Minnesota Medicine
Published monthly by the Minnesota Medical Association
February 2003/Volume 86
The Perils of Trumpeting

Trumpet playing subjects the respiratory system to high, sometimes harmful pressures, and is a workout for even the most well-conditioned lips and agile tongues.
by Charles R. Meyer, M.D.
In 1999, Adolph Herseth, the dean of symphonic trumpeters, celebrated his 50th anniversary as the first-chair trumpeter in the Chicago Symphony. Herseth, now retired from the orchestra, was the stocky trumpet player seated at the back of the orchestra whose face turned deeper shades of crimson as his notes climbed higher. This deepening facial plethora looked very unhealthy, yet it belied durability unrivaled in brass instrumentalists. Herseth’s red face also belied an awesome ease with which he navigated even the most devilish demands of the trumpet repertoire. But it raises the question: How healthy is trumpet playing for the player? 

The Physiology
White hair flowing, barrel chest thrust forward, jazz legend Maynard Ferguson strides onto the stage, lifts his horn to his lips, and makes his horn scream. The “Maynard strut” epitomizes the macho in trumpeter culture. Listen to trumpeters talk and you will hear constant reference to “a good set of chops” and “He can really scream.” The truth behind this jargon is that playing the trumpet is real physical work, and physical conditioning of at least some muscle groups is crucial to producing a good sound. A trumpeter who lays off for more than a week or so returns to find lips of mush and a tone of splat. What it takes to play tirelessly for hours and hit Maynard-like notes that only dogs can hear is perhaps the most debated topic among players. But it is clear that the physiology of trumpet playing drives the technique of playing and provides clues to the maladies of the trumpet life.
Trumpet playing is simple. All you need is a respiratory system, a tongue, and three fingers. The tone is produced by air moving past vibrating lips, which start a column of air vibrating at the mouthpiece. The frequency of the note is determined by the tightness of the lips and length of the tubing through which the sound travels. The three valves on most modern trumpets vary this pitch by varying the length of the tubing through which the air passes. The physics of this arrangement means that the lips are the primary tonogenic “instrument.” That’s why “chops” are crucial and a “good set of chops” a trumpeter’s highest compliment. The physics also determines the notes that can be played with a given set of valves because a given length of tubing can generate only so many harmonic frequencies. The 130 cm of 11.5 mm tubing that comprise the modern B-flat trumpet allow the player to hit a C, G, C, E, G, and C with no valves pressed. Although pitch can be varied slightly by lip tension, especially at the higher range, the vibrating tube essentially locks in the harmonic series; the lip chooses which note in that series is played. 
The fancy name for chops is embouchure, which Webster’s says is derived from the French emboucher meaning “to put in the mouth.” The embouchure of a brass player refers to the shape and size of the lips and the contact they make with the front teeth. The larger mouthpieces of the tuba, trombone, and baritone allow more relaxed lips, which, if allowed to vibrate without the mouthpiece, make a sound much like “raspberries” accompanied by a lot of spit. Some have contended that large mouthpieces demand large lips and that the small mouthpieces used in trumpets and French horns only work with thin, Edward R. Murrow lips. I had a trumpet teacher (actually a closet baritone player) who, after weeks of listening to my discordancies in the confines of a soundproof booth at Schmitt Music, suggested in his most diplomatic tone that I might consider giving the baritone a try since my embouchure seemed to match that instrument better. I pictured the generous-lipped face of Satchmo, saw through my teacher’s prevarication, buried the fat lip-big mouthpiece myth, and got myself a new teacher.
Most teachers contend that breath support drives all good sound, but flabby chops won’t make great music, even with hurricane-force wind. The wind-producing technique is basically a modified Valsalva maneuver. Antonio Valsalva was a 17th-century Italian anatomist who described the physiological maneuver of holding one’s breath and bearing down, familiar to all who have ever defecated or given birth. The trumpeter’s Valsalva is modified because air is released through the resistance of a .144-inch-diameter hole at the mouthpiece throat and through 5 feet of brass tubing. The respiratory tract pressures generated by trumpet players have been measured and are impressive. Mouthpiece pressure on the lip during normal playing has been measured at 5 to 10 pounds. Higher-register playing produces greater pressure. Herseth’s red face is his Valsalva mask. 
The other part of the trumpeter’s noisemaking arsenal is the tongue. Music’s words are notes, and the tongue articulates each note for the trumpet player, breaking the stream of air into chunks—from the lugubrious to the lilting. The trumpeter’s tongue forms the sound “tu” for slow articulation. When the music moves faster, even the most facile tongues can’t make it back behind the teeth in time to start the next “tu.” To overcome these lingual liabilities, trumpeters have devised two forms of cheating, double and triple tonguing, which substitute “tuku” and “tutuku” for all “tus.” Tonguing dexterity, like screaming high notes, is a badge worn proudly by trumpeters such as my cornetist friend whose car sports the vanity plate “TUKU.”

The Pathology 
Wind, chops, and tongue are the trumpeter’s music-making triumvirate; they are also the Achille’s heel for disease and disability. The physiology of trumpet playing predicts what impairs a trumpeter’s performance: Block the wind and tone sours. Slow the tongue and black notes are torture. Hurt the lips and hitting accurate notes is a dart in the dark.
Common ailments such as canker sores, cold sores, braces, and inadvertent bumps to the trumpet while on the lips can sideline a trumpeter for days or months. Respiratory tract problems can wreak havoc on a hornplayer’s wind. Playing the trumpet with the common cold results in the uncommon, unpleasant sensation of pounds of greenish stuff getting forced into the remote corners of the sinuses. Long tones get interrupted by spasmodic coughs. When I have a cold and play my horn, I have the unsettling thought that I am creating a tubular culture plate for future reinfections, although I can find no microbiological study to support my paranoia. Similarly, no study I’ve found proves that trumpeters suffer from more sinus infections, though I’m sure that respiratory tract infections cause them to suffer more than other instrumentalists. A violinist, after all, can cough, snort, and fiddle at the same time.
Mucous is not the only possible pathological hindrance to a trumpeter’s airflow. Asthma decreases the volume and velocity of exhaled air. Smoking-related obstructive lung diseases such as emphysema and chronic bronchitis create similar difficulties. Because good breath support is one of the inviolable commandments of trumpeting, asthma should not mix with trumpet playing. Yet a sampling of opinions expressed about asthma in that font of 21st-century folk wisdom, an Internet discussion group, reveals disparate views. While one mild asthma sufferer complained that “when playing long sustained passages, I become short of breath,” another trumpeter-asthmatic claimed therapeutic benefits: “Since taking up trumpet at the age of 13, my asthma gradually all but disappeared.” This anecdote finds no support in a textbook of performing arts medicine, which states that wheezing and horn playing don’t mix and that asthma in brass players needs aggressive treatment.
The trumpeter’s variation on Signore Valsalva’s maneuver generates pressures in the mouth of up to 234 cm H2O depending on loudness, note frequency, and size of instrument. In general, the louder the sound, the higher the note, and the smaller the instrument, the higher the pressure. Virtuoso Maurice André navigating the piccolo trumpet’s high range in Bach’s Brandenburg Concerto no. 2 is putting more pressure stress on his bronchial tubes than Herseth playing a lyrical orchestral passage two octaves lower. And that barometric stress is transmitted to the entire respiratory tract, from the mouth to the small bronchioles of the lung. A red face and a brief headache are all that most trumpeters experience, but more pathologic consequences have been reported.
In 1973, a volley of letters to the New England Journal of Medicine described wind parotitis. The typical story of these patients was inflammation of the parotid gland, similar to that occurring in mumps, which appeared in trumpet and French horn players (and also one person who had been blowing up big balloons). Although one writer postulated that the pressures generated within the mouth forced bacteria from the mouth through the tube that drains saliva into the mouth from the parotid gland, most writers believed the symptoms were caused by trapped air within the gland.
The bulging cheeks of Dizzy Gillespie are a case study for the potentially damaging effects of a trumpeter’s pressure farther down the respiratory tract. Trumpet teachers go to great lengths to discourage their fifth graders from bulging their cheeks. Dizzy’s cheeks got larger and more pliable as the years progressed. He eventually developed swelling under his jaw when he played, a condition called a pharyngocoele, which is like a hernia of the tissues of the throat caused by high intrapharyngeal pressures. A similar bulging, a laryngocoele, can occur at the level of the larynx. Although Dizzy never seemed bothered, the stretching involved can be disturbing, if not painful. One trumpeter told the Internet discussion group, “My neck puffs up Gillespie style when I play, and it’s getting worse.” Another complained that his neck had only recently become painful since he’d started playing more (three to four hours a day) and doing more work with the piccolo trumpet, which has the most back pressure. Recalling trumpeters who had their careers ended by the malady, respondents urged them to seek help.
Pressure is blamed for a host of illnesses described in trumpeters. Transient dizziness and blacking out (syncope)—a result of thoracic cavity pressures decreasing blood flow to the head—are common enough not to merit journal reports. Other events range from the dramatic to the cataclysmic. The journal Neurology reported a 17-year-old trumpet player who complained of numbness on one side of his face during intensive playing. After routine tests were negative, Doppler ultrasound measurements of cerebral blood flow showed that the boy had been born with a partially open foramen ovale, the hole between the atrial chambers of the heart that normally closes at birth. Many people live uneventful lives with this defect, never discovering that they have it. However, this trumpeter increased his intrathoracic pressure to cause blood, and some small clots, to flow across this opening and travel from the left side of the heart to a blood vessel in the head. Surgical closure of the foramen eliminated the problem.
A 23-year-old trumpeter came to the emergency room after developing severe upper back pain following a performance of Peter Maxwell Davies’ St. Thomas Wake. Spurred partly by the prophetic name of the piece but mostly by the rapidly developing paralysis of the musician’s right leg, the emergency room physicians quickly diagnosed a ruptured blood vessel in the space surrounding the spinal cord. This epidural hema-toma was evacuated, and the patient recovered. Although pressure is a part of life for trumpeters, there is no evidence of increased incidence of hypertension in brass players.
Pressure also takes its toll on the lips. The embouchure is formed by the ring of muscle called the orbicularis oris and strengthened by the other muscles of the face. Trumpeting is isometric exercise of these muscles, and a good set of chops the result of years of conditioning. After extended playing, these muscles respond just like biceps doing curls: They ache, they swell, and they stop responding. When this happens, a poor substitute for tensing the muscles takes over: pressure. Pushing the mouthpiece harder against the lip and the underlying teeth can wring some additional range out of tired lips. It can also tear them up. And like the ironpumper who pushes his passion too far and tears a muscle bundle, overeager trumpeters have stretched their orbicularis oris past its limit. Rupture of this muscle causes a possibly career-ending droop and weakness of one section of the lip, usually the lower in trumpeters. Case reports in the 1980s described career-rescuing surgery to repair this defect. 
A peculiar syndrome called facial dystonia is the trumpeters’ version of writers’ cramp. Facial dystonia in trumpeters causes lips or cheek muscles to lock or stiffen after a period of playing. The cramp disappears with rest but naggingly returns when playing resumes. Also called occupational cramp, occupational neurosis, and craft palsy, dystonia usually affects male, veteran professionals who suffer the symptoms only when playing their instrument. Since the cause is thought to be part physiological and part psychological, treatments include physical therapy, psychotherapy, technique modification, and medication. The cure can be elusive. 
The tongue is the precision part of a trumpeter’s anatomy. While the muscles of the lips, abdomen, and diaphragm need strength, the tongue needs agility. For the trumpeter’s “tus,” “tukus,” and “tutukus,” faster is better. Anything that swells, cuts, or slows the tongue, such as canker sores, lacerations, and allergic swelling, drags the arpeggios and blurs the attack. Although legends attest to epic alcohol intake by trumpet virtuosi, most trumpeters will tell you that alcohol’s effect on tonguing in particular and playing in general are similar to what Shakespeare said about alcohol’s effect on another part of the body: “It dulls the performance.”
Given the above, one might think trumpeters are destined for an early demise. Ron Hasselmann, retired associate principal trumpet in the Minnesota Orchestra, told me he felt any early death or disability of trumpeters he knew was explainable by their lifestyle away from the trumpet. Doc Severinsen, still touring and soloing after the age of 70, was quoted by an Internetter as saying that exercise and taking care of his body were a part of his job. Adolph Herseth claimed a few years ago that he was 80 percent of the trumpeter he was 20 years ago, but that still makes him close to the best. He reportedly weathered a coronary bypass and returned four months later to solo flawlessly on the Haydn Trumpet Concerto. 

The Joy
So trumpeters aren’t destined to die early from blowing their heads off. But they are vulnerable to maladies. Because most musicians would rather play than give in to suffering, in the last 15 years performance medicine has become a thriving specialty that aims to keep players playing. 
The reason professional musicians want to keep playing may be partially economic, but for most players it’s mainly joy that drives them. In For the Love of It, literary critic Wayne Booth describes his journey as an amateur cellist. He captures the reason to play the trumpet, or any instrument, despite the perils: “Since all other motives—fame, money, power, even honor—are thrown out the window the moment I pick up that cello bow, the only plausible reason for doing it is that overworked word ‘love,’ the irresistible motive that leads in mystifying ways to both intense pleasures and intense pains. I play because I love doing it, even when the results are disappointing. In short, I do it to do it.”
A dozen years ago, knowing my perverse passion for blowing through 5 feet of brass tubing, my mother gave me a lesson with Adolph Herseth as a birthday present. I timidly carried my “ax” into Orchestra Hall in Chicago and told the guard that I had an appointment with Mr. Herseth. We met in a small, cluttered practice room in the bowels of Orchestra Hall. He asked what piece I would like to play for him, and when I answered Charlier’s lyrical Etude no. 2, he encouragingly said, “Good choice.” When I was halfway through the piece, Herseth stopped me, likely recoiling from my dissonant rendition of Charlier’s masterpiece. The remainder of the lesson was mainly talk about wind, chops, and tongue. But what I carried away from that lesson was not just new pearls of technique. It wasn’t just watching that famous face turn crimson as he played the first eight bars of the trumpeter’s Everest, Bach’s second Brandenburg Concerto, on my horn, hitting notes my trumpet hasn’t heard before or since. What I saw that afternoon was a musician, then approaching his 70s, staying with same job he’d held for 40-some years—because he loved it. For Herseth, as for many trumpeters, the joy makes any perils worth it. MM

Charles Meyer is editor-in-chief of Minnesota Medicine.

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