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 coordination. 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.