Question No. 5. No, unless the operation has been deemed necessary in the opin- ion of the physician, to avoid grave misery and special pathological conditions. These questions must be separately studied in each individual by the phj^sician. Remarks: (1) The function of the tonsils is not known. (2) The benefit that may be derived by the excision of the tonsils, if it is of great utilitj^ in cases of hypertrophy, to avoid greater damage, it may be of some benefit to the human voice in general: it may not be of any benefit to special- ized organisms endowed with exceptional and valuable voices, said voices being of great value precisely for the virtue of the mucosa tissues; for the softness of the muscles and nerves; for the perfection of the different cavities of reson- ance; finally, for the marvelous structure of the entire vocal apparatus. Then In these uncommon conditions, an}'' surgical operation whatsoever, it matters not how perfect, may cause harm to the precious instrument. (Signed) Caelo Sebastiani. Napoli, March 31, 1910. SIX VOICE QUESTIONS 265 Question Number Six. Remarks ? William Shakespeare: "1 suspect that most swollen tonsils are the result of a rigid manner of using the voice, both in singing and in speaking. My own pupils have no difficulty with the ton- sils, and generally I am looked at askance by throat specialists as a kind of enemy, which I am not. Should swollen tonsils arise from, say, con- stitutional weakness, I feel they may be removed with advantage. A skilful surgeon can do this without cutting into the adjacent muscles, but I have had pupils who have suffered from faulty operation." Vincenzo Sabatini: "Only time I have ever recommended removal of the tonsils has been in cases where they were abnormal, and the result has always been a marked improvement in the voice. But when normal, the best advice is to leave them alone" Mme. Clara Kathleen Rogers: "My observa- tions and experience lead me to the following conclusions: In a healthy, normal throat each part has its proven normal function, passive or active, direct or indirect: That the emission of vocal sound, given a musical sense and impulse, follows naturally a healthy condition of the whole throat as nature made it; and that disease or malformation alone warrants the removal of the tonsils, just as the intervention of surgery is required for a hare lip or a tied tongue.'" Mme. Irene San Carola: "My whole scheme 266 THE TONSILS AND THE VOICE of instruction is opposed to any avoidable inter- ference with nature, being based on the convic- tion that intelhgent use of the natural means for the full development of the vocal organs eventuates in an ability to control every part of the machinery of voice production." Mme. Katherine E. von Klenner: *'I make a point in replying to your questions upon the word 7iormal in each case. JMy observations agree with those of my teachers, Manuel Garcia and Pauline Viardot-Garcia, both of whom ob- jected seriously to any artificial means for im- proving the singing voice — where the vocal ap- paratus was normal. When removed, I have always found a certain lack of sweetness in the tone quality — and difficulty in supporting the tone in certain registers." Charles A. Rice: "An abnormal tonsil will disturb or impair both quality and tone place- ment by displacing the walls of the pharynx, etc. The poor tonsils are made the scapegoat for almost all the failures of the vocal student. When there is a failure in the voice, the teachers blame the tonsils, never themselves. "As to singing, the normal tonsils give the pupil no inconvenience ; in fact, they never know that they have such a thing when the voice is properly placed. In proper voice placement and tone production, the tonsils always remain nor- mal, but nothing will enlarge the tonsils as quick- ly as had placement of the voice. Not only are the tonsils enlarged, but the intrinsic muscles are often impaired, and sometimes this extends to a paratysis of the arytenoids. Then the ton- SIX VOICE QUESTIONS 267 sils are removed, with little or no relief, for the trouble has not been with the tonsils, but caused by strain on the entire vocal apparatus. "After studying with some twenty or more vocal teachers, I found only one that understood vocal physiology and could place the voice from scientific knowledge. A vocal teacher must be more than a person that has studied to train his own voice. Find the teacher that has studied to teach, one that puts himself through some of the studies and researches that a physician has to go through, and has developed and made a suc- cess with his own voice (if he cannot develop his own voice in tone placement and quality, he cannot train others) , and you are likely to find a vocal teacher or trainer of the voice." Sir Charles Santley: "My experience is that they (the tonsils) contract an unhealthy condi- tion through 'inattention to diet,' an error to which singers as a rule are addicted. If people would confine themselves to what is good for them and not insist upon merely pleasing the palate, neither their tonsils nor their systems in general would suffer much." Stephen Townsend: "To me it is very difficult to conceive of any one having a normal tonsil removed. I can see nothing to be gained by such an operation. Just what the use is of the ton- sils, its function, is, I believe, a mooted question even among the medical profession. "There is every reason why an enlarged, dis- eased tonsil should be taken out, and this is ap- preciated as much by the vocal instructor as by the medical man. It, however, requires a skil- 268 THE TONSILS AND THE VOICE ful operator to perform this operation, as a bungling 'job' is very liable to more or less im- pair the voice, at least for a longer or shorter period." Miss Cecelia Winter: "It is a vrell-known fact amongst singers that the throats that have not been tampered with surgically are the strongest and least apt to be subject to indispositions from the weather, etc." David Bispham: "Most persons have constant trouble after removal of the tonsils, and though their voices are not 'ruined,' the healthy opera- tion of the parts that contribute to good singing is interfered with. I am sure the 'doctor habit' is bad for a singer and his throat, and that the more he goes to throat specialists, the worse he becomes. I am also sure that the vocal cords should never be touched on any account ^ and that the application of acids and sprays to throat and nose only tends to continue any irritation that may be and that doctors are not sufficiently care- ful to ascertain the personal equations — as it were — of their patients. I am a well man and singer to-day because I do not go to throat spe- cialists any longer! Excuse my frankness — but you want my opinion, I take it." Mme. Schumann-Heink: "There is nothing I am more violently opposed to than any radical treatment of a singer's throat. More voices are ruined by ignorant throat spe- cialists than by use. Dry powders, scraping operations, acids, instead of rest, massage and oil, do the greatest damage to singers. My spe- cialist has enabled me to sing oftentimes when I SIX VOICE QUESTIONS 269 believed there was not a note in my throat, by ap- plications of oil, oil, oil, and if any heroic meas- ures were necessary, they were used only after a coating of oil, and only in the mildest form. A mild electric treatment externally on the chest and neck and back was an infrequent treatment." Mme. Lilli Lehmann: "No, I never would ad- vise the removal of anything from the throat and would always try to cure it without any opera- tion. If someone is troubled with something in his throat, you never can tell the cause if you don't know the person well and his manner of singing. I am quite sure that every bad stand- ard of health in the throat can be cured in learn- ing how to use properly all the muscles. But how seldom are they used! Never with knowl- edge. Singers who sing well, as they should do, will never be troubled by anything. We do not feel the f aucial tonsils nor the vocal cords ; we can arrange our tones with all our organs, to make them perfect, quite high and low enough, strong and soft at once. You should know well both the person and his manner of singing. I can only say that I in my whole life never had a suffering pupil because they sang right. I am sure that every organ, vocal organ, or muscle, etc., in an ill way, may trouble some people. But if you don't know how they speak or sing, you never can be sure of the reason : whether the trouble comes from false usage of the vocal or- gans, or whether the false (bad) singing or speak- ing comes from a bad condition of the vocal organs." Mme. Lillian Nordica: "One should so sing as 270 THE TONSILS AND THE VOICE not to injure one's self. Something is very wrong when after singing the throat or nose or lungs, or anj^ one part of the body, suffers. A general fatigue should follow — such as a few hours' sleep will repair. So it seems to me I would let normal organs alone." Mme. Cappiani: "It is wrong and very wrong to have the tonsils removed, "(1) Tonsils are full of blood, situated in the fauces like two stoves warming the outside winter air, before it reaches the bronchial tubes and lungs, thus preventing bronchitis, pulmonitis, etc., etc. "(2) Tonsils are guardians against hard sub- stances: they close instinctively, like the eyes do when an object comes near them, and often Mn- der the hard substances to be swallowed." Carlo Sebastiani: "(1) The fimction of the tonsils is not known. (2) The benefit that can be derived by the excision of the tonsils, if it is of great utility in cases of hypertrophy, to avoid greater damages, it may be of some benefit to the human voice in general; it may not be of any benefit to specialized organisms endowed with exceptional and valuable voices, said voices being of great value precisely for the virtue of the mucosa tissues; for the softness of the muscles and nerves; for the perfection of the different cavities of resonance; finally, for the marvelous structure of all the vocal conduct. '^'Then, in these uncommon conditions any surgical operation whatsoever, it matters not how perfect, can cause harm to the precious instru- ment." SIX VOICE QUESTIONS 271 Lamperti: "I am decidedly opposed to the growing tendency of having tonsils cut and re- moved. In almost all cases I have found — in the fifty years of my teaching — that the voice is injured, often beyond remedy. The tonsils are as necessary in the modulation of the voice as the nostril is to breathing ; remove the latter, and you obstruct the passage of breathing, remove the former and you prevent the voice from ex- panding in a crescendo and drawing together again for a diminuendo. "I trust I have made myself plain. I wish you every success in the collection of material upon so important a subject to all singers, who unfortunately are only too ready to remove ton- sils." CHAPTER XI DIAGNOSIS. The scientific consideration of the organ neces- sarily rests upon a clear conception of what con- stitutes a normal faucial tonsil — a scientific defi- nition is essential. The scientific treatment of diseases of the tonsil depends primarily and absolutely upon a correct diagnosis. A faulty diagnosis vitiates therapeutic success. To treat without a diagno- sis is a clear case of the blind leading the blind into pitfalls. He who fails to make every effort to establish an accurate diagnosis is unworthy of scientific consideration. And what of him who attempts to minimize its value? The treatment of any disease, of any organ, without a diagnosis, is a hazardous performance. SajouSj, in his great work on the Internal Se- cretions, declares that at the present day investi- gators do not avail themselves of the enormous array of solid data available to ascertain the truth : and that the confusion which characterizes the medicine of our day is due to the habit of theorizing with a few facts as foundation. With the purpose of simplifying diagnos'is, I divide diseases of the tonsil into six groups, namely : ( 1 ) Primary. (2) Secondary. (3) Symptomatic. 272 DIAGNOSIS 273 (4) Reflex. (5) Mechanical. (6) Hyperplastic. Primary. Von Levinstein thinks that many diseases find their entrance to the organism through the ton- sil, but he believes that the infection theory of Winslow is too extreme when it considers the ton- sil as a menace to the organism. We are not entitled to talk of a danger to the organism from this organ. Von Levinstein admits that angina follows coryza, but he does not concede that it is always secondary to nasal affection. That the latter mode of infection does not happen rarely Von Levinstein has conceded. He also mentions the well-known angina following endonasal opera- tion, called by Frdnhel "angina traumatica," in which the germs are transported from the nose via the lymph vessels to the tonsil. Von Levin- stein emphasizes that primary disease of the ton- sils is a common occurrence and that the prim- ary disease of the lymphatic apparatus can be observed at least as frequently as the primary dis- ease of the other organs of the throat. Von Levinstein states that he has sometimes been able t,o prove that a patient first suffers from an angina which is followed in a few days by an acute catarrh in the nose, so that in these cases angina is the primary disease. The pos- sibility of primary infection of the faucial tonsil is conceded by the advocates of the protective 19 274 THE TONSILS AND THE VOICE theory only when the protective mechanism is disturbed. Schoenemann states that the ordinary angin- ous affection of the tonsil is not a primary dis- ease, but is always secondary to catarrh of the nasal mucous membrane. Goerke considers primary disease of the tonsil possible only when the protective mechanism is disturbed, either through a direct injury or through a cold, and that the organ rarely becomes a victim of primary infection. If the tonsil is in a state of acute infection, we should consider whether the disease is local or general. The observation of Stokr that the epithelium of the tonsil sometimes represents an open wound, thus making it easy for micro-organisms to here enter into the organism, has been well refuted by Frdnhel and Jacohi. The observation of Stohr sometimes spoken of as Stohr's phenomenon, is seen especially in the fossula tonsillaris. Everywhere in the fossula white blood corpuscles are seen passing through the ej^ithelium. The immigration at certain places is so strong that it is difficult to find the epithelium. If we assume, as Frdnhel states, that the lym- phatic current simply takes along the lym- phocytes like the river carries logs, we have to omit the idea that we have to consider here an open wound but that we have to learn to consider it a protective mechanism, for the micro-organisms would have to swim against the current and meet cells which possess a certain phagocytosis. DIAGNOSIS 275 If, as Frdnhel states, in the immigration of white corpuscles through the walls of the blood vessels, no holes are made in the walls of these vessels, neither is it necessary that holes are formed in the epithelium of the tonsil when lym- phocytes pass through. The insult to the epithe- lium by the current loaded with lymphocytes does not produce the effect that microbes get more easily into the tissues, as the intervals in the epithelium are constantly filled with the lymph current, and the possible lesions to the epithelium are never lasting defects, but disap- pear as soon as the intensity of the current is diminished, and then the epithelium layer closes instantly. It seems to be sufficient that the clefts between the epithelium cells allow the lym- phocytes to pass, and that only exceptionally, as Stolir has pictured, there are large streaks in the epithelium which really look like an open wound. I was compelled to make these foregoing ex- planations, Frdnhel remarks, because they are important in studying the infectious diseases of the pharynx. Jacohi remarks that "clinical observations will rarely be numerous enough to decide the exclus- ive or partial port of entry of a poison into the circulation. For we are seldom in a position to separate the tonsil from its neighborhood during the acute invasion or the rapid progress of a microbic or toxic poison." He states that "doz- ens of years ago he could prove that diphtheria, when limited to the tonsils, was least dangerous. That the thousands of other lymph bodies dis- 276 THE TONSILS AND THE VOICE seminated in the fauces and posterior nares are more guilty than the two dozen which form the tonsils. It is thej^ that should be considered in the preventive treatment of all the infectious dis- eases of childhood. In cases of membranous throat disease, whenever the membrane is limit- ed to the tonsil there is little or no glandular swelling in the neighborhood. On the other hand, if a membrane extends from the tonsil to its neighborhood, or starts at a distance from the tonsil, neighboring lymph bodies swell at once. These clinical observations" Jacohi states, "have stood the test of time and must he reckoned with. Microhic invasion through the tonsil is not ijredominant over that which takes place through the lymph apimratus of the pharynx J" "Almost like injection material," Jacohi con- tinues to remark, "living invading material may enter the lymph or the blood circulation, iwovided there is a break in the wall, hut not with the same facility as injection material forced in. A sur- face lesion must always he supposed to exist when a living germ or toxin is to find access." "If that were not so," Jacohi states, "no hu- man or inferior animal could exist under the clouds of microbes and toxins surrounding us. It looks rational, therefore, to admit that when there is merely a surface lesion, though ever so slight, there may be an invasion into the tonsil. When, however, the vessels are exposed to pres- sure hy newly formed cells or tissue, there is no invasion, certainly not heyond the tonsil itself, no ganglionic swelling, and no toxic poisoning. DIAGNOSIS 277 It is even rational to believe that now and then when tonsils, or what is more common, a single follicle, becomes inflamed, the very venous ob- struction will eocert the bactericidal influence of the stagnating blood serum." There are no lymphatic sinuses around the tonsil, according to Retterer, Labbe, Hodenpyl and 3Iost. The lymj)h current near the tonsil is less active than that of the pharynx at some distance, ac- cording to Labbe and Hodenpyl. Retterer proved that the periphery of the lobules of the tonsil is more vascular than the centers. In the experiments of Lexer the emulsions of bacteria which he brushed on the tonsils only oc- casionally entered into the tonsillar tissue. Goerhe believes that in the experiments of Lexer the infection did not occur through the tonsil but through other parts of the mucous membrane of the pharynx. Menzer, in his experiments and researches found in persons who suffered from acute articu- lar rheumatism streptococci in the tonsils only within the epithelium layer and he could prove, on the other hand, that a larger amount of infec- tious germs were present in the connective tissues surrounding the tonsils. Goodale injected carmine powder directly into the fossula of the faucial tonsil. Upon micro- scopic examination he found carmine powder within and underneath the epithelium. Brieger and Goerhe do not consider Goodale's experi- ment free from objection. The colored particles 278 THE TONSILS AND THE VOICE were injected with a certain energy. How can we exclude the possibility that the foreign particles were forcibly put into the tonsillar tissue, through tearing the epithelium; but granting, says Goerke, that artificial tearing did not occur, even then, the experiment proves nothing. Is it not very probable, asks Goerhe, that by filling up a fossula the free flow of the lymphatic fluid is interfered with, and therefore, the lymphatic cur- rent which can flow to all points of the epithelium at this point of greatest resistance is turned and flows to many other points of lesser resistance, taking along particles of the foreign material in- jected into the fossula? Groher demonstrated the comparative absence of a direct communication of the tonsil with the rest of the body through the surrounding fibrous capsule. His injections into the tonsils accumu- lated in large quantities underneath the capsule. Thus it happened that the organ was often en- larged to a considerable extent. In order to diagnosticate tonsillar diseases a knowledge of infectious processes is absolutel}'- essential as well as a knowledge of the anatomy and clinical features of the tonsil. The mucous membrane of the mouth harbors at all times jlarge numbers of cocci, bacilli and spirillae, and among these are often found micro- organisms of violent character. The infection of the tonsil from its outside surface is by the same process of infection that occurs on the outside surface of any other part of the body. There is no proof that the normal epithelium DIAGNOSIS 279 of the tonsil ever presents an open wound, as claimed by Stohr. There is no proof that the normal tonsil is ever a port of entry, an open door, for infectious germs. There is no proof that the normal tonsil has any absorbent power whatever. The f ossulae of the tonsil are lined with mucous membranes having the ordinary function of other mucous membranes so far as known. The blood supply to the tonsil is scant; and it has little or no communication with Waldeyefs lymphatic ring. The faucial tonsil differs in anatomical character from other tonsils, and from other lymphatic tissues. The external deep sur- face is encased in a firmly adherent, strong, fibrous sheath. Nothing like this capsule surrounds any other lymphatic body. So dense and tendinous and strongly adherent is this capsule that one may consider the organ as being armor-plated. It is not perforated by lymphatics, nerves, arteries or veins. And from the standpoint of diagnosis, and the possible invasion of the tonsil by the in- fection process, it is also well to remember, that the capsule sends a network of fibrous tissue as outrunners along the walls of the blood vessels. The capsule also sends connective tissue into and between the folds of the mucosa. Thick or thin, the fibrous sheath is firm and solid. That is why abscesses do not open into the maxillo-pharyngeal space. And that is why it is difficult for bacteria and toxins to enter the tonsil from that point. The capsule with its out- 280 THE TONSILS AND THE VOICE runners protect the tonsil from invasion. The capsule is not an anatomical accident. It is always present. In the diagnosis of primary disease of the fau- cial tonsil, I draw attention to the following points : 1. There are no lymphatic sinuses round the tonsil. 2. The lymph current near the tonsil is less active than that of the pharynx at some distance. 3. The tonsil and its immediate neighborhood are inferior in regard to facilities for absorption to the rest of the pharynx and nares. 4. There is a comparative absence of direct communication of the tonsil with the rest of the body through the surrounding fibrous capsule. 5. We must distinguish the true from the false hypertrophies: the merely swollen from the hy- perplastic organ. 6. It is necessary to distinguish the normal from the pathologic organ. 7. Involution is an expression of immunity against certain infections peculiar to children. The removal of simple hypertrophic tonsils, as a rule, causes no febrile reaction. The removal of enchatoneed tonsils, as a rule, causes more or less febrile reaction. 8. Persons with enlarged tonsils are generally healthy. 9. The number of newly found lymphocytes is always considerably larger in the hyperplastic tonsil than in the normal. 10. The flow of lymphocytes through the DIAGNOSIS 281 epithelium to its surface is always increased when the tonsil is enlarged. 11. Briegefs suction therapy is intended to encourage the outward flow of lymphocytes from the center of the tonsil to the surface of the epitheHum. 12. Acute inflammation of the tonsil shows an increased infiltration with leucocytes which causes enlargement of the organ, also an increased amount of lymph in the intercellular spaces. 13. Not only do the faucial and pharyngeal tonsils atrophy normally at a certain age, but the same change occurs at the same time in the lym- phatic tissues of the digestive tube. 14. Primary disease of the tonsil is favored by bacterial or toxic invasion of the pharyngeal se- cretions. 15. A surface lesion must always exist when a germ or toxin is to find access. 16. When the vessels of the tonsils are exposed to pressure by newly formed cells or tissue, there is no invasion. IT. When the tonsil or a single follicle be- comes inflamed, the venous obstruction will ex- ert the bactericidal influence of the stagnating serum. 18. Exposure, and many diseases, change the structure and harden the surface of the tonsil. 19. Cell infiltration and cicatricial tissue render absorption less possible. Blood and lymph ves- sels are compressed and undergo atrophy. The tonsil becomes harder and smaller and infections become less. It is well known that with increas- 282 THE TONSILS AND THE VOICE ing age the tendency towards the commoner ton- sillar inflammations lessens. 20. The so-called acute tonsillitis, inflamma- tion of the lining of the fossulae, lacunar tonsilli- tis, impaction of the fossulae with debris and bac- teria, chronic follicular tonsillitis, are not diseases of the tonsil. They affect only the outside sur- face of the organ. 21. Membranous affections limited to the ton- sil cause little or no adenitis, or constitutional symptoms. There is, therefore, no absorption from the surface of the organ. 22. Primary disease of the tonsil is disease that begins at or in the tonsil. 23. We have assurance that disease of the ton- sil is primary when the pharynx, nares, and lar- ynx are in normal condition. 24. Whenever any part of the pharynx, nares or larynx is affected, it then becomes especially difficult to determine whether the tonsil affection is primary. 25. When cervical adenitis occurs, we must not assume that absorption took place through the faucial tonsil. It has not been proved that the faucial tonsil absorbs. But all authorities agree that the thousands of lymphatic glands in the pharynx, nares, and larynx are very active ab- sorbents. Therefore, whenever cervical adenitis occurs, we must make sure in every case that no absorption took place through some of these lym- phatic bodies. To prove that in any given case, infection entered the general system through the faucial tonsil, it is necessary to prove that it did not enter through any of the other lymphatics of DIAGNOSIS 283 the pharynx, nares or larynx, which latter are most absorbent when in norinal condition. Otherwise^, there is no absolute proof that any in- fection entered by way of the faucial tonsil. If no disorder is visible in the lymphatic glands of the pharynx, nares and larynx, they are then in the best possible condition for active absorp- tion. ( 26 ) If the bacilli of tuberculosis and the cocci of rheumatism are to be found in the peritonsil- lar tissues, then we can have no assurance that these tissues did not absorb the respective micro- organisms of tuberculosis and of rheumatism. (27) If the tonsils look natural in color and in size, then the adenitis, and the absorption of bacilli and cocci, most probably took place through the numerous lymphatic bodies of the pharynx and nares, and the tonsil cannot be held responsible ; certainly not solely accountable. (28) The faucial tonsil is rarely attacked by suppuration: there exist suppurative follicles, but the interstitial tissue itself does not suppu- rate. Tonsillitis with suppuration means, in the vast majority of cases, peritonsillitis. It is the peri- tonsillar tissue which forms the abscess, and most frequently it is at the superior pole of the tonsillar loge where the pus is sought. (29) It has been proved, both microscopically and macroscopically, that the tonsil is very often only in part affected, not the whole organ. 284 THE TONSILS AND THE VOICE Secondary. Any disease of the tonsil arising from disease in another locahty, either by continuity of sur- face, or by direct communication via the lymph or blood vessels, is secondary to the latter affec- tion. The great majority of tonsillar diseases) are secondary affections. The tonsil may be secondarily infected hy mi- crohic penetration of its surface. For example, in peritonsillar abscess the micro-organisms in- vade the tissue surrounding the tonsil, causing an inflammation which leads to penetration. It is less known that this not only occurs on the faucial tonsil, but on all other tonsils. On the base of the tongue, inflammations occur which affect the epiglottis, taking their origin from angina of the lingual tonsil. This is not rare. Angina of the pharyngeal tonsil has caused abscess in the naso-pharynx. The tonsil may be secondarily infected from the blood, the lymphatic vessels carrying in- fected material to the inside of the tonsil. It is important to know that the tonsils can be in- fected via the blood and lymphatic vessels just as from the surface. Secondary infection from its surface is the same as in other parts of the body. Infection from the blood has not been sufficiently considered. Frederici and Goerke have given experimental proofs of the infection of the tonsil from the blood. Secondary infection of an organ means noth- ing else but that germs circulating in the blood or lymph current find conditions in this organ favorable to their settlement. DIAGNOSIS 285 Lately, experiments have been published by Von Lendrt which proved the statement of Frdnkel that secondary infection of the faucial tonsil follows operations in the nose. Von Le- ndrt has proved that the lining of the nose is directly connected by lymphatic vessels with the center of the tonsils. We are sure infectious material is carried to the tonsil from the nose. Very commonly in my daily practice, in many cases, I have observed swollen, tender and pain- ful faucial tonsils, following an attack of acute coryza. And I have demonstrated to many phy- sicians, in many cases of exacerbation of chronic nasal catarrh, the immediate improvement and the prompt subsidence of the tonsillar condition after cleansing and sterilizing the nares. While the tonsils are infected mostly from the nose, via the lymphatic vessels, they are also in- fected via the blood and lymphatic vessels with tuberculosis. These latter cases belong mostly to the latent tuberculosis. The children are com- paratively healthy. They are only troubled by the hyperplasia of the tonsils, either in the pharynx or in the throat. In the tissue of the amputated tonsil we find tubercular nodules or bacilli; we often find also in children swelling of the glands of the throat. These children appear scrofulous and we can assume that the swelling of the glands is caused by resorption of the nodules of tubercular bacilli in the tonsils. If we make tuberculin injections in children, we can often show a local reaction in the pharyngeal tonsil. If these children show a general re- action, nothing is proved, as they might have 286 THE TONSILS AND THE VOICE tuberculosis in other parts of the body, but if one sees in such cases that the tonsils show a local reaction one can make the latent tuberculosis a manifest one. There is a primary lupus of the pharynx as also a primarj^ miliarj'- tuberculosis, but in most cases these are secondary. I believe it sufficient if you consider these forms, the latent one, the visible tuberculosis which is seen sometimes as miliary tuberculosis and at other times as lupus. Symptomatic. As a matter of diagnostic convenience, the ton- sillar manifestations of constitutional diseases, such as general tuberculosis, and of scarlet fever, measles, etc., may be termed symptomatic, in con- tra-distinction to secondary affections that may be rather directly traced to another locality. There should be little trouble, generally, in the recognition of symptomatic conditions. Refiecc. The subject of tonsil reflex is very complex and very obscure. The faucial tonsil is well situ- ated and admirably equipped for reflex effects, through its connection with the fifth, ninth and sympathetic nerves. Reflex processes involve not alone the sympa- thetic nervous system, but ^hey include as well the motor and sensitive nerves; and their prob- lems are proportionately intricate. The remarks of Jonathan Wright, in his work on the "Nose and Throat in Medical History f^ on the subject of reflex nasal neuroses, may be per- DIAGNOSIS 287 fectly well applied to reflex tonsil neuroses: "How grossly, after a few years, this subject was exaggerated and distorted is apparent, now that the exaggeration is decreasing." And LerjnoyeZj, in an article on '^'^ Accidents Which Follow Nasal Operations" states: "Tardy, but fatal, the reaction has set in against the excessive operations which have followed an exaggerated generahzation of the discoveries of Voltolini and of Hack. In the concert of preco- cious enthusiasm, some discordant voices had much difficulty in making themselves heard. Times have changed. Now, silence has come." Frdnkel, inaugurating the laryngological sec- tion of the Congress at Berlin, said: "The study of nasal reflexes seems for some time past a little neglected by the specialists. The thing is not re- grettable ; it concerns the future of this specialty that it proceeds with calmness and avoids every dangerous impetuosity. We will thus assure the good of patients, and above all, the confidence of the great medical public in our specialty." Charles P. Grayson, in the Medical Record, December 12, 1908, states: "I am very much of the opinion that before any further addition is made to the list ( of reflex disturbances for which the nose has been held responsible) the founda- tion upon which it rests should be critically exam- ined to see if it be secure enough even to support the strain to which it has already been subjected." Sir Felias Semon, in his work on "Diseases of the Upper Air Passages," says: "We come to the subject of 'nasal reflex neuroses'; in my hum- ble opinion one of the most unsatisfactory in 288 THE TONSILS AND THE VOICE modern medicine. In my experience, our knowl- edge with regard to diagnosis and our results with regard to treatment of nasal reflex neuroses are still extremely unsatisfactory." Tlie words of Wright, Lermoyez, Frdnkel, Grayson and Semon apply with equal force to the tonsils. In fact, they apply to these organs with more than equal force, pr^oviding that the cavernous condition favors, and the congestion of the erectile tissue of the nasal mucosa depends upon reflex action. Without cavernous and erectile tissue, there would pi^ohahly he less vaso- motor excitement, and consequently less action of reflex character. The faucial tonsils may suffer from reflex neuroses. Affection of the faucial tonsil, as a result of reflex from a distant part, is a new study. Not one case of the kind has ever been reported. The subject is not mentioned in any work on physiol- ogy, nor in the textbooks of Wright, Knight, Ballenger, Escat, Moure, Coakley, Grayson, Kyle, Bosworth, Browne, Chiari, Castex, Fred- erici, Gruenwald, Wlacheiizie, Seiler, Sajous, Shurly, Williams, Burnett, Cohen, hi gals, nor by any other writer, as far as I have been able to ascertain. The subject has been wholly neglected, hut is hound to heconie more vital with time. Skilled diagnosticians will regard the matter with in- creasing importance, in view of the teachings ( 1 ) of Frdnkel, Brieger, Goerke, and others, that the tonsils are important protective organs ; ( 2 ) that according to Von Lendrt, Poli, Frederici, DIAGNOSIS 289 Frdnkel, Von Levinstein and others, they are fre- quently affected in a secondary way, from nasal trauma; (3) of the teachings of Miller, Van Baggen, Moure, Laniperti and others, that they have mechanical functions ; and ( 4 ) that on the other hand, their complete re7noval is advised as an ordinary routine by most American opera- tors. It is no doubt true that every natural anatom- ical structure in the throat, every muscular fibre, every nerve filament, every lymphatic gland, has a physiological function. The very latest advances in pathology and in biological chemistry must be drawn upon, for there is exceedingly great danger of confoundiiig secondary diseases with reflex trouble. An exact differential diagnosis must be made, a positive line of demarcation must be drawn between those diseases which are supposed to be reflex, and those which Frdnkel, Von Lendrt and other in- vestigators have proved to be due to secondary absorption from nasal trauma. By the law of reflex action, reflexes must be capable of extending in either direction, with equal ease and facility. If a lesion of the faucial tonsil is capable of provoking reflex disturbance in a distant part, then the tonsil must be subject to reflex influence from the identical distant part. The trifacial and glosso-pharyngeal nerves are extremely sensitive. They both send branches to the faucial tonsil. So does the sympathetic nerve. Any affection of these nerves may, by the law of reflex, provoke disturbance of the faucial tonsil. The trifacial is the sensory nerve 20 290 THE TONSILS AND THE VOICE of the mucous membrane of the nose and of its accessory cavities; and it sends sensory branches to the organ of hearing. The trifacial is respon- sible for the radiation to the ears of pains, which have their origin in the naso-pharynx, the pillars of the fauces, the lateral walls of the pharynx, the tongue and the f aucial tonsils. The f aucial tonsil is sometimes affected as a reflex from a distant part. The author has fre- quently noted cases of pain, vasomotor disturb- ance, acute swelling and hyperplasia, which appeared to be of reflex origin. Some of the so- called "rheumatic tonsils^' appear more like reflex vasomotor disturbance; and some of those cases called "rheumatic" are certainly instances of secondary disturbance from the absorption of the morbid material of nasal catarrh. "Pain in any part, when not associated with in- crease of temperature, must be looked upon as sympathetic pain, caused by an exalted sensitive- ness of the nerves of the part, and it is to be re- garded as a pain depending upon a cause situated remotely from the part where it is felt." (John Hilton, "Rest and Pain") It is not uncommon to see the f aucial tonsil congested and painful without apparent cause. There is no reason why pain may not occur as a symptom of hysteria. In a number of cases the author has observed a painful condition of the faucial tonsil associated as a reflex with painful affection of the nares. And in one case during the progress of necrosis in a molar tooth, at each and every exacerbation of trouble in the tooth, pain developed in the tonsil; and every time, DIAGNOSIS 291 after the tooth had been treated, the pain in the tonsil subsided, until finally, after the tooth was cured, the pain in the tonsil permanently ceased. It is a common experience for the j aw to become stiffened with all the muscles of the pharynx firmly set, and pressing on the tonsil, pushing it out of its natural position, and causing pain in it, as well as in the whole region of the condyle — as a reflex condition from bad teeth. Reflex spasm and congestion are sometimes the measures of nature to protect injured parts. I have seen this especially in cancer. It is a common experience for pain to shoot into the ear when the faucial tonsil is touched with a probe, painted with iodine, or touched with an electric point. Pain produced by carious teeth is often felt in the tonsil, temple, or the ear. But, in every case of suspected tonsil reflex neurosis, whether from, or to, the organ, until proved, should be viewed with doubt. Reflex neuroses, as manifestations of hysteria, are of very common occurrence. Almost every disease may be simulated by hysteria. Anaesthe- sia, complete loss of hearing, smell and taste, may occur due to hysteria. The mucous mem- brane of the nose, mouth and larynx become analgesic from the same cause. The muscles af- fecting the voice may be affected in hysteria, causing complete loss of voice. The hysterical barking cough is a good exam- ple of reflex. Hysterical cough, by the irrita- tion which it produces, will sometimes cause or- ganic disease of the throat. Hysterical aphonia without paresis, without 292 THE TONSILS AND THE VOICE inflammation, without any apparent laryngeal irritation, is not uncommon. I was consulted recently by a contralto whose glorious singing voice was entirely lost through fear of repeated criticism. The whole respira- tory tract was absolutely normal. It was a case of pure psj^chic reflex. Contraction of the wound after removal of the tonsils is sometimes very great, and extensive ad- hesions often form, leading to distortion of the parts and over stretching of the mucous mem- branes, and providing endless reflex actions. Sahli, ''Diagnostic Methods/" 1906, states: ''Pain may he subdivided into parenchymatous and neuralgic. In imrenchymatous pains the sensory fibres are irritated at their terminal rami- fications, in neuralgic pains, at the trunks of the sensory or mixed nerves, in the sensory roots or in the sensory centers." "In the former, the termination of the sensory fibres are irritated quite independently of their organ, and therefore the pains overlap the boun- daries of peripheral sensory areas, apparently at will." "Neuralgic pains, on the contrary, according to the law of eccentric projection, are localized in areas that correspond exactly to the peripheral distribution of the nerve trunk or nerve involved. Pain may, however, be felt in neighboring nerve territories from irradiation of the pain from the involved nerve into them." "Neuralgic pains are generally much more se- vere than parenchymatous pains, for the reason that in the former a much larger number of fibres DIAGNOSIS 293 are painfully irritated, and ordinarily at the same moment. Probably for the same reason remis- sions in a severe pain are more decided in neu- ralgic than in parenchymatous pain. Another distinction is that generally with parenchymatous pains the entire painful area is sensitive to pres- sure. This is sometimes the case with neuralgic pains; but, as a rule, only that portion of the nerve trunk is sensitive to pressure which lies superficial or upon a hard foundation (neuralgic pressure points)." "So-called sympathetic or refleoc sensation is related to hyperalgesia. The best known of this is pain irradiation, in which the pain is perceived far beyond the limits of the painfull}^ irritated peripheral part (pain in the entire trigeminal distribution, occasioned by a single carious tooth). This phenomenon can be explained only hy assuming that the painful stimulation in the central organs overlaps or irradiates to neigh- boring tracts by means of dendrites and collat- erals, and that, in accordance with the law of eccentric projection, confusion as to the origin of the perception results." "The pain sense is not always concerned in re- flexes either of primary or secondary nature." ''In testing reflexes, it is advisable to distract the patient's attention as much as possible from the parts under examination. The simplest device is to direct him to close his eyes. The fatigue of a reflex is sometimes responsible for mistakes in diagnosis. It is a safe rule to ob- serve each reflex quickly and accurately, and to utilize repeated, carefid examinations in order to 294 THE TONSILS AND THE VOICE discriminate in any doubtful case, for the reflexes, like other nervous functions, often vary at dif- ferent times /^ "Ordinarily reflexes are local in character, id est, they take place in the region of the body that is irritated. But with an increase in the reflex irritability, which may be partly within the nor- mal physiologic limits and depend partly upon reflex stasis, the reflexes may be diffused in cross and longitudinal directions to other muscle areas and to other extremities. This corresponds to Pflilger's laws of reflex dispersion. Increase of the reflexes, as well as decrease or absence and qualitative abnormalities, are {the so-called pathologic reflexes) of considerable importance for diagnosis." "Formerty it was believed that the spinal cord was the center of all reflexes. Modern neuro- pathologists, however, following the teaching of Bastian, endeavor to dethrone the cord from its position as a reflex organ." "According to Jendrassik, there are spinal and cerebral reflexes, as well as a combination of the two, id est, reflexes requiring both cerebral and spinal centers for their normal performances." (1) 'SPINAL REFLEXES. This divi- sion includes tendons, periosteal and joint re- flexes. Their characteristics are as follows: (a) They are generally discharged from parts which possess little sensation, (b) The reflex is associated with no particular feeling, (c) The discharge takes place by means of a simple me- chanical irritation, such as a blow, (d) The in- tensity of the reflex depends upon the intensity DIAGNOSIS 295 of the irritation, not upon its duration, (e) The reflexes are quite as easily excited in ourselves as in others, (f) The latent time of the reflex, corresponding to its origin in the spinal cord, is the shortest, (g) The ensuing movement is a very simple one and serves a recognizable pur- pose, (h) Making other muscles tense increases the reflex, (i) Slowing of these reflexes never occurs pathologically, (j) Psychical influences have no effect upon these reflexes aside from dis- traction of attention, which increases them." (2) "CEREBRAL REFLEXES. These are to a large extent the cutaneous refleoces. The palatal and conjunctival reflexes belong to this group. Their characteristics are as follows: (a) They are discharged from sensitive spots which are not ordinarily accustomed to a light touch (tickling), (b) The liberation is asso- ciated with a specific sensation (prickings, cold, tickling, etc.). (c) Brief stimulation is effica- cious for their liberation, (d) A light touch has often a more vigorous action than a stronger one ; individuality has a decided influence, (e) These reflexes can scarcely ever be liberated by the per- son himself, and then only very slightly, (f) The latent time is longer and not as constant as with the spinal reflexes. It is quite independent upon the sensation time and corresponds to the reaction time, id est, the time which the voluntary reaction demands of a sensory stimulation, (g) The resulting movement is simple, and its prin- cipal characteristic is that it shows an effort to escape from the irritation, (h) Increased activ- ity of other muscles never increases the reflex, 296 THE TONSILS AND THE VOICE but may even diminish it. (i) These reflexes are diminished on the paralyzed side in cerebral hemiplegia, (j) They are delayed in cases of delayed sensation, (k) Psychical influences can either diminish or even increase these reflexes; distraction of the attention impairs them." "(3) COMPLEX REFLEXES. To this group belong reflexes which have complicated cen- ters, within which the reflex occurs, not as a single movement, but as a series of such, as sneering, vomitings swallowing, coughing, etc. The char- acteristics in common are as follows: (a) They are liberated from sensitive places, (b) The hb- eratioii takes place with a specific sensation, which plays even a greater role in the origin of the re- flex than in those of the cerebral group, (c) The hberation requires protracted stimulation, (d) Individuality has a great influence upon the oc- currence of the reflexes. (e) The stimulation which produces these reflexes is a specific and complicated one. (f) The latent time is longer than for any of the other reflexes, (g) The re- sulting movement is very complicated and bilat- eral: small muscle groups take part, and in some of them the reflexes act antagonistically, (h) Muscular activity produces a certain enfeebling in their action, (i) Psychical influences produce a great effect, (j) Reflexes of this group belong to the vegetative functions." "The distinction between groups 3 and 2 is essentially this : in the latter the sensation is trans- posed directly into simple reflex movement; whereas in the former the sensation, i.e. : the cor- tical stimulation first of all excites a complicated DIAGNOSIS 297 reflex center to activity. This center is composed of different separate centers, and within the main center the reflex process then takes an indepen- dent course." "The demonstration of the presence of a rejieoc is of greater diagnostic significance than the demonstration of its absence, because its presence is conclusive evidence of an intact refieoo arc; whereas, although its absence may mean that the arc is interrupted, it may also mean that the re- flex is affected by a nerve inhibition or by remote influence from some circulating disturbance. Similarly, an increase of a reflex is ambiguous. The latter Tuay be caused by lesions which directly stimulate the reflex centers or tracts, or by those which remove inhibition or injure inhibitory fibres. The pathologic relations of the reflexes are, therefore, evidently complicated." We know so httle about the vasomotor rela- tions in nervous diseases that it is scarcely worth while to enter upon a general discussion. While it is a common assertion that cicatrices, deformities, and altered secretions, provoke re- flex lesions; on the other hand, there is evidence to show that abnormal conditions at times pre- vent by reflex action the development of distant neuroses. MacDonald has recorded a case of complete nasal obstruction for ten or twelve years, in which severe bronchial asthma developed six weeks after the restoration of free nasal breathing". Circumstances, which one might or- dinarily judge would provoke reflex actions, many times do not. Instance, for example, the two fol- lowing remarkable cases. Krause reports the 298 THE TONSILS AND THE VOICE case of a tenor whose glottal lips looked like two ridges of red flesh, and whose tones appeared nevertheless unusually sweet and soft. And Im- hofer observed a singer with hypertrophy of one of the ventricular bands so that the glottal lip appeared as only a small edge beneath the heavy mass of the ventricular band resting upon it ; with this apparently unavailable larynx, he is a suc- cessful tenor on one of the largest German stages. The natural reflex action of the normal faucial tonsil may be impaired by operative interference. In the investigation of tonsil reflexes it is a safe rule to take nothing for granted. Demand proof for everything. "How greatly would the number of operations on the tonsils diminish if only those which neces- sity imposed were performed, and above all, if in the treatment of the nervous accidents called re- flexes, one addressed himself to the primary cause of all the trouble, to neurasthenia, dyspepsia, etc., and not to the tonsil lesion, which most frequently is only between the cause and the effect merely a negligible intermediary." (Lermoyez.) Before permitting the faucial tonsil to be re- moved, absolute clinical proof should be demand- ed that the disease from which it suffers is not reflex nor secondary. And on the other hand, clinical proof should be demanded for all al- leged reflexes from the tonsil, namely: that they can only be produced as reflex neuroses from the faucial tonsil; that they may be completely ar- rested by anaesthesia of the tonsil ; and that they can only be cured by direct treatment of the ton- DIAGNOSIS 299 sil. These points must be insisted upon in all doubtful cases. MECHANICAL. By reference to that part of my chapter on physiology which treats of the mechanical functions of the f aucial tonsil, I will save repetition here of matter which bears upon the diagnosis of its mechanical diseases. In my chapter on physiology, I have dwelt at great length on the mechanical affections of the faucial tonsil to show the great difficulties that lie in the way of correct diagnosis. But the in- telligent interpretation of all these affections of the tonsil and voice must be enforced, if we wish to preserve respect for our science. Mechanical affections of the tonsil, associated with the mis-use of the voice, are beyond the ken of the medical profession. Maladies, for example, of the timbre of the voice, of the middle register, of solidity, intensity, compass, agility, the tremolo, etc., do not belong to the consideration of physicians. Many years of experience as an expert laryn- gologist, and the careful examination of many thousands of patients with diseases of the nose, throat and lungs, enables me to endorse Castex when he states that: "It often happens that we are consulted by professional voice users, in whom the examina- tion of the larynx, and of the entire vocal ap- paratus, nasal fossae, pharynx, trachea, bronchia and lungs, does not reveal to us anything but small lesions and sometimes nothing. The various troubles of which these patients complain are not found in any known pathology. In some, 'the 300 THE TONSILS AND THE VOICE medium is out of balance,' or the 'transition' is missed, or 'they no longer have any mezzo-tone,' etc. These are difficult cases for the laryngolo- gist. There may be vocal trouble while the larynx remains immune. On the contrary, an ex- cellent voice may be up to par with a larynx in bad condition. I have seen the cords thick, red, presenting all the symptoms of corditis, in artists in whom the voice gave no trouble. Krause and others have made the same observation." "To disentangle voice maladies is not easy, in spite of the knowledge, zeal, and reflection that one may bring to it." "The diagnosis of a malady of the voice is difficult. Every laryngologist has been a witness to the discouragment of singers, when their voice is in jeopardy. It is in such cases that a good professor of singing, or elocution, will indicate the causes. A rational method in singing, or speaking, counts for much." "Patients submit for years at a time to cauter- ization of the nasal mucosae, resection of the horns or spurs, galvano-cautery of the pharynx, cauterization and massage of the larynx, removal of tonsils, etc. Then they complain that all the treatment has accomplished nothing. The doctor, in these cases, compromises the credit of laryn- gology." "The treatment to pursue in vocal cases is not always evident." In all matters pertaining to the voice, it must be distinctly understood that voice mechanicians, expert larjaigologists, and experienced voice tramers, the teachers of singing and the teachers DIAGNOSIS 301 of elocution, are the voice authorities; they are the men who know, the men who represent the voice profession. And it must be clearly recog- nized that in all matters pertaining to the voice, the ordinary throat specialists, the laryngecto- mists, and the general medical profession repre- sent nothing but the laity. The medical profes- sion is the laity to the voice-profession in inatters of the voice. There are charlatans in the voice profession, as in every other profession, but cast them aside, and take the scholarly, conscientious, and experienced voice teachers, those trained to teach, for their knowledge of the voice and its affections. It is beyond the knowledge, and absolutely out of the sphere of physicians to judge of maladies of the timbre of the voice, of affections of the middle register, of the solidity, intensity, com- pass, agility, etc., etc. Mechanical affections of the tonsils associated with the mis-use of the voice demand the knowledge, experience and skill of voice mechanicians and voice trainers. "The student whose voice has been injured, either by mal-treatment of a charlatan, or un- hygienic habits of living, must not attempt to cure himself, nor should he go to any but a teacher whose skill is unquestionable, for the slightest imperfection in the cure may ruin the voice permanently." (Mme. Cappiani.) I wish to mention a peculiar mechanical condi- tion which I have sometimes observed. If a bolus of food, in its passage through the pharynx, receive any impetus at all from pres- sure of the f aucial tonsil, then enucleation of the 302 THE TONSILS AND THE VOICE tonsil plus the contraction of tissue due to cicatri- zation may interfere with the act of swallowing. Especially in elderly persons, in whom the act of swallowing is sometimes tedious, appearing like a condition almost of semi-paralysis, we may find an aggravated condition owing to enuclea- tion at some previous time. These cases of slow process in swallowing are not so uncommon in old people. In a case of this kind, slightly magnified by an acute swelling of the lingual tonsil, the attending physician made the diagnosis of "paralysis of the vocal cords," and "advised an immediate tracheotomy." I was then called into consulta- tion; changed the diagnosis; and we promptly cured the patient of his lingual tonsillitis. Escat (Technique Oto-Rliino-Laryngologi- que, 1911) says: "The various symptoms of isolated troubles in professional singers are quite varied : the greater part are impossible to classify, by reason not only of the difficulty of penetrating their mechanism, but even to define them, for empiricism, in spite of the very earnest researches of which vocal physiology has been the subject, reigns still as master in this pathology of singing : the bond of union still remains to be found be- tween these two sciences, which have refused so far to permit themselves to be penetrated." Hyperplastic. To enable one to draw the differential lines of diagnosis in the scientific differentiation of ton- sillar enlargement, it becomes a sine qui nan that DIAGNOSIS 303 we must accept a clear definition of what consti- tutes a normal tonsil. The microscope will show the actual histologic structure of the tonsil. Having a normal histo- logic constitution, the relative size of the organ then comes into question : a large tonsil in a large mouth is normal : whether it is out of proportion depends upon whether it presses unduly upon neighboring tissues, or protrudes into the lumen of the fauces so as to interfere with deglutition or phonation, or with both. The organ may be histologically normal, and yet he too small to properly perform its mechanical function in sing- ing and speaking. Having a normal structure, it is necessary to determine with great care whether the enlarge- ment is temporary or permanent. Temporary being due to some transient cause, as for example, an acute coryza, or a mis-use of the voice, giving rise to momentary increased functional or cellular demand — mere swelling, or simple enlargement. Continued coryza, or continued abuse of the voice mechanism, will more permanently increase the size of the cellular structure, by reason of a sustained demand on functional action — the organ thus becomes simply hypertrophied — cells are enlarged. Simple hypertrophy is enlarge- ment of normal specific structural elements, due to increased functional activity. Increase in size of the structural cells is hyper- trophy: increase in their number is hyperplasia. The same tonsil may be both hypertrophic and hyperplastic. 30 1 THE TONSILS AND THE VOICE Hyperplasia of the tonsil is more often scrof- ulous than tubercular. Sarcoma, carcinoma, and other forms of en- largement are to be diagnosticated by the micro- scope. Many years in the practice of my profession have taught me to respect the opinions of others, the opinions of younger men, and particularly the opinions of those who are older and more ex- perienced than myself. Knowledge is ripened by experience. Henry Clay "depended on nothing else so much as on experience." Madame Bern- hardt with advancing years has materially changed her interpretation, softened the char- acter and made more etherial her impersonation, of the unfortunate Camille, The very highest value is to be placed upon the knowledge obtained from the practical ac- quaintance of the many years of personal expe- rience and repeated observations of authorities like A. Jacohi, Casteoc, La7nperti and Mme. Cap- piani. They know the pastj and they look into the future. "In fearless youth we tempt the heights of arts; While from the bounded level of our mind, Short views we take, nor see the lengths behind; But more, advanced, behold with strange surprise New distant scenes of endless science rise!" "Modern 'pothecaries, taught the art By doctors' bills to play the doctor's part, Bold in the practice of mistaken rules. Prescribe, apply, and call their masters fools." (Pope's Essay on Criticism.) DIAGNOSIS 305 There are many diseases of the faucial tonsil and many appropriate lines of treatment. To cure the various diseases, and to preserve the important functions of this valuable organ, require the most accurate scientific discrimina- tion between affections that are primary, second- ary, symptomatic, reflex, mechanical, and hyper- plastic. Every case is important: valuable func- tions are involved. Every case must be scientif- ically differentiated; or the attendant may pos- sibly be charged icith ignorance and crime. 21 CHAPTER XII HYGIENE OF THE FAUCIAL TONSIL: HYGIENE OF THE VOICE. The hygiene of the tonsil, the preservation of the health of the organ, will be safeguarded by- observing the various sources of trouble, and by the establishment of rules or principles of hygiene that will tend to sj^stematize the knowledge of the different sources. The chief sources of trouble arise in the mouth, nose, general system, nervous system, and from mechanical causes. To protect the tonsil from disease in the ^outh, the buccal secretions, as well as those of the f ossulae or crypts of the tonsil, must be kept free as possible from inhaled dust containing micro-organisms and other noxious material, ad- mixed with particles of decomposing food some- times found about the teeth and gums, which irritate and inflame the free surface of the mucous membrane which covers the tonsil and also acts as a lining of the fossulae. The teeth and gums must be kept in good condition. When necessar}^ the fossulae should be drained and aero-suction applied, or aero-electrotomy, to strengthen and make more resistant to irritation the lining of the fossulae and the covering mem- brane of the tonsil. Dust, germs, decomposing food, and other noxious material, affect the surface of the tonsil, and the surface of the lining of the fossulae. 306 Vertical section of nose, pharynx and larynx. Showing especially the location of the dust-traps. I. Cavities in the bones of the head. 2. The nasal passages. 3. Orifice of Eustachian Tube leading to ear. 4. Uvula. 5. Pillars of the fauces with the tonsil between them. 6. Epiglottis. 7. Thyroid cartilage. ' 8. Cricoid cartilage. 9. Ventricle of larynx. 10. Vocal cord. 11. Trachea. 12. ELsophagus. 13. Front dust-trap (nasal vestibule). 14. Rear dust- trap (post-nares). HYGIENE OF THE FAUCI-AL TONSIL 307 To protect the tonsil from infection from the nosCj by morbid material carried by the lym- phatic vessels from the nose to the inside of the tonsil, in the manner as proved by Von Lendrt, and accepted by Frdnkel, Von Levinstein, Jaco- hi, and others, the nasal passages should he kept absolutely clean and constantly sterilized. The effect of the transmission of noxious ma- terial from the nose to the inside of the tonsil is to render the organ tender, painful and swollen — it seldom causes inflammation or suppuration. The nose is a much abused and greatly ne- glected organ. Persons of intelligence and refine- ment, fastidious in taste, and immaculate in dress, are, nevertheless, ignorant of the transcendent importance of the necessity of a toilet of the nose, a subject on which no treatise has yet ap- peared. The nose is the commencement of the respira- tory tract. The air we breathe should enter through the nose, not through the mouth. It is warmed and moistened in the nasal passages. The volume of air required daily for each person, in ordinary natural respiration, is 10,000 litres. Thirty cubic inches of air are inhaled with every ordinary inspiration; there are eighteen respira- tions every minute, and 1,080 respirations every hour; 540 cubic inches of air are inhaled every minute, and 32,400 cubic inches every hour. And all this goes, or should go, in through the nose. Air carries into the nose many impurities — dust, smoke, germs and other noxious material. Germs are floating in the air, everywhere, in large quantities. Whenever dust is raised, in the 308 THE TONSILS AND THjE VOICE street, in factories, in schools, in hospitals and in other places, we inhale with the cloud a large number of microbes. It is stated by Von Schrotter (Hygiene of the Lung) that "In the parks of Berlin^ fhe air con- tains always from 100 to 1,000 germs per cubic metre. There are as many as 800 per cubic metre on top of the tower of the Rathaus, while the air of an inhabited room contains from 6,000 to 10,- 000 per cubic metre." "In one gramme of dust from the floor-cover- ing of one of our chief public institutes, 6,600,- 000 to 21,000,000 bacteria were estimated in a scientific investigation." Dust is collected in the vestibule of the nose as in a trap, and the deflection of the current of air in the back of the nose, at the sharp angle of the fauces, acts as another dust-trap. It is now apparent that the nasal passages should be kept open and clean. The nasal vestibule being the port of entry de- mands scrupulous attention; it should be zealous- ly guarded against the invasion of dust and germs. Protection of the vestibule will prevent penetration of the deeper passages. Nothing must be permitted to go beyond the vestibule. Accumulations should be carefully and gently mopped out, not washed far^ther in by sprays or douches. Don't spray. Dont douche. The nasal vestibule should be gently and thor- oughly mopped morning and evening as a fln- ishing touch to the toilet, with a wad of absorbent cotton saturated with a solution of powdered HYGIENE OF THE FAUCIAL TONSU. 309 borax, 68 grains, warm water, one pint, and es- sence of peppermint, 20 minims. Don't pluck the hair from the nose. It pre- vents the entrance of dust. Never blow the nose violently. Whenever the nasal passages are con- gested or uncomfortable from an acute cold, ap- ply heat to the bridge of the nose by a sponge or towel wrung out of hot water, or by a thermic electric ray. To protect the tonsil from trouble arising from the general system^ constitutional treatment is required. To protect the tonsil from affections of the nervous system, occurring as a matter of reflex, the original trouble must be sought for and abated. In recurrent tonsillar trouble, from any cause, the general system should be hardened by sys- tematic exercises, fresh air, habits of cleanliness, wholesome food, good digestion, regulated bowels, ventilated and sanitary sleeping apart- ments, proper sleeping hours, etc. 310 THE TONSILS AND THE VOICE HYGIENE OF THE VOICE. D. Ffrangcon-Davies in his admirable work (The Singing of the Future) says: "A purely scientific or a mathematical brain would not make much of the singer's art. The whole spiritual system, spirit, mind, sense — soul, together with the whole muscular system from feet to head, will be in the wise man's singing, and the whole man will be in the tone." Frank E. Miller says: "It is more difficult to keep the keen edge of the voice in good repair than that of the sharpest razor. No one more than the singer requires to observe the moral and physical laws," Inquiry among the greatest artists has elicited the fact that they are scrupulously careful of their health. 3Iadame Adelina Patti, now the Baroness Cedarstrom, in a personal communication to the author, has stated that "I have never had any trouble with my throat or voice during my entire career as a vocal ar- tiste." Madame Nordica communicated to me the statement that "I have never had my throat touched, or sprayed, in my life." Madame Homer, in her personal communica- tion, said: "I remember with pleasure your kind and most helpful treatment. I have never heard of a sing- er who had their tonsils removed. I have the greatest prejudice against it." HYGIENE OF THE VOICE 311 Miss Cecelia Winter told me that "It is a well-known fact among singers that those voices are strongest and best where the throat has not been tampered with by surgeons." Many young voices are ruined for want of care, Casteoc, one of the greatest authorities on the maladies of the voice and voice hygiene, in his work entitled ''Hygiene de la Voix Parlee et Chantee/' states: "The singing and speaking voices differ from each other in three principal qualities of sound. The compass is smaller in the speaking voice, the intensity is less, and the timbre greatly different." "Actors have found it well to learn to sing, in order to make the voice carry and last. Gai'cia several times had occasion to give lessons in sing- ing to military officers, who wished to have their voices carry well when issuing commands, with- out causing fatigue." "In a general way, speech fatigues the phon- ator organs more than does singing." "A voice in its decline finds itself more at ease in tragedy than in comedy roles, which exact a much greater flexibility." "In a general way to conserve the voice, it should be kept in the medium tones of the organ." "A methodical and rational elocution is the best guarantee against the various affections which may attack the vocal apparatus of an orator." "Granular pharyngitis is more frequent in preachers and lawyers, who are more pre-occu- pied with the substance than with the form, than 312 THE TONSILS AND THE VOICE among actors closely attached to the form of the elocution." "To put himself in proper form the orator should apply himself to various exercises as fol- lows: "(1) Extend his voice in the low as well as the high registers." "(2) Emitting clearly, one after the other, each note of his vocal compass in working succes- sively on each vowel, then associating consonants with vowels, for the clearness of the articulation of the consonants will supplement the insuffi- ciency of the voice." "(3) Establish his habitual voice at a height, a medium diapason, an intensity and a medium on which he can speak without fatigue. He should exercise each day." "(4) Exercise making sudden variations of tone. Nothing is more useful in arresting the attention of the hearer." " (5) Study the times and the modes of respir- ation." "(6) Attack clearly the sound by a stroke of the glottis." " (7) Do not lose breath before the emission of the sound." "(8) Exercises in agility are good for the speaker." "(9) To 'place' his voice at the level of his lips." "(10) Make his voice resound at its best, in well disposing the resonators." "(11) It is necessary to 'complete, equalize, and tune the instrument': to lead it successively HYGIENE OF THE VOICE 313 in the various registers, to arrive at that variety of timbre which is at once a charm for the auditor and a repose for the reader." "(12) Habituate himself to proportion his voice to the locahty in which he speaks, to the end that his voice may 'carry' at its best in the various places. Singing lessons are very useful to the orator, as lessons in diction are to the sing- er. There is here a supplementary education which is not to be despised by either. Finally, if the orator wishes to use his voice at its best, he should know how to write for the voice, that is to say, how to compose his discourses in short and sonorous phrases. The orator should watch over his general health, and that of his lungs, bronchi, trachea, larynx, pharynx, mouth and nose." "He must exercise then in a rational way. He must have a good technic." "if he shouts, his voice will not carry. He should speak slowly at the start." "If an orator is compelled to begin speaking when his voice is veiled, then let him begin just as it is, without trying to clear it by coughing or forcing it. 'Start from where you are.' Little by little, the voice will warm up, and if it does not become entirely clear, at least it has not be- come extinct. Even a hoarseness may disappear on condition of having commenced 'piano.' "The antique mask of the tragedians and come- dians seemed to have had, among other usages, that of reinforcing the voice by means of a resr onating plaque of some kind." "The singing voice has its own conditions very 314 THE TONSILS AND THE VOICE distinct from those which we have recognized in the speaking voice." "The singer should take care to breathe well, fully but silently." "For the proper conservation of the voice, it is important not to overwork it and to manage it with ease and without violence, especially when the artist finds himself charged with a heavy vo- cal service." ''These precautions assure the conservation of a voice, not only during the evening hut as ti-ell during an entire artistic career'' "All pure exercises of art must conform to physiology. Every defective method brings on a harmful congestion of the larynx." "The voice runs great danger in being used when hoarse. Nothing is more pernicious than to sing with a cold." "A particularly fatiguing thing to artists is the necessity of singing, alternately, roles of dif- ferent pitch." "We should conserve especially those voices which are naturally beautiful. They are more fragile than voices somewhat manufactured." "The face and all the exterior of the singer, should not betray the effort; no grimaces, no wrinkling of the forehead, no swelling of the veins of the neck. Exterior constraint leads to troublesome contraction of the internal organs. It is necessary to sing calmly." "When singing becomes painful and is ac- companied with a sensation of local fatigue, of embarrassing tension, of spasm, it is necessary to stop. It is singer's cramp which is announcing it- HYGIENE OF THE VOICE 315 self. It occurs particularly when one has sung a piece which is too high, with too great a range for the natural compass of the voice." "The duration of voice exercise is of great im- portance. To avoid tiring the voice, the exercise should be limited to one hour of work a day, di- vided into four periods of a quarter of an hour each. And rests should be taken in these quarter hour periods." "Fatigue, or professional affections of the pharynx, sometimes determine an alteration of the timbre, which is erroneously sought for in the larynx." "Artists should make sure of one or two months' vacation each year, during which they should leave their voices in almost complete re- pose. This is also a good method to assure the duration of the voice." "Artists should consider the capabilities of the human larynx, and avoid compositions not suit- able for the voice." "After having acquired its development, the voice has need of regular exercise. Sing with medium force. Avoid 'bawling'." "The happy effect of training upon the voice is appreciable, even in the course of a single day. Singers have made the remark that the voice of the 'morning' is fresh, but hard, and that the voice of the 'evening' on the contrary, though less clear, can be used for a longer time without fa- tigue." "Above all, the singer should care for his gen- eral health, for the various states of this react ac- 316 1HE TONSILS AND THE VOICE cording to their nature, in good or harm for the voice." "Little or no alcohol, nor dishes irritating to the throat (mustard, cayenne pepper, etc.). A complete toilet of the vocal apparatus is called for every morning." "These cares are a natural preparation for that other toilet that Faure justly calls the 'toilet of the voice.' By this is meant, the morning exercises. Thanks to these various habits the singer will no longer be exposed to the inconvenience of hav- ing his voice 'dirty,' following the ordinary com- parison." "A mischievous habit is that of coughing be- fore singing. This easily causes hoarseness and congestion." "On the day of a performance the artist should avoid any particular fatigue of his larynx, and the general fatigue of his body; no fencing, no riding. Some even have the habit of going to bed a portion of the day. Women should spare their voices for two or three days at particular times of the month." "Hygiene for singers is strict, who, to speak truly, are the subjects of an extremely sensitive organ." "Do there exist certain recipes for putting the singer in voice? Some authors attach to this a certain importance." "To-day when vocal hygiene tends to become more exacting and scientific, one cannot accord any particular virtue to the various recipes and I make no decision. It is for each one to use what his own experience shall have designated to him HYGIENE OF THE VOICE 317 as preferable. There are no rules to be estab- lished in that." Casteoc (Maladies de la Voice, 1902) : "Maladies of the voice, and maladies of the larynx are very different things, since a vocal trouble may have its cause in the nasal fossae or in the lungs, or even in the general health, while the larynx remains immune. If it relates, on the contrary, to a veritable affection of the larynx, as cancer or tuberculosis, the question of voice then becomes negligible. An excellent voice may be up to par with the larynx in bad condition. I have seen the cords thickened, red, presenting, in fact, all the symptoms of corditis, in artists in whom the voice gave no trouble. Krause (Berlin) and others have made the same obser- vation. This distinguished professor is said to have treated a young tenor in whom the cords were transformed into two red fleshy cushions. The voice was soft and agreeable." "It is the diagnosis of a malady of the voice, which is difficult." "A rational method in singing, as in speaking, counts for much in the preservation of the vocal apparatus." "It happens at times that a vocal trouble shows itself in the singing long before it appears in the speech." "Alcohol is very damaging to the voice. It causes a constant congestion in the pharynx and the larynx, which finally results in chronic phar- yngo-laryngitis. I have had voices lost by the use of alcohol." Coffee, grog, punch, or champagne, give only 318 THE TONSILS AND THE VOICE a transitory energy, soon followed by a vocal de- pression." "Fatty aliments are favorable. On the whole, a mixed diet, animal and vegetable, agrees the best." "Three hours should elapse as a medium be- tween the repast and the exercise of singing." "The artist should guard against dyspepsia. One may sing, having a great number of mala- dies, but it is no longer possible with an affection of the stomach, which interferes with the play of the diaphragm, and depresses the ensemble of the forceis. Keep the mouth and teeth healthy." "The entire nervous system, the brain above all, has an influence on the voice. Passions de- press it. Emotions of gaiety, joy, render it facile. To quote Mandl, 'The voice is the mir- ror of the soul.' " "Smoking tobacco is detrimental to the voice. Cigarettes are particularly damaging, producing hoarseness. Especially bad for tenors and for those who begin to feel the first disabilities of age." "Wear wool. No tight corsets. Don't wear neck wrappings. Dust and smoke are bad." ''Vocal nodules. They arise from vocal ex- cesses, overwork or bad management of the voice. They may develop rapidly, or insidiously." "Treatment consists in complete vocal repose for several weeks. The nodules may disappear by this means alone. Avoid forcing of the tones : Keej) the voice in the middle register, and do not allow it to wander into the high : change teachers if there is reason to do so." HYGIENE OF THE VOICE 319 "As a general rule, one must be exceedingly cautious in operations on the larynx of artists, for vocal repose and less offensive means often suffice to put them in good order." "Resume. The physical alterations of the structures of the larynx, united under the term laryngitis, whether they proceed from a veritable malady, or from fatigue, generally attack the timhre" "The abuse of speech, ill advised enthusiasms, or a too rapid education, compromise chiefly the solidity" "Vocal excesses, or exaggerated efforts may diminish the compass." "In trouble in the agility, a latent laryngeal tuberculosis may be suspected." "If the medium is affected, look first to the chest (pulmonary bellows)." "Troubles of clearness (cats, graillons, phlegm, etc. ) coincide ordinarily with a catarrhal state of the chief respiratory passages." "Troubles of resonance are almost always of nasal origin." "When the intensity weakens, search at first for the cause in a weakening somewhere, of the general condition." "For nervous troubles, it goes without saying, that they arise from the neuropathic tempera- ment of the subject." "This parallel has served me often. It is why I reproduce it here, not without saying that a de- tailed investigation for each patient, is the neces- sary complement." Garcia {Hints on Singing) asks the question: 320 THE TONSILS AND THE VOICE "To what would you ascribe the fatigue of the vocal organs?" "Answer. Besides the different ailments of the vocal organs, which concern the physician, there are other causes, such as misdirected study or overwork." "Question. Are there any other symptoms?" "Answer. Hoarseness, relaxed throat, languor of the organ, which refuses to execute passages generally possible ; dryness or heat in the throat, difficulty in swallowing, fatigue after a few min- utes exercise." Mme. Cappiani (Practical Hints and Helps for Perfection in Singing) says: "An earnest student adopts a sensible, sys- tematic plan of living and studying in order to obtain the best results. I would suggest: "(1) A moral life, plenty of sleep and fresh air." "(2) Eating at regular hours, food that is easily digested." "(3) Avoid alcoholic drinks." "(4) Hearing concerts and operas during the daytime when possible, in order to avoid late hours." "(5) Between lessons, practicing along sys- tematically, twent}^ minutes at a time, then tak- ing a half hour's rest which can be employed to advantage in doing other work, such as : studying languages, pianoforte, musical history, physical culture, dancing, fencing, designing, painting, etc." "(6) Wearing suitable clothes for changes of temperature to guard against colds." HYGIENE OF THE VOICE 321 "(7) Avoiding invitations that involve too many social duties, calls, etc., which waste time better employed in outdoor exercise." "Do not be over sensitive in giving weight to gossip about your voice and skill. Have con- tempt for flattery. Have patience in your art. Be cheerful. Have faith in yourself; be earnest and diligent, and then with indomitable persever- ance, you will succeed." "What is good for the general health is good for the voice. All kinds of nuts, because of the oil they contain, should be avoided on the day of a public performance." "Drinks, such as hot coffee and tea, or drinks that are too cold, taken just before singing, are injurious." "Beware of eating ice cream before singing." "No alcoholic drinks whatever should be used by young singers; they, at best, being harmful stimulants." "On two occasions I had pupils, a tenor and a baritone, who were to sing. Both of them took champagne, expecting thereby to gain courage. The result was a rush of blood to the throat and neither was able to sing." "For experienced singers, advanced in age, or for singers of anaemic constitution, half a glass of good, pure claret is serviceable as a stim- ulant." "For further information on diet, I would ad- vise all singers to take the counsel of a compe- tent physician." ''Important Suggestions : .22 322 '^HE TONSILS AND THE VOICE "Singing in open air is permissible only in a calm atmosphere." "Singing or speaking in a carriage or in a rapidly moving train is very bad." "To preserve his voice, a singer should never scream, laugh or speak unnecessarily loud." "Stiff collars and tight ribbons, act like tight corsets on the throat and are dangerous fashions for the general health." "Wearing corsets, so loose that one can put them on as they are taken off is rather an advan- tage as they protect the spine. A singer must be provided with corsets that allow the lowest ribs to expand." "Those who cannot abstain from smoking should exercise in moderation and should never inhale the smoke. Swallowing the smoke and let- ting it out through the nostrils is very injurious." Mme. Patti, whose marvelous voice was mar- velously preserved, says: "Dieting for the sake of the voice is nonsense. There must be moderation, of course, in all things, for the singer, above all other persons, must study intelligent!}^ her individual health conditions. She must learn how to keep herself well. The girl who is ambitious to sing need not deny herself anything she fancies at the table unless that par- ticular thing happens to disagree with her, un- less, indeed, she is to appear on the stage that same day. On the day of public performance it is necessary to eat very little." "Soup is really the best food for singers, strong soup, well made. Rare beef is good, fruit and vegetables. Pastry and sweets are not good, HYGIENE OF THE VOICE 323 but are to be avoided more because they hurt the complexion than because they affect the voice especially." "What wines may a young singer allow her- self?" "If she really means to succeed, no wines at all. I don't believe in wine. It hurts the throat almost invariably. Some young singers, I know, are not strong, and doctors prescribe claret for them, but it is bad practice to drink it. For my- self, I never drink wine. I drink water, or, if I need a stimulant, I take water with a little whisky in it." "If you were interested in a girl with a voice, would you have her go in for athletics to build herself up physically?" "That would be ruinous policy. The girl who is going to rank as a singer must keep out of the gymnasium. She can't fence. She can't row. She can't ride horseback. I enjoy nothing more than horseback riding, and I ride well. I used to ride about Mount Vernon when I was only six years old. But I have given up all that en- tirely. I never ride now. It interfered with the firmness and evenness of the voice and gives a tremolo." "Walking is the singer's exercise. The singer who has a good pair of legs must think herself highly fortunate. I can walk three or four hours at a good pace and I do so frequently. I believe in regular exercise, and the best way to take it is to drive, then leave the carriage for a while, but let it follow to pick you up if you find yourself getting tired." 324 THE TONSILS AND THE VOICE "If I were interested in a student I would urge her to be careful as to what sort of air she breathes. It is very necessary to give attention to the ventilation of one's bedroom. It should not have a fire in it and the air should be fre- quently renewed. She should not associate too closely with tobacco users. Even the fumes of the weed are bad for the throat." "How would you dress a young singer?" "No directions are necessary except the hint that good voices have been spoiled before now by tight lacing. I believe in a well-made and property-fitted corset, but it should not fit closely enough to impede free breathing and the proper expansion of the chest. Growing girls especially should be careful not to practice with lacings tightly drawn." "Everything is summed up in the advice to take sensible care of one's self. The singer must go to bed early and not allow herself to get tired. She mustn't fret. Weariness and woriy tell on the voice terribty. She must have as few outside cares as possible, and concentrate her efforts in a single direction, live for her art and live hap- pily." Mme. Lehmann (How to Sing) says: "There are no magic cures for the singer." "The repairing of a voice requires the greatest appreciation and circumspection on the part of the teacher." "There are teachers and pupils who boast of having effected magic cures in a few hours or days." ^"^Of them I give warning! and equally of un- HYGIENE OF THE VOICE . 325 principled physicians, who daub around in the larynoj, hum it, cut it, and make everything worse instead of better." Sir Charles Santley (The Art of Singing, 1908) : "I do not advocate smoking; those who find themselves perfectly well without, should leave well alone; those who find themselves perfectly well with it, ditto!" "Hoarseness attacked me when there were flowers in the room, particularly the (to me) deadly gardenia, stephanotis, hyacinth, lily, etc." "I was singing at a private party one evening, in which Gardoni, the tenor, a soprano, the daugh- ter of Varesi, and others were engaged. I left home in splendid form, and was in the drawing room about half an hour before the concert com- menced. I began to feel rather husky. When it came my turn to sing I almost collapsed, for I could scarcely produce a sound. Mile. Varesi was in the same plight. Gardoni was husky and all the others were more or less incapacitated. The concert concluded, I was conducted into a room literal^ packed with 'harem lilies,' the deadly exhalations from which had penetrated the drawing room. I got away as soon as I could and had not been out of the house ten minutes before my voice was as clear and fresh as when I entered it. I have since had many proofs that my theory, as far as my own throat is concerned, is correct. I would advise all singers to be on their guard against scented flowers." John Howard (Physiology of Artistic Sing- ing) : 326 THE TONSILS AND THE VOICE "Spirituous liquors inflame all mucous mem- branes and their influence upon a tone is unmis- takable. Malt liquors appear to be most harm- ful." Miller {The Voice) says: "Personal cleanliness is one of the first requi- sites. Bathing regular — not extreme." "Singers should avoid beef, lamb and mutton. White meat of the fowl is the best meat for the vocalist. Milk, eggs, toasted bread, string beans, spinach, lettuce, rice and barlej'^ are excellent. Fruit stewed — with little sugar. Ice cream is bad. No harm in a cup of coffee, cocoa, or tea, for the singer in good condition. Smoking is in- jurious. Silk underwear is dangerous. Lisle thread or flannel excellent." Poyet: "Walking is the best exercise. A well understood hygiene concerns the totality of the functions." "After singing exercises that cause perspira- tion, rub down with flannel and alcohol and change clothing. Alcoholics absolutely forhid- denr "Observe strictly general hygiene. Smoking irritates the pharj^nx, reddens the vocal cords, and may cause heart trouble harmful to singers." "Avoid scented toilet powders. Two hours' work a day in study or singing is a maximum." "Studies in the bypaths of vocal hygiene must be dealt with as they appear." Hesume. Whatever contributes to the general health favors the health of the tonsil, and, also, the best condition of the voice. The hygiene of the mouth, nose, throat, stom- HYGIENE OF THE VOICE 327 ach and bowels is favored by general and spe- cial cleanliness, fresh air, well ventilated sleep- ing apartments, abundant sleep, or repose, whole- some food, regular hours for eating, regularity of the bowels and regular hours for sleeping. Walking, in moderation, in the open air, is the exercise par excellence for voice users. Alcohol is irritating to the mucous membranes, and, also, for other reasons, has no place, as a rule, in the general system of hygiene. As a younger man I felt more inclined to be easy with tobacco users, but the older I grow the more I see the bad effects of tobacco, and the less I am inclined to condone or cater to the habit. A clean nose, a clean mouthy clean bowels, clean habits, are conducive to clean tonsils and a clean voice. CHAPTER XIII PRINCIPLES OF TREATMENT. Professor John N. Mackenzie, of Johns Hop- kins University, in an address on "The Massacre of the Tonsils/" reported in the Maryland Medi- cal Journal, June, 1912, says: "Never in the history of medicine has the lust for operation on the tonsils been as passionate as it is at the present time ; it is a mania, a madness, an obsession." Evidently the treatment of the tonsil is in urgent need of revolution. Professor Henry L. Swain, of Yale Univer- sity, in an article entitled, ''Are the Tonsils a Menace or a Protection?'" published in the An- nals of Otology, Rhinology and Laryngology, September, 1911, after referring to "the alluring, spectacular, and gory operation called tonsillec- tomy,"' and to "the practice in recent years of many operators all over the country, of enuclea- ting the tonsils as completely as possible, in all cases, as a routine procedure," states that "The question of relative size, healthiness of structure, or any such matter is apparently never thought of. Even in adults there are other methods of bringing about a satisfactory^ and safe condition of the tonsils besides tonsillectomy." Sir Felix Semon says: "I consider total enu- cleation not only dangerous, but also generally superfluous." 328 PRINCIPLES OF TREATMENT 329 Marage says: "There is not one treatment for enlarged tonsils ; there are many J" [Note. — The most skilful and experienced operators in the world have reported deaths from removal of the faucial tonsils; the list including such eminent technicians as Mayo-Collier^ Schmiegelow, Lennooc-Browne, Escat, Sandfort, Marage, Haymann, Damianos and Herman, eight cases; MacBride, Zarniko, Henking, Schuchardt, Burger, Kenefick, Thomson, F. Stewart, Smith, six cases ; E. M. Holmes, Gradle, Stucky, Huhhard, Goldsmith, Crockett, twelve cases; Sewall, nineteen cases; Richadson, Wish- art, and others. Serious accide