Abstract
Many things can be indicated by hoarseness, in the examination of which at least four different levels, not to be confused with each other, must be taken into account: (a) the psychological, (b) the acoustical, (c) the patho—physiological, (d) the patho—anatom—ical. A description of the above levels will be followed by a discussion of the mechanism of voice strain. A new theory is formulated, according to which vocal nodules develop chiefly as a result of excessive loading on the tenser ligaments in incorrect “open—voice” phonation.

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