HX641 37392 
 QP306 .C94 The effects on the \ 
 
 ^ECAP 
 
 ON THE VOCAL CORDS 
 
 OF IMPROPER METHODS OF 
 
 Voice Production and their Remedy 
 
 BY 
 
 H. HOLBROOK CURTIS, M. D. Pli. B. 
 
 liS Madison Avf., Npal Y'tyk. 
 
 PRESENTED AT THE 
 
 PAN-AMERICAN MEDICAL CONGRESS, 
 
 Washington, D. C 1893. 
 
 COLUMBIA UNIVERSITY 
 
 DEPARTMENT OF PHYSIOLOGY 
 
 College of Physicians and Surgeons 
 
 READ BY INVITATION BEFO^O^F '^"^ '''^T" ST«E6T 
 
 NEW YORK 
 
 NEW YORK STATE MUSIC TEACH ER^HpSQCI. TION, 
 
 RDcTiextcr. I8a:i. 
 
 New York 
 EDGAR S. WERNER 
 
C(/^Jr?^ 
 
 ^Ls^ 
 
 CDlutttbia S!nit)ersiitp 
 intlieCitpoflirtutork 
 
 College of ^\^^i\i\m^ anb burgeons! 
 
 Hifararp 
 
Digitized by tine Internet Archive 
 
 in 2010 witli funding from 
 
 Open Knowledge Commons (for the Medical Heritage Library project) 
 
 http://www.archive.org/details/effectsonvocalcoOOcurt 
 
THE 
 
 EFFECTS ON THE VOCAL CORDS 
 
 OF IMPROPER METHODS OF 
 
 Voice Production and their Remedy 
 
 BY 
 
 H. HOLBROOK CURTIS, M. D. Pli. B. 
 
 us Madison Ave., New York. 
 
 PRESENTED AT THE 
 
 PAN-AMERICAN MEDICAL CONGRESS, 
 
 Washington, D. 0., 1S93. 
 
 READ BY INVITATION BEFORE THE 
 
 NEW YORK STATE MUSIC TEACHERS' ASSOCIATION, 
 
 Rochester, 1803. 
 
 New York 
 
 PDGAR S. WERNER 
 
 1894. 
 

THE DYNAMICS OF SINGING. 
 
 By H. Holbrooe Curtis, M. D., of New York. 
 
 It would be strange indeed, if a laryngologist who was daily m the 
 habit of examining very many throats of singers did not have his 
 attention particularly attracted to the difference in the appearance of 
 the glottis as the direct result of different methods of voice-production. 
 Several years ago, as early as 1884, I observed, that many pupils of a 
 certain professor of singing, presented marked peculiarities in regard to 
 the position of the free borders of the vocal-bands. The slightly ellip- 
 tical shape of the chink of the glottis which this class of pupils pre- 
 sented, in emitting the usual sounds to allow the proper view of the 
 larynx, led me to inquire as to the particular method of teaching, which 
 would produce in so many throats a typical appearance. I soon found 
 out that these pupils were in the habit of taking daily exercises almost 
 entirely on a single vowel, that single vowel being the letter "O." 
 The vocal cords appeared striated, with frequently a congested area at 
 their anterior attachment. Frequently a nodule, more or less defined, 
 would be observed about the center of the free edges on either cord : 
 this is a picture which every laryngologist will recognize. Another type 
 of which the study is most interesting, is that of a class of pupils 
 undergoing instruction at a conservatory, where the pernicious Fi-ench 
 method, the so-called stroke of the glottis (coup de glotte), is daily 
 practised. In this type the writer has observed the middle-third of 
 the cords to be slightly bulged, the cords presenting a convexity, in 
 contradistinction to the concavity exhibited in the last group. These 
 pupils had been singing chiefly on the vowel "A," pronounced as "Ah" 
 in English, and with the emission of each note the middle portion of 
 the cords would clash and by constant attrition become hardened and 
 callous. The cords in this particular type do not usually show con- 
 gestion ; their appearance is usually of a good pearl color and healthy- 
 looking in every way. The complaint which they make upon consul- 
 tation, is a difficulty in singing the so-called viezza voce and a lack of 
 richness of tone and timbre, with extreme weakness of two or three 
 notes in the upper-medium register. It was these two opposite ap- 
 pearances of vocal cords, which are every day observed in singers' 
 throats, that led to an investigation of methods employed by the 
 various schools of singing, and has opened up a field which I think 
 has been entirely neglected, though of the greatest importance to every 
 laryngologist who has to do with the singing voice. 
 
 Two names are intimately linked with the traditions of method in 
 
— 4 — 
 
 sinking: Those of the older Lamperti, (that ilhistrious exponent of the 
 best Italian school) and Mandl, who by his ingenious arguments, though 
 founded on a false physiological basis, succeeded in completely over- 
 turning the art of voice-production which previously had been taught 
 throughout Europe. He substituted in i)lace of the so-called Italian 
 school a method of al)doniinal resi)iration, which was at t)n(>e adopted 
 in the Paris Conservatory, and has obtained to within the last three 
 years an almost universal recognition in the best schools of the 
 Continent. 
 
 It is the writer's purpose, without going t^io deeply into the history 
 of singing, to discuss the various methods of respiration and initial 
 tone-jiroduction, and to show, by a series of exi)eriments made upon 
 individuals, the effects of certain methods of voice-building, hoping to 
 arrive at some definite conclusion as regards the proper exercise and 
 jiosition of the larynx and consequently jn-oper tension of the vocal 
 cords, during tone emission. For the brief historical sketch which I 
 shall give, I am indebted almost entirely to the able article of Dr. Joal 
 of ]\Iont-Dore, which appeared in the Revue de Laryngologie d'Oto- 
 logie et de Rhinologie, Nos. 8, 9 and 10, 1892, Paris. The position which 
 Dr. Joal occupies at Mont Dore (the favorite resort of almost all the 
 European artists) has enabled him to consult freely, for a number of 
 years, the most distinguished vocal talent in Europe, and his views 
 upon voice-production should be carefully read by every instructor 
 who wishes to profit by the exceptional opportunities which that author 
 has enjoyed. One cannot read his able discourse upon the singing- 
 voice without feeling that his every utterance is ex cathedra. In 1842 
 Beau and Maissait divided the respiration of singers into three charac- 
 teristic tyi)es : the superior-costal, inferior-costal and abdominal. The 
 superior-costal may be illustrated as the breathing of a woman tightly 
 laced ; the respiratory expansion taking place chiefly in the cone of the 
 thoracic cavity, the upper ribs, collar-bone and sternum rising and 
 falling during the respiratory act. In the inferior costal type, the in- 
 ferior ribs (commencing with the seventh downward) are rotated and 
 elevated ; the sternum moving only in its infeiior portion, the abdomi- 
 nal wall being contracted during the respiratory act. In the true abdo- 
 minal type, the thorax is supposed to remain completely fixed, the dia- 
 phragm taking the ribs as a fixed point, lowering the abdominal 
 viscera, thus distending the wall of the abdomen in inspiration. It is 
 this latter type of breathing, which has- been taught for the last thirty 
 years in Fi-ance. Mengozzi,* together with the masters of one of the 
 conservatories, determined upon the following rules illustrative of the 
 breathing of singers: "The respiratory act in singing difl:ers somewhat 
 from that used in speaking. In speaking, the abdomen is extended in 
 inspiration and recedes in expiration, while in singing, the abdomen 
 must be drawn in during inspiration, returning slowly to its natural state 
 
 * Op. Cit. 
 
as the chest contracts in expiration, thus retaining as a negative force the 
 air which has been introduced into the lungs." In a revision of this 
 method, published in 1866 by Baptiste, these laws are repeated, with the 
 addition of a note by Dr. Mandl (the apostle of abdominal respiration), who 
 advocated the advancing of the abdomen in inspiration. Mandl carried 
 his point and his ideas became generally adopted by the Conservatory. 
 M. Bonheur and Dr. Cheval, of Brussels, advocated the superior-costal 
 type of breathing, in contradistinction to the method of Mandl. Mandl 
 in his work states that the larynx becomes very much depressed and 
 the glottis enlarged in the costal-method of respiration. Joal answers 
 him in these words : "We do not find this depression of the larynx 
 referred to in any of our classical treatises on physiology, anatomy, 
 nor in any one of the numerous works which have appeared since 1855 
 on laryngology ; consequently, we suppose that writers do not share the 
 ideas of Mandl on the subject. Besides, we have examined a number 
 of persons whom we engaged to breathe alternately from the abdomen 
 and from the shoulders. We ourselves, in singing, have often observed 
 the movements of our larynx, and we have never observed that the cla- 
 vicular inspiration caused the thyroid to fall." Nicaise explains this fact 
 by demonstrating, experimentally, that during strong inspirations the 
 trachea contracts and becomes shorter, which draws down the larynx * 
 
 It is very difficult for a professional man to take cases of distin- 
 guished singers in his own private practice and hold them up by name 
 as models of perfection of certain types. Joal made the assertion in an 
 article published in 1890, that great artists, especially women, used the 
 superior-costal method. The distinguished critic of "Le Temps" chal- 
 lenged Dr. Joal at once to mention some of these artists ; the Doctor 
 responded : "I Avould be happy to gratify Mr. Weber's desire, but it is 
 very difficult for a physician to go into personalities and to say that a 
 certain singer is using a vocal method considered disastrous and exe- 
 crable by masters of criticism." Melchissedec, however, offered him- 
 self as an example of the superior-costal respiration, saying that it had 
 enabled him to sing constantly for twenty-five years. Both his strength 
 of tone and tremendous endurance, with an almost perfect glottis, 
 attest that the method has not been injurious to him. 
 
 The abdominal method of breathing has many powerful advocates : 
 M. Obin and M. Faure, for example, speak most highly of it : Shake- 
 speare, of London, Behnke and Lennox Browne are also its advocates. 
 The instructors of both methods are veiy apt to quote great artists as 
 the exponents of their particular school. Joal cites the case of Rubini, 
 the celebrated tenor, who Massini and his pupils declare, originated 
 abdominal respiration; Bonheur, on the contrary, states that he ex- 
 panded his upper chest ; AValshe even going so far as to say that he 
 fractured his collar-bone in making a violent effort to reach B-flat in 
 "The Talisman of Pacini." Lablache and Laget acknowledged that, in 
 * Revue de Medecine, 1889. 
 
— G — 
 
 spite of long and attentivp observation, they had not been able to dis- 
 tinguish in the theatre liow this illustrious tenor breathed. Joal goes 
 on to stat« that the famous Lamperti is alternately represented as a 
 l)artisiin or opponent of the abdominal type of breathing, but I think 
 that, having treated many of the elder Lamjierti's pupils and interro- 
 gated them very particularly upon this question. I may unhesitatingly 
 aflirni that the elder Lamperti was a strong advocate of the lower 
 cost^il-respiration, always arguing that the abdominal wall should 
 remain (luiet, or be slightlj' drawn in during inspiration. The evidence 
 of C'ampanini, Jean de Reszke and Clara Heyeu is in support of the 
 above. Joal says if we except the works of Laget and Bonheur we find 
 nowhere the praise of clavicular breathing in men. The ancient method 
 of the Paris Conservatory and the works of Maunstein, Caruth and 
 INIanuel Garcia, all advise thoracic respiration by the elevation of the 
 ribs and drawing in of the abdomen. 
 
 If we take up any work upon the voice and studj' the photographic 
 appearances of the cords during the emission of certain notes, we 
 remark that the cords are not vibrating longitudinally, but that their 
 free borders approximate, touch or overlap, and that the posterior 
 opening of the chink is longer or shorter and different in appearance 
 for each note. I wish to put on record here my opinion, of the absolute 
 impossibility of photographing the vocal-cords during the proper emis- 
 sion of tone, fi'om the verj^ fact that the laryngoscopic mirror placed in 
 the ])harj'^nx interferes with the right focus of the respiratory attack, 
 and it is only possible to observe the vocal-cords in the photograph 
 when the so-called stroke of the glottis is used in the emission of a note. 
 The photographs of singers' cords, and the deductions that have been 
 drawn from their appearance during the emission of different notes, 
 only demonstrate, in every case that I have ever seen, that the larynx 
 is elevated by the pulling up of the thyroid, the cords relaxed, and the 
 free borders more or less approximated. If we ask a singer who is in 
 the habit of using the so-called high-chest method of costal-respiration 
 to take a note (the attack entirely taken from the cords and focussed in 
 the masciue, bringing into play the hai-monics lent by the sound-waves 
 passing behind the uvula and soft-palate), introducing the smallest pos- 
 sible size of mirror, so that the color given to the note by nature's 
 resonance-pipes, the antra and nasal cavities, will be as little as possible 
 interfered with, we are surprised to find that on the emission of every 
 note of the soprano medium register the cords appear equidistant from 
 each other, throughout the entire extent that it is possible to see them. 
 
 The part which the intrinsic muscles of the larynx play in the ten- 
 sion of the vocal-cords becomes an interesting study. It is very easy for 
 us to see by the depression of the thyroid how the |cords must be elon- 
 gated, but it is extremely ditficult for us to comprehend the minute dif- 
 ferences of tension caused by the movements of the thyroarytenoid and 
 cricoarytenoid muscles. I have frequently been surprised upon exami- 
 
nation of the vocal-cords with the head held down, the chin resting upon 
 the chest, to find the cords present a beautiful pearly appearance, 
 entirely homogeneous ; but upon attempting to show the patient his own 
 cords by an adjustment of double mirrors, the head being slightly thrown 
 back, upon the same note the cords suddenly have become dusky, semi- 
 congested and striated. How much of this is due to the slight elevation 
 of the thyroid cartilage, and how much to the intrinsic muscles of the 
 larjmx, or to the relationship between the chink of the glottis and the 
 trachea, it is difficult to determine. To a careful study of these differ- 
 ences of tension am I indebted for the discovery of a fact which I here 
 write about for the first time, the appreciation of which fact, however, 
 has entirely changed my treatment of the singing-larynx and has caused 
 me to institute a system of tone exercises by which certain intrinsic 
 muscles of the larynx are so strengthened, that any medicinal application 
 through the medium of sprays, probangs, and I may say instrumenta- 
 tion, has oft-times been entirely done away with. 
 
 If we take a good sized laryngoscopic muTor, No. 4 for example, and 
 ask a patient to sing E or Ah, the cords come into view for two reasons : 
 First, the epiglottis becomes more perpendicular, allowing a better view 
 of the bands, and, secondly, the cords themselves are on a more elevated 
 plane, owing to a slight elevation of the thyroid cartilage and con- 
 sequent relaxation of the intrinsic tensors of the cords. In this 
 position we remark that the free borders of the cords come together 
 in the anterior and central portions, and we are able to study the initial 
 tone attack, the membrane separating as the tone bursts through the 
 closed chink. This picture may be said to be an imitation on a small 
 scale, of the so-called stroke of the glottis. In this method of producing 
 a tone, the initial attack being upon the cords themselves, the central 
 portions of the cords necessarily touch. The pecular muscular 
 equilibrium which is employed in this mode of attack, invites a 
 reflex elevation of the soft-palate, cutting off the oral from the nasal 
 cavities. As we look at this picture our minds revert to the singing 
 teacher who commands her pupils to keep their palates up, sing in the 
 back of their heads, and strike the glottis. Could ever villainy be more 
 compounded ? Let us take the same patient and requu-e him to sing the 
 same note, but in an entirely different way. We win first ask him to 
 expand his upper-chest, not necessarily by respiration, but by elevation 
 of the superior ribs by a muscular effort, at the same time slightly 
 drawing in the abdominal wall. We now introduce the smallest mirror 
 and ask our patient to sing A, pronounced as in law, or maw. With this 
 position of the larynx and muscular poise we observe two things : First, 
 the epiglottis does not assume its most vertical aspect, not iuclining as 
 near the perpendicular, and the soft-palate and uvula do not spring up- 
 ward and backward to make the partition between the mouth and naso- 
 pharynx. Different in every respect is the tone produced by 'the cords, 
 which may be assumed to vibrate longitudinally, but never touching 
 
each other in the middle jiortion, even in making th(» initial attack. The 
 cords appear narrower, tenser, lower anteriorly, ecpiidistant from each 
 other, more liomogeneous and whiter in color. 
 
 These two pictures should be well considered, as they become the 
 basis of criticism in distinguishing the correct and eliminating incorrect 
 methods on the one hand in singers' voices, and of the greatest assist- 
 tance to the laryngologist in correcting i)atiu)logiral conditions, the 
 result of bad training. Tlie ])n)i)er appreciation of these oi)i)oslte condi- 
 tions and their effect on the (luality of tone immediately calls our atten 
 tion to the subject of respiration. 
 
 Within the past three years the entire theory of musical education 
 has changed in France; the explanation of this change being that there 
 is at present a better appreciation of the influences bearing upon the 
 production of tone and a better understanding of the physiology of the 
 larynx by reason of the advances made in laryngoscopy. 
 
 Modern t«iching tends to cultivate tone harmonies and sympathy 
 in the voice at the expense of brilliancy of execution. The same judg- 
 ment sliould be exercised in the training of an individual who proposes 
 to make singing his or her art, as .should be employed in advising the 
 painter that his sijecial forte lies in landscapes, rich in color, to which he 
 may give expression to his imaginative genius, rather than to the sterner 
 fac simile of portraiture. 
 
 How many singers we hear whose technique and brilliant staccato 
 in the Bell Song of Lakme calls forth our admiration and amazement, 
 but who are as absolutely unable to put any sympathy whatsoever into 
 the simplest ballad. We should study color harmonies in music in the 
 same way that they must be studied in painting. There is no rule for 
 the palpitating sunlight effects and prismatic play of colors in the school 
 of Claude Monet; it is certainly a subtile feeling which is given by an 
 ingenious mingling of pure spectrum colors. In the human voice, that 
 added coloring of tone, which appeals to the heart as well as to the ear 
 of the listener, must be brought about by the employment of those har- 
 monics, which are added to the original tone by intervibrations within 
 the accessor^' cavities of the nasal passages. To sing dans le viasque, 
 as the French say, is to give this added richness to the initial tone; but 
 to sing in this manner requires the soft-palate and uvula to be lowered 
 in the production of tone. Likewise to make the purest initial tone from 
 the cords, we must get the utmost possible tension, which may only be 
 arrived at when the thyroid, or "Adam's apple," is depressed, for in pro- 
 portion as the thyroid is elevated, the cords tend to assume the base of a 
 right angle triangle instead of its hypotenuse. Several elements beside 
 this enter into the question of the gi'eatest possible tension, one of the 
 most important of which is, that the trachea be drawn down to assume 
 the position that it takes when the apices of the lungs are filled to their 
 greatest extent with air. One of the greatest singers that the world has 
 ever known told me, that the reason he adopted a fixed high chest was, 
 
— 9 — 
 
 that lie had found after an operation performed on one of his cords, that 
 the only way in which he could be at all sure of his voice while singing, 
 was in the maintenance of the so-called high chest respiration. This is 
 easily explained by the fact, that in this position the upper ribs remain- 
 ing fixed, the apices of the lungs always remaining in contact with the 
 thoracic wall, are expanded to then- fullest extent ; the cords tending to 
 keep in their state of greatest possible tension. In this position the 
 breathing becomes entirely inferior-costal and diaphragmatic. The posi- 
 tion of the thoracic cavity as indicated above permits the lungs to expand 
 to their fullest extent, thus adding a secondary resonance to the voice 
 from below — a sort of complementary timbre — the fixed upper thorax 
 allowing of the least possible change of color during tone -production. 
 
 It is this combination of facial and thoracic tone fortification, which 
 gives the enormous carrying power to tones produced by this method. 
 For a number of years, before I made a special study and estimated the 
 great sigiiificance of these factors in singing, I have deluged the throats 
 of singers with sedative and astringent sprays when their cords appeared 
 congested and swollen, oftimes presenting nodules in their centre which 
 I had never previously recognized as being due entii'ely to singing with 
 an improperly poised larynx. 
 
 I may cite several cases to show you the difference from a medical 
 standpoint, in the treatment of the singer's throat, where I now substi- 
 tute respiratory and tone exercise for the amelioration of conditions, 
 that I have always been taught were only to be cured by rest and the 
 diligent use of drugs. The cases cited are typical of a class of singers 
 which I have treated with equally good results, since I have made a par- 
 ticular study of the peculiar value of the proper tone production in the 
 human voice. 
 
 The first day of January last I was consulted by Miss F. , age twenty- 
 three, who had had a contralto voice of large power which she had em- 
 ployed constantly for several years, and had finally, after a prolonged 
 concert tour with a well-known orchestra, entirely broken down. Her 
 cords were congested with a slight nodule in the middle of either band ; 
 she complained of great pain in producing her notes, and her medium 
 register had no power in it whatsoever. She had been told by two of 
 the best authorities on the throat that she must not sing a note for a 
 year, and must have her cords painted with astringent solutions and 
 tone up her general health. Upon testing her voice, I remarked an ex- 
 tremely breathy tone and clavicular respiration. 
 
 In accordance with the principles which I have attempted to demon- 
 strate, I forbade her speaking a single word for a week, but placed her 
 at once upon the so-called inferior- costal respiration, maintaining a high 
 chest, and giving her directions to take a medium "C" with the chin 
 almost resting upon the clavicle, singing the word "ma" for five 
 minutes of each hour of the day, the tone first to be f ocussed in the face 
 with the mouth closed, and the attack to break upon the lips as much as 
 
— 10 — 
 
 possible on opening the mouth. At the enrl of seven days the cords, 
 instead of presenting an elliptical appearance, were straight, and the 
 nodule was so far rotated upward on either cord, that it did not touch 
 the nodule of the o])posite side in the emission of tone. At the end of 
 the week this young lady, who considered her voice hopelessly destroyed, 
 liaving acquired a new method of resjiiration. sang in a concert. She has 
 since sung regularly in church, in many oratorios during the Avinter, 
 and is at present singing three times a week in grand opera, learning 
 new roles continually, apparently perfectly restored. She tells me her 
 voice is far more powerful than she had ever anticipated. 
 
 Case II:— Miss P. H. consulted me on March 2 in great distress. 
 She was obliged to sing in a comic opera on that evening or close the 
 theatre. Examination .showed inflamed and bulged cords with great 
 hoarseness in the sjieaking voice; middle register impossible, but the 
 high notes obtained with great effort. I sent her at once to my assistant 
 who gave her exercises to maintain tension and at the end of an hour's 
 work with tension exercises and inferior-costal breathing the cords 
 responded and she sang with ease. 
 
 Case III :— Miss H. B. consulted me in May having lost her position 
 as prima donna by reason of loss of voice. Had been constantly treated. 
 Her cords showed the nodules of attrition, the result of the employment 
 of the coup dc (jlotte and faulty respiration. In this case a week's work 
 caused the nodules to disappear. She adopted a proper laryngeal poise 
 and again assumed the leading role. 
 
 Observation : — In this class of cases, rest causes a relaxation of the 
 cords and singing becomes impossible for some time, whereas, constant 
 work with tension of the cords and non-approximation of the same, 
 gives immediate relief. 
 
 Case IV :— Fraulein K. consulted me in the spring, her cords ap- 
 peared swollen and the membrane was injured but not hyperiemic. Had 
 been obliged to cancel her engagements and return to New York for 
 treatment. I recognized the familiar picture and sent her to my assist- 
 ant, who cured her in a week without other treatment than the establish- 
 ment of a proper laryngeal poise. 
 
 With many cases like these may I not be excused, in calling atten- 
 tion to what I consider the most important ground principle of the 
 singer's art, namely : The proper employment of the muscles of respira- 
 tion, the poise given the cords and the proper use of the intrinsic 
 muscles of the larynx, not forgetting thebringing into play of the 
 accessor}^ cavities of the face, which lend so much color to the tone, 
 removing entirely from the cords the deleterious effects of an improper 
 initial attack ? 
 
 To rehear.se briefly the deductions wliicli I have attempted to draw 
 from my argument, I maintain that the best method of respiration is 
 the inferior-costal or diaphragmatic, faithfully maintaining the ele- 
 vation of the upper ribs without raising the shoulders. Next in im- 
 
— 11 — 
 
 portance is the depression of the thyroid cartilage, brought about 
 through the agency of the crico-thyi-oid muscles, and the pulling down 
 of the trachea, by increasing the capacity of the upper lobes of the lung. 
 Anatomically speaking a pose causing the thyro-arytenoid muscles to pro- 
 duce tension instead of the cricoarytenoids. Be careful that the initial 
 attack is removed entirely from the cords. Lower the uvula and soft- 
 palate, that the sound-waves may obtain their intercurrent vibrations 
 or harmonics, by partly passing into the nasal cavities from behind. 
 Let us not fall into the error, that the roof of the mouth alone is the 
 sounding board of the singing voice, for without that added richness 
 and timbre to be given by calling into play nature's resonance pipes, 
 the nose and its accessory cavities, we may perhaps sing, but the singing 
 is at the expense of the cords, and the life of the voice is necessarily 
 shortened. 
 
 If I have said enough to arouse a new interest in what I consider a 
 most necessary accessory to laryngology, I shall feel amply repaid for 
 my endeavors to set the theme before you in a clear and comprehensive 
 manner, 
 
'. -/; ■ .. 
 
r-"' ,-. 
 
 COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the rules of the Library or by special arrange- 
 ment with the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C2e(ll4l)M100