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Intended to represent the vocal cords in the position which gives rise to the nodules of attrition.
Moure states (Revue Hebdomadaire de Laryngologie, etc., February 8, 1896) that this affection is frequently met with in children. This I am unable to confirm from personal observation, having never seen the condition in a child, but it is to be presumed that the shrill upper register tones of children, especially when calling out while engaged in play, might readily give rise to a similar disorder to that sometimes caused in singers by the persistent use of high notes in the upper medium register.
Further confirmatory of this mode of causation was a case seen through the courtesy of a professional friend, in a young man engaged in the capacity of a bill clerk, whose occupation necessitated his calling off figures in a high sing-song monotone; this resulted in the production of a nodule on one of the vocal bands. A similar case was that of a young man, 19 or 20 years of age, who was captain of a company of cadets in a military school. Compelled to issue commands in a loud tone, the strain upon his already raucous voice gave rise to a chorditis tuberosa of the right vocal band, this presenting a nodule as large perhaps, not, as commonly stated of these growths, a pin head, but a millet seed.
Improper use of the voice is, then, the chief factor in the production of these nodules. To faulty method of singing or persistent overuse of the voice may be ascribed most of the cases of "singer's nodule" seen in vocalists-false attack, use of the coup de glotte, or stroke of the glottis, being a chief factor. Singing with congested cords or a cold may also be mentioned among the causes, while Holbrook Curtis, of New York, whose study of the causes of singer's nodule has been most
thorough, also calls attention to the fact that changing from one language to another in singing-for example, from French to German-may in a single evening give rise to this disorder.
Singer's nodules are, as I have stated, usually found at the junction of the anterior third with the posterior two-thirds of the vocal band, and are most commonly observed to be about the size of a pin head, but may attain much greater size, considerably larger, as in the second instance cited by me. Other than that they usually are of a pale pinkish color, and sometimes are surrounded at the base by a reddish inflammatory zone, they present no other characteristics to the eye of the observer with the throat mirror. Although most often single (the opposite band at times having a dent upon its free border, where the opposing nodule has rubbed), these growths may not infrequently be found double; and Compaired, of Madrid, has recently reported (Revue Hebdomadaire de Laryngologie, etc., May 13, 1899) the case of a baritone singer in the Madrid Opera-Comique, who presented upon his vocal bands four nodules of extraordinary size, two to each band. It is notable in this instance that the patient was a baritone - it being, as I have stated, rather the exception to find these nodules in the voices of lower register than the soprano or tenor. Noteworthy also was the fact that this singer had been able, notwithstanding the condition of his larynx, to use his voice almost continuously in his professional capacity, his consulting Compaired for a hoarseness following singing leading to the discovery of the nodules. I have here endeavored to reproduce the drawing of this patient's larynx as presented in the report of this case. (See fig. 2.)
It has not been very long since I was consulted by a prominent tenor singer of this city, late one afternoon, who had a difficult rôle to carry that evening in that beautiful song cycle "In a Persian Garden," whose chief complaint was of a beginning hoarseness and clouding of his upper tones. Laryngoscopic examination revealed a large nodule on his right vocal band, about as I have here illustrated it (see fig. 3). Prompt treatment gave him temporary relief and enabled him to sing as programmed. Prolonged rest of the voice has since restored its function. The drawing I have here presented of this patient's larynx shows very well the laryngeal picture of a typical singer's nodule.
A typical "singer's nodule." Also representing a case recently seen by the author.
The question of the treatment of these growths is not one to be touched upon lightly or to be shoved to one side with a mere word or two, for it involves the question of the future of many fine voices. Primarily, I may say, treatment of this disorder resolves itself into one essential-rest. The next step should be to change the method of singing-correct the attack. At the hands of a skilled laryngologist, astringent applications of solutions of nitrate of silver or sulphate of zinc may be made. to the growth, but these are not always to be advised, and indeed some throat men are altogether opposed to their use. Watson Williams claims excellent results from the use of thuja occidentalis (arbor vitæ) in solution applied locally, and the internal use of mercury protoiodide, one - tenth grain three times daily. A popular method among European laryngologists of removing these growths is to snare or clip them away with a Jurasz or similar cutting forceps, and when the growth
is sufficiently large this procedure would not be inadvised. The nodules may also be burned away with chromic acid or other chemic cautery. I should not advise the use of the electric cautery for this purpose, for there is likelihood of too much tissue destruction, and the scar left behind may prove equally as ruinous, or more so, to the voice than was the growth. The method which appeals to me as being by far the best for the correction of this condition of the vocal bands is that suggested by Holbrook Curtis, of New York, consisting of a system of voice exercises which give to the vocal bands a different vibration and tend speedily to restore their symmetry. This method would require for description more space than can be accorded it in this cursory article, but consists in simple of the use of consonants preceding vowels in vocal practice, such as “ma” and “maw," and bringing the tone to the lips before it bursts forth-singing dans le masque, as it is called. These exercises will of necessity have to be practiced under a vocal teacher. When other resources are not at the command of the physician, rest for the voice, absolute, and change of method, give promise of the greatest degree of permanent benefit to the singer who is so unfortunate as to be a victim of this affection. Porter Building.
BY ADELE E. SHAW.
Few physicians ever preach from this text; fewer yet make a personal application of it; and no class of men need more than they to show by their works their belief in the deadliness of this thing that prematurely ages, diseases and kills more American men and women than any other known disease. It destroys physically as well as mentally, and every detail of its method is known to the scientist. The neurologist will tell you that annually hundreds of deaths attributed to other causes are simply the result of worry. It does its work through certain cells of the brain, as slowly and persistently as the continual falling of a drop of water in one spot. The normal brain can cope with an occasional worry
about different things with an interval of rest between; but the person who thinks constantly of one trouble, allowing that subject to exclude all other interests, is keeping continually at work only one set of nerve cells. That is why the brain wears out quicker from worry than from work. In work all parts of the brain are exercised and then allowed to rest.
When some man who figures conspicuously in public affairs puts in a century or two of life within the space of three-score years and dies suddenly, they say his brain has broken down from overwork; but no man who finds life satisfactory goes out of it by that route because he has been giving his brain a big amount of work to do, but because of some hidden worry that gets such control of the victim, waking or sleeping, that it cannot be shaken off. The one set of cells thus affected are, after a time, destroyed, and, being closely connected with the cells of the other parts of the brain, the mind, and finally the body, becomes affected.
Scientists claim that worry causes a kind of poison to form in the cells, which is thrown off during a period of relaxation, the cell returning to its normal condition, but without the necessary rest. The inactive cells lose their vitality and affect all the other brain cells. A weak physical organ is next attacked, and when the victim dies it is generally supposed to be from some local disease.
There is no remedy but to educate the will to throw off care and take the proper amount of rest-to live closely up to the creed that there is no trouble in life big enough to warrant a surrender to this slow species of suicide.
REPORT OF TWO CASES OF TYPHOID FEVER.
On April 5, 1899, I was called to see a patient, female, colored, aged 23. Temperature 105° F.; diarrhea, bowels moving twelve or fifteen times in twenty-four hours. Gave a liberal dose of acetanilid, with the result of reducing the temperature only half a degree. Repeated acetanilid at regular intervals,