during menstruation, during pregnancy, and in certain uterine affections, which from their effect on the singing voice are generally much better appreciated by singers than by physicians. Ruault 1 observed hemorrhages from the vocal cords accompanying the menstrual flow.

Sensory disturbances in the form of paresthesia and hyperesthesia, depending on sexual influences, have been described in all the mucous membranes of the upper airpassages; they manifest themselves in dryness of the throat, a feeling as of a foreign body, and desire to cough. They may be due partly to the hyperemia of these parts, but more particularly to the irritable condition which characterizes the entire nervous system at these periods. Irritation of the olfactory nerves, in the form of hyperosmia and parosmia, is sometimes observed. In speaking of asthmatic attacks as produced by disturbances in the genital region we approach perilously near the boundary-line between conditions due to sexual disturbances and coexistent hysteric phenomena, a boundary which is difficult to define in practice.

Finally, we must mention those phenomena which manifest themselves during the sexual development of the biody in functional disturbances of the voice. The most famliar of these is the change which occurs at puberty. It is a purely physiologic process, due to the increased development of the larynx, which occurs at this time and necessitates the adaptation of the muscles to the increased size of the organ. In most cases the change from the childish treble to the adult register takes place during the time of puberty without any marked disturbances, providing the voice, which at this time becomes easily hoarse and fatigued, is not unduly strained. Occasionally a slight hyperemia is observed in the vocal cords, but there is no abnormality in the movements of the larynx. The change of voice may be considered pathologic only when it lasts for some time and when the voice after puberty retains a childish or uncertain tone, without the character of a definite register. In the male this consists in a high, piping voice, which often changes suddenly to a deeper tone for a few words under the influence of emotion; or, if it changes to a higher register, gives out altogether; while in the

1 See "Semon's Centralbl.," VI, p. 323.

young girl, as pointed out by Störck, it becomes abnormally deep and rough.

In the male this falsetto voice, which must be regarded as the effect of an abnormal prolongation of the voicechanging period, is designated as the eunuch's voice (Fournier); it may last for only a short time after puberty, or may, as shown by numerous cases, persist a greater length of time as a more or less ridiculous vocal anomaly. Although the condition causes the patient a good deal of annoyance, it, as a rule, readily yields to treatment.

There is no alteration of the laryngeal image, either in the form of redness or anomalies of motion of the vocal cords, notwithstanding Fournier's attempt to construct a series of clinical pictures. This is what we should expect if we remember that the eunuch's voice is the expression of a disturbance in the coordination of the laryngeal muscles, consisting in a failure of the mechanism to adapt itself to the dimensions of the fully developed larynx, and the persistence of a false register. By a judicious series of exercises, consisting mainly in training the voice to adhere to a lower key, a cure can usually be effected in a few sittings.

The vocal changes which accompany old age, and consist in roughness or shrillness, may be due to ossification of the laryngeal skeleton and to consequent changes in the

vibrations.

RELATIONS BETWEEN THE SEXUAL ORGANS AND THE EARS.

Stepanow, Eitelberg, and Gradenigo 2 have observed. cases in which hemorrhages from the ears occurred either vicariously or coincidently with menstruation. In most of the cases the organ of hearing had been affected with chronic catarrh or chronic suppuration, and the power of hearing was more or less reduced during the intervals between the attacks. The hemorrhages from the ear usually occurred on the day before the appearance of menstruation, and, in the cases of menstrual anomalies, on the days on which the menses should have appeared. They were usually confined to one side, the same ear being affected in every attack. The amount of blood varied from two drops

1 Mon. f. Ohr.," 1885, No. II.

2" Arch. f. Ohr.," vol. XXVIII, p. 82.

to quantities greater than that of a normal menstrual flow. The hemorrhage is usually heralded by a kind of aura, consisting in headache, slight vertigo, and tinnitus aurium. The region of the hemorrhage appears to be the tympanic membrane and the external meatus, especially the mouths of the cerumen glands on the posterior and upper walls. After the hemorrhage has subsided, nothing abnormal is usually found except a slight hyperemia of the gland ducts referred to, though in Eitelberg's case the tympanic membrane was the seat of petechiæ.

We may mention that certain observers have reported the occurrence of hemorrhages at the time of menstruation in cases of perforating chronic otitis media, associated with granulations. These cases are too obscure to be regarded as vicarious hemorrhages. The same statement applies to a few doubtful cases in which hemorrhage is said to have occurred in the labyrinth at the appearance of the menses. (Jacobson,1 Koll2.)

The changes in the auditory function during these vicarious hemorrhages from the ear are interesting. During the hemorrhage there is a uniform hyperesthesia of the auditory nerve for all registers, and a diminution in the electric reaction. The sensibility is reported in some cases as increased; in others, as abolished. At the time of menstruation tinnitus aurium is often observed; it is probably due to the hyperemia accompanying the flow.

Masturbation is said to aggravate an existing aural affection and to exaggerate a chronic catarrh or suppuration. It is sometimes given as the cause of subjective noises, which are probably an expression of abnormal irritability of the

vasomotor centers.

The connection between pregnancy and the puerperium and chronic catarrh of the middle ear is so generally recognized among the laity that it is given as the cause of deafness in an abnormally large number of the cases, but the value of the patient's statement in this respect is much reduced when we find that in most cases it is possible to demonstrate objective alterations in the ear which can not possibly be referred to that physiologic condition of the female organism. If, as I believe we are justified in doing, we exclude all cases of obstinate catarrh of the middle ear,

1 Arch. f. Ohr.," XXI, p. 280.

2" Arch. f. Ohr.," xxv, p. 88.

the cause of which can be demonstrated in diseases of the nose and pharynx, and cases of former purulent otitis media with remaining alterations in the middle ear and on the drum membrane, there remain only the forms of so-called chronic catarrhal otitis media without alteration of any kind in the tympanic membrane, and cases attended with tinnitus aurium. Bezold 1 has found that among 190 women suffering from this form of middle ear catarrh, 17.9% referred the beginning, or at least a subsequent aggravation of their deafness, to pregnancy or the puerperium. In some cases there was a successive deterioration in the auditory power at each pregnancy.

These auditory disturbances are no doubt closely related to the disturbances in the circulation to which the female organism is subject during the time of menstruation and pregnancy, and to the anemic conditions which follow the puerperal period. Thus we find that, analogous to the influence exerted by diseases of the circulatory system on the ear, anemia and hyperemia constitute important etiologic factors in the production of functional disturbances of the auditory organ. As the deafness and tinnitus aurium which occur during menstruation may be regarded as the result of the general determination, and as representing hyperemic conditions in the deeper portions of the organ of hearing, it is equally plausible that the chronic venous stasis and increased irritability of the entire nervous apparatus which characterize pregnancy should be capable of producing disturbances in the auditory function. Concerning emboli in the ear during the puerperium, and pyemic disease of the ear after puerperal fever, we have very few contributions.

3. GONORRHEA.

The occurrence of gonorrhea in the nose and in the pharyngeal cavity is now beyond dispute, and the many assertions made to the contrary in former times are wholly without foundation. These depended partly on theoretic speculation in regard to the mode of infection of mucous membrane covered with squamous and cylindric epithelium in gonorrhea. The rarity of nasal infection in comparison to the frequency of gonorrhea is to be

1. Arch. f. Ohr.," vol. XXV, p. 225.

attributed to the fact that the vestibule of the nose is lined with epidermis. Infection is usually due to uncleanliness in the use of handkerchiefs; the skin, however, opposes a natural barrier to the invasion of the virus. We find not only in the new-born, in connection with gonorrheal conjunctivitis, where infection takes place during birth, but also in adults, as the result of direct transmission to the nasal mucous membrane from other sources, a purulent rhinitis as the result of this mode of infection, the nature of which is proved by the bacteriologic demonstration of the gonococci (Miller 1). I once had occasion to observe two cases of purulent rhinitis in the secretions of which typical gonococci were found within the pus-cells, occurring in two children of the same family, aged four and six respectively, who lived amid poverty-stricken and uncleanly surroundings and shared the bed of their gonorrheal mother.

In this connection it is interesting to note the possibility of gonorrhea being conveyed to the oral mucous membrane of infants (Rosinski 2), where it manifests itself in the form of a whitish exudate; Cuttler 3 and Salzmann 4 each report a case of gonorrheal ulcerative stomatitis, the result of an infection contracted by coitus per os.

Occasionally arthritis may be localized in the articulations of the larynx and produce symptoms similar to those which occur in acute articular rheumatism. Liebermann 5 and Simpson describe a disease of the crico-arytenoid articulation which appeared in connection with swellings in other joints after an acute gonorrhea. In one of these cases the left arytenoid cartilage was the seat of redness and swelling, most marked over the articulation, and this on sounding was found to be fluctuating. The left vocal cord failed in adduction. At the same time there were aphonia and violent pain in the region of the larynx, increased by pressure on the thyroid cartilage. Gradually the voice improved, and after six weeks the swelling disappeared, although the vocal cord continued slug

1 Störk, "Nothnagel's Handb.," XIII, 1st half, p. 86. 2"Zeitschr. f. Gynäk," 1891.

See "Semon's Centralbl.," vi, p. 166.

4 Kraus, " Nothnagel's Handb.," XVI, I Th., I Abth., p. 244.

5 From "Soc. méd. des Hôpit.," 1873, p. 388, reprinted by Archambault, Thèse de Paris, 1886.

6 From "Med. Rec.," July, 1889, reprinted by Lacoarret, "Rev. d. Laryng.," 1891, p. 398.