Frank E. Miller

NODES AND THEIR CURE

I use the scale of E as a means of revealing to the ear points wherein the voice shows signs of failure. I use this scale because within it lie all the principal resonances involved in voice-production. By this I mean that somewhere between the interval G# to C# an oral resonance is developed in the majority of voices. This seems to be coincident with the action of the lips, the tongue and the soft palate, and the other muscles that go to increase or to decrease the size of the oral cavity. From C# to E above middle C the principal changes occur which contribute to the development of the nasal resonance. Some rare voices, however, continue their oral resonance as high as F# before changing. It has occurred to me so often in the course of my practice that a peculiarly apt reason exists for making E the foundation-note of the test-scale employed in the operating room, that I lay particular stress upon it. It has seemed the most easeful note for the patient to sound, whatever his vocal condition, and I have been tempted to call it the "nature tone," because it may be said to sing itself. At least, it can be sounded with naturally open throat and without calling into perceptible use the multiplied enginery of muscular forces which are required for the formation of the higher tones of the scale.

Consider for a moment this enginery of muscular forces at the command of the singer, and which his intelligent and ripe knowledge must guide. The muscles used in voice-production may be divided as to action and location into ten groups. In these ten groups there are one hundred and seventeen individual muscles. Three of these act alone. One hundred and fourteen act in pairs, making fifty-seven pairs. Again, these muscles are controlled by nerves, some of which act alone and others in combination. In one instance, a single nerve presides over two large groups of muscles. Then, in still another instance, two separate nerves are required to control the action of one small group—the palate group. The distribution is as follows: Single muscles, 3; muscles in pairs, 114; groups of muscles, 10; nerves acting alone, 17; nerves acting with others (eight groups), 88.

By taking these figures and increasing them in arithmetical progression, it is possible to calculate what a multiplicity of nerve and muscle effort is involved in a sneeze. Everything that appertains to the vocal mechanism is spasmodically involved at once, and the enormous sum total of muscle and nerve movement, individualized, is 465,120. This shows how absurd is the theory of conscious control of the machinery of voice-production. As I have frequently pointed out, the adjustments of the vocal tract to the tone to be produced are responses to the will, physical reflexes of the tones which the singer hears mentally; so that voice is mental audition converted by responsive physical adjustment into audible tone.

Teachers and singers are aware that wrong methods of tone-production result in nodes on the vocal cords. The node, therefore, is one of the most familiar forms of vocal catastrophe.

In its simplest form the node is a superficial swelling on the edge of a vocal cord, sometimes appearing on one and then on the other and ofttimes on both, dependent entirely upon causation. For instance, the cause might be simply a severe spell of coughing, and this, of course, might befall a person who was not a singer at all. It has been known to occur to animals. The node is, in fact, an oedema or dropsy, a swelling from effusion of watery fluid in the cellular tissue beneath the skin or mucous membrane. This oedema appears on the edge of the vocal cord, as a slight tumor or swelling filled with water. If aggravated by continued use of the voice, it may develop and become exceedingly dangerous, by extending inward to the real tissue of the cord itself. The membrane is thickened by the watery secretion, and much the same thing happens as in the case of a pinching bruise or a blistering burn. Nature's cure for this state of things is by absorption of the fluid contents and a consequent diminution in the size of the node until finally a normal condition of the cord is restored and the voice returns in all its fullness. In the formation of the node it is worth remarking that the coughing node may appear at any point on the cords. It shows first at one point and then at another. The node caused by vocal weakness or abuse of the natural powers, however, displays an exasperating, and sometimes puzzling, affinity for particular portions of the vocal cords. It is generally found protruding from the anterior and middle third on one or the other side of the glottic opening, or on both, in chronic cases. The other nodes may be found at any place on the cord. In fact, it frequently happens that the coughing node, and what for convenience may be styled the "vocal node," are simultaneously present, each to be distinguished by its well-defined location, although produced by totally different causes.

There are cogent reasons for the affinity of the vocal node for certain fixed positions on the cords. They can be explained by the trick of the vibrating string and bit of paper. If the paper is laid upon the string at a certain point, it will be flirted away; while at another chosen point it will slip unagitated to the floor. Inasmuch as the vocal cords are subject to the same laws of vibration, the lesson drawn from the string and the bit of paper applies to them, the node taking the place of the paper. Note, however, the difference. The string is single, and there is no attrition. If there were two strings, the bit of paper might be caught and twisted in the miniature whirlwind of opposing vibrations. But the vocal cords are wedded in phonation, and by their attrition the node is formed. Very often strands of tough mucus appear spanning the chink or slit between the cords when they are drawn up in tone-production. The presence of these bands of mucus is an assured precursor of the node. Often they indicate the existence of a node which is hardly perceptible through the laryngeal mirror. The mucus is nature's effort to relieve the attrition, and so to ease the inflammation at the point of difficulty. The obstinacy with which the nodes caused by vocal disaster thus form in the anterior and middle third of the cords may be explained as owing to the presence in the vocal cords of a point which may be called the centre of resistance for the intrinsic muscles, and indicates that they are caused, in the majority of cases, by undue and improper muscular effort in tone-production. Consequently, the necessity for the most painstaking care on the singer's part to avoid singing under unfavorable conditions. A trifling over-exertion at an afternoon rehearsal in a cold hall, too much talking on the train, a bad night's rest in a sleeper berth, all may conspire to weaken the voice for the time and lay it open to attack. Under such circumstances, particularly, it is necessary for the vocalist to exercise large discretion and to aim for a conservative middle course, and especially so in a preliminary rehearsal.

Another cause of the node is a lack of cordal coÖrdination. Were the human form perfect, both cords would be equally strong. As a matter of fact, in my own experience, I have found that the major portion of nodal formations appear on the left cord, indicating that it is the weaker. The fact that one cord is slightly lax while the other vibrates at full tension along its face causes trouble. Another source of difficulty is subglottic, owing to inflammation of the mucous membrane in the trachea, which extends upward and involves the cords. The inflammation, passing upward, may easily affect the voice. Such inflammation is discovered by a tickling sensation in the trachea, causing a dry, harsh cough about the third day after a cold has found lodgment "in the head," as the phrase goes.

The node has been the cause of vocal catastrophe from opera houses to concert halls, yet a reasonable amount of precaution will minimize the chances of attack. Singing in a room where there is smoking is a prolific source of node formation. Breathing dust-laden air, continued effort to carry on conversation on the cars or amid street noises, are fruitful causes of vocal disorder.

The mucous membrane of the vocal cords obeys natural laws in restoration. A node may disappear in three days, if not teased with effort. More often, however, it requires from seven to ten days for it to disappear without treatment. If the singer foolishly persists in using the voice, the node will extend into the cord tissues, and result in a most unfortunate condition. The cord loses its elasticity. It refuses to respond. It will neither act nor will it consent to be acted upon. It is in a state of collapse, and the voice for singing purposes has gone, never to return.

Let me illustrate what rest will do for a node. A singer came to me with a node of three months' standing, on the left cord. She had been singing with her teacher in the regular course of her lessons at an unfortunate time, when, too, she was vocally weak. In singing up the scale, and at the C (as nearly as she could remember), she became hoarse, and, as she described it to me, "the voice had a hole in it." Throughout the remainder of the lesson, unless she exercised great care, she would always break at the point named. Her nose seemed stuffy, and she compared her nose and throat to a cornet lined with velvet. After the break, and for the remainder of the lesson, her voice was husky. Her teacher advised her to seek expert advice. Previously, the voice had been clear, though she was a novice in singing. After remaining away from her lessons for two weeks or more and finding that recovery was not rapid, she came to me. The node could be plainly seen on the left cord. Before examining her, I tried the voice with the E scale, wrote down the diagnosis and handed it to her to read. My written conclusions were verified with the laryngeal mirror. I found no trouble except with the left vocal cord, the node being in the anterior middle third. On the summit of the node the mucous membrane appeared very red, budded, and almost warty. I cocainized the cord, and immediately applied pure alum in solution to the node itself, but to no purpose. This treatment was continued for two weeks, without any perceptible change for the better. Then I ordered the patient to remain quietly in a closed room; she was to see no one, she was not to talk at all, she was not to laugh. As harassing as was the experience, she faithfully observed the directions, and on the fourth day every vestige of redness had disappeared. Only a slight elevation remained on the cord where the node had been. The treatment was continued three days longer. At the expiration of that period no trace of the node could be seen. Now no one would suspect that a node had once affected her voice. Experiences like this indicate why I counsel against use of the voice under diseased conditions.

As a general proposition, all throat spraying is dangerous. A New York singer, suffering while on a concert-tour from a case of sub-acute laryngitis, sought advice from a physician who honestly tried to aid him, but shot wide of the mark through injudicious use of a spray, in which he used menthol and eucalyptus, a combination much affected by a certain well-meaning class, and which for a time gives to the throat a delightful sense of coolness. The singer became afflicted with a violent, explosive cough, which caused the formation of a node. He gave up singing, losing nearly $1,000 in engagements. He went to his own room and to bed. He remained in his room for three weeks. The temperature was carefully watched. He did not expose himself in the slightest degree, nor did he use his voice. The result was a perfect cure.

Another case is that of a church singer whose throat during a religious festival service became filled with the smoke of incense. The irritation caused a troublesome cough, and she lost her voice entirely above the top F#. It required fourteen days to effect a cure. She stopped singing for six days and then sang in church, with the result that the difficulty returned, augmented. She sensibly rested the succeeding week and perfected a cure. Rest did far more than any amount of medicine, however it might have been administered.

Paralysis of the vocal cords constitutes a second form of vocal catastrophe. It should need no definition. In reality, however, the paralysis does not lie in the cords themselves, but in the leading muscles that control in phonation. There are many forms of this particular example of vocal catastrophe, though I am now dealing only with those which are liable to attack a singer, and which are most frequent in my own experience.

With the singer one form is common, viz.: paralysis of the left adductor muscles, or those which inspire the arytenoid cartilage in drawing the left vocal cord forward to meet its fellow for the production of tone. No one can ever forget the sight presented by the left cord in its helpless condition: the arytenoid, tipped with its cartilage of Santorini, extending far over the median line of the glottis and drawing after it the right vocal cord in a vain endeavor to put it in position where it can aid its injured mate.

The paralysis may, of course, occur on both sides, and then it is that, on the side which is most exercised, there is felt a sense of distress, of pain and sudden fatigue. This condition generally arises from prolonged singing, and many of the cases I have seen have been the result of overwork during Easter and Christmas; and all of the cases which have come under my observation were associated with rheumatic constitutions. Fortunately for these singers, when the conditions were made known to them, they were in a position, or at least were perfectly willing, to rest, because of the fear that a knowledge of their condition instilled. Indeed, the situation is always one to cause serious alarm. The beautiful symmetry of the arytenoids is impaired and the agility of the voice is destroyed. If the singer persists in his vocation, total disability results. As a rule, complete rest is enforced by reason of inability to sing at all. If the voice is continued in use, the affection becomes permanent and there is one more case of irremediable vocal collapse. The remedy is rest, and that, too, before the disease has passed recoverable ground. If the singer experiences pain on either side of the thyroid cartilage, or on either side of the Adam's apple, then let him by all means have a care, for those are the symptoms of this peculiarly menacing form of paralysis. In the voice a palpable hoarseness is manifest. The voice becomes "fuzzy" throughout its entire compass. A pronounced disability to make a crescendo arises, and when the effort is made (for in the described circumstances use of the voice is attended with undue effort), the tone becomes coarse and uncontrollable. The range of the voice is lessened and the singer finds difficulty in reaching the upper tones. In the general debilitation the singer tries, or rather is compelled through weakness, to poise the voice from the cords themselves and not from the diaphragm.

Of the other forms of vocal-cord paralysis there is one of great interest, known as hysterical paralysis. It is usually only temporary, and is sometimes produced in singers whose nervous condition grows upon itself until the system passes into the trying disturbance diagnosed by the rudely critical public as "stage-fright." Artists of marked pretension have been compelled to abandon a public career because of this affliction. There are other examples of it even more difficult to understand. I have in mind a case of a singing-teacher in a conventual school, who was under a peculiar strain of preparation for the commencement exercises of the school and of her own class and their appearance in public. She brought her class up to the appearing-point. Then her nervous system gave way, and when she came to me she was absolutely voiceless. Sometimes in coughing her vocal cords could be seen to move. With rest she recovered, but she has a recurrent tendency to the same trouble every year. The case would seem to illustrate the uselessness of all effort on the part of the person so affected permanently to overcome it. The remedy is at hand, however, in numerous cases, in resort to a careful and uninterrupted upbuilding of the nervous system.

I will mention some other cases of vocal disorder and cure. An operatic tenor came to me with a tendency to break in scale-sounding, and with a nasal or catarrhal color to all his tones above E. I found attached above and back of the soft palate a mass as large as a hickory nut and completely blocking up the dome of the pharynx. A little cocaine was applied, and with a single sweep of the curette he was minus an adenoid on the third tonsil, a tonsil of Luscha. Within ten days his voice was completely restored.

Sometimes the physician is obliged to seek far for the cause of catastrophe to the voice. A fine and thoroughly well-trained tenor singer came to me with a singular tremor in his voice. The entire scale was tremulous. I found nothing the matter with any part of his vocal tract save that, on closely studying the condition of his mouth, there was a rapid muscular contraction of the soft palate and surrounding tissues. This led me to examine him from head to foot for possible nervous disorder, of which, however, I found no trace. Then, satisfied that there must be a more remote physical cause, I pushed the examination further and discovered traces of kidney affection. He was successfully treated for this and, with its cure, his voice also was restored. This case shows the close relationship between parts of the physical constitution and the voice, and illustrates the importance to the singer of a generally healthy physical condition.

Another case illustrates a further and somewhat peculiar phase of the subject. From the posterior nasal passage of a singer I removed nine large adenoid tumors. He was a tenor, and within a few days his upper tones were perceptibly freer and fuller. He had recently changed his instructor; and subsequently I found that he was attributing to this teacher the marked improvement in his voice. The physician was receiving no credit as a voice-builder whatsoever from either of them—which shows that in addition to a keen knife, the specialist should also possess a keen sense of humor.