dle ear finds the most favorable conditions for the spread of the disease. The comparative benignity of the middleear affection can be explained by the drainage facilities through the perforated membrane, which are wanting in the mastoid cells, where the carious process accordingly continues its work of destruction. It should also be said, in justice to the opponents of a primary osteitis, that there are cases in which the bone disease appeared late in the course of a chronic purulent otitis media, just as there are others in which an acute suppuration terminated favorably without involving the mastoid cells.

In this connection a case of Naunyn's 1 is peculiarly interesting. In a severe case of diabetes a violent otitis media developed on the fourth day; the patient, a boy of eight, complained of severe headache, and there were marked cerebral symptoms, with vomiting, great hebetude, and "large respiration, as in diabetic coma." Paracentesis was performed on the fifth day and a large quantity of pus was evacuated; recovery followed in a few days. I once saw a similar case in a boy of fourteen, with grave diabetes, who experienced pain in the ear and a slight otorrhea two days before the occurrence of diabetic coma. On the following day, while the coma continued, the flow subsided, and the ear-drums, which were perforated and showed the scars of former lesions, were seen to be slightly swollen and of a uniform bluish-red color, which soon disappeared. Six months later, the same ear was attacked by acute middle-ear inflammation, necessitating paracentesis; after the discharge had lasted about a week the patient again recovered.

In reviewing the facts before us, it appears that there are unquestionably cases of simple diabetic otitis which prove the existence of a diabetic disease localized in the middle ear; but it is equally certain that there are many cases, reported by Kuhn, Körner, and others, which as emphatically justify the assumption of a primary osteitis, especially since we possess the description of a case of diabetic osteitis and multiple periosteitis elsewhere in the body, which confirms the possibility of such primary bone disease in diabetes.

However that may be, whether we have to deal with a

1" Diabetes" in Nothnagel's "Spec. Path. u. Ther.," p. 287.

primary osteitis or a primary otitis media, the occurrence of suppuration from the ear in diabetes constitutes a grave complication, which must be combated from the outset with all the means at our command. There was a time when operative treatment of diabetic otitis media was thought to be contraindicated, because a few deaths had been reported. If the wound is properly treated, this fatal result must be charged to postoperative diabetic coma (two out of four cases by Buck1), and not, so far as I can see, to the operation itself 2 (one case reported by Sheppard died of intercurrent erysipelas and purulent meningitis 3). As it is well known that the morbid process in the bone spreads very rapidly in diabetes, without giving rise to any pronounced subjective symptoms, trephining of the mastoid process is indicated whenever the ominous sinking of the posterior wall of the meatus has been present for some time, or deep abscesses have made their appearance in the mastoid process itself. A high sugar percentage is, however, an absolute contraindication, as it enhances the danger of postoperative diabetic coma; this is probably the direct result of chloroform narcosis, which is followed by a rise in the percentage of sugar, as observed in Körner's cases and in my own that terminated favorably (from 0.2 to 1.85% in my cases). Since, therefore, the danger lurks in the anesthesia as well as in the operation itself, one should never operate without first reducing the sugar as much as possible by a long course of dieting. Recent experience teaches that in this way we also diminish the danger of sepsis, which, according to Schwartze, "renders the prognosis as to life a doubtful one, even in mild grades of diabetes, because there is danger of an unfavorable postoperative course, ending in sepsis." At all events, it is not great enough to forbid operative interference, any more than the imaginary danger5 of uncontrollable hemorrhage, which appears to be founded on a case of Moos, in which "the operation was interrupted by an uncontrollable hemorrhage, lasting three-quarters of an hour"-its origin is not stated, and who is to say that it was due to the diabetes?

4

1. Arch. f. Ohr.," XL, p. 138.

2 I recently saw a death during coma on the fourth day after the operation; at the autopsy a large abscess was found in the deep muscles of the neck.

3 "Zeitschr. f. Ohr.," XXIX, p. 268.

4

Handb.," II, p. 841.

5 Haug, "Krankh. des Ohres," p. 167.

6" Deutsche med. Wochen.," 1888, No. 44.

4. GOUT.

The most familiar examples of gouty alterations are the catarrhal phenomena in the pharynx and larynx. They occur most frequently in the form of angina uratica, with dark-red discoloration of the mucous membrane of the uvula, soft palate, the two pillars of the fauces, and the tonsils. Sometimes an acute edema is superadded, as has been observed by Vaton,1 M. Mackenzie,2 and Danziger. 3 Solis-Cohen 4 insists on the frequency of pains and abnormal sensations in circumscribed areas of the mucous membrane which appeared to be perfectly healthy, and in which he found only dilated vessels or a dark-red discoloration. Acute attacks of angina uratica always make their appearance two or three days before a typical outbreak of gout, and subside as soon as the gouty joint-affection has declared itself. There is also, as a rule, chronic pharyngeal catarrh, associated sometimes with tophi (Litten).

Gouty disease of the larynx is rarely observed. It manifests itself in a great variety of forms, the inflammatory redness and swelling being often attended with the deposition of urates in the joints and cartilages. The mucous membrane of the vocal cords is involved, as well as that of the rest of the larynx, and not infrequently there are circumscribed swellings in special portions of the larynx. Thus, in a gouty patient I have seen an infiltration of the right ventricular band persist for many years following a laryngitis which had come on after an acute attack of gout. M. Mackenzie 6 observed a gouty inflammation of the left false vocal cord, with granulations, which had been diagnosed as cancer. Virchow, Litten, Morell, and Mackenzie saw gouty deposits: in one case a white body as large as the head of a pin, at the posterior extremity of the right vocal cord; at other times, as infiltrations in the cords and articulations of the larynx. In Mackenzie's case it was the crico-arytenoid articulation that was affected, and the resulting imperfect approximation of the vocal cords gave rise to aphonia. Litten found postmortem marked infiltra

1❝Semon's Centralbl.," VIII, p. 85.

261

Journ. of Laryngol.," 1889, p. 313. 3" Mon. f. Ohr.," 1895, p. 14. 4" Semon's Centralbl.," XI, p. 318. 6 Loc. cit.

5" Virch. Arch.," 66.

7 Virch. Arch.," 44, p. 137.

tion of the same joints and their ligaments (the clinical appearance of the larynx is not given). The gouty process in the cartilages not infrequently goes on to ossification.

Of the gouty alterations in the organ of hearing those which affect the concha have been known a long time, and every physician is familiar with them. In nearly all of Garrod's case histories we find mention of small gouty nodules in the concha, sometimes on the posterior surface, more commonly on the helix and fossa navicularis. The cartilage is said to be the seat of a peculiar induration and of the formation of small softening foci. In some cases there is inflammation of the external auditory meatus (pruritus). The statement that exostoses in the external meatus are due to gout (Kirchner) has never been proved. Judging from the frequency of complaints from arthritic patients to the effect that they suffer from difficulty in hearing, especially progressive loss of hearing and tinnitus, we must infer that other lesions occur in the organ of hearing. We are not inclined to accept angina as the explanation of the loss of hearing in gouty subjects, as suggested by Haug; for there really is not any form of aural complication that might not occasionally be referred to a hypertrophic pharyngeal catarrh. Ebstein's arguments in his treatise on "Aural Vertigo" seem to us more plausible. 2

The clinical picture of gouty ear disease, which, as has been said, has for its principal features a progressive diminution of the hearing, with tinnitus and vertigo, may be explained in as many different ways as there have been causes assigned for gout itself. It is still a question whether the gouty process is in the middle or in the internal ear; we can not say positively that the chalky deposits seen during life on the tympanic membranes of gouty subjects consist of urates, for the manner in which the morbid process affects the organ of hearing is very imperfectly understood. A specific gouty affection of the organ of hearing may be situated in the tympanic membrane, where the resulting functional disturbance would probably be slight, or in the chain of ossicles in the form of arthritic disease. Unfortunately, we are without anatomic experience on this point, and even the clinical stock of observations at our command is very limited. A case history, to have any statistical 1 Deutsche Uebersetzung von Eisenmann, p. 101. 2" Arch. f. klin. Med.," 58, p. 1.

1

value in showing a connection between gout and diseases of the middle ear, should contain not only the results of an accurate functional examination, but also some information in regard to the movability of the chain of ossicles. Brieger 1 reports a case in which the usual prodromata of an attack of gout were followed by an acute otitis media, with marked bulging and swelling of the tympanic membrane, and interprets it as an arthritic process in the articulation, between the malleus and incus. According to Agnano, 2 persons with the gouty diathesis usually develop deafness between the ages of fifteen and twenty.

Still more uncertain are we whether the labyrinth is ever attacked by the gouty process. Since the imaginary hemorrhages which are sometimes supposed to form the basis of the phenomena in the labyrinth, mentioned previously under the name of Ménière's symptom-complex, must be rejected as being without anatomic foundation, the most natural explanation of these symptoms is suggested by the vascular changes which are a constant feature of gout, and we are therefore inclined to seek the cause of these aural phenomena in a primary arteriosclerosis. This view appears to be supported not only by the observations of Ebstein, but also by de Lacharrière's statement that "aural phenomena are most common in persons who, besides being subject to attacks of genuine articular gout, show their inherited gouty tendencies in attacks of gastralgia, dyspepsia, migraine, and neuralgia." Ebstein is right, no doubt, when he says that it must, for the present, remain an open question whether the ear disease in gouty subjects is to be referred to the primary disease, to obesity, or to cardiac changes the result of overindulgence in alcoholic beverages.

ICTUS LARYNGIS OCCURRING IN THE COURSE OF OBESITY, GOUT, AND DIABETES.

That there is a certain relationship between the three constitutional anomalies, obesity, gout, and diabetes, appears from the way in which they manifest themselves in individual members of a gouty family-now under one form, now under another. They produce chronic catarrhal

1 Klin. Beitr. zur Ohrenheilk.," p. 77.

2

Rev. hebd. de lar.," 1896, p. 703.