disease from the time of its appearance as a complication and from its general character. It occurs regularly during the period of desquamation-at a time, therefore, when there exists a tendency to other complications as well; for, except in the rare cases of diphtheroid scarlatina, there is no record of its occurring immediately subsequent to the scarlatinal angina which lasts only a few days. That the resisting power of the mucous membrane of the tubes and of the tympanum to the invasion of pathogenic germswhich might set up a suppurative process in the middle ear independent of the scarlatina—is especially lowered during this period of the disease is not only not proved, but is even improbable, as no such condition of affairs is observed in the mucous membranes of the upper airpassages, where secondary streptococcal infections usually follow immediately after the scarlatinal angina, in the first week of the disease.

Again, if we assume that the aural complication is merely accidental, or that it is dependent on the pharyngeal condition, it is, to say the least, remarkable that simple catarrh and mild otitis media without perforation do not occur in scarlet fever, or at least are so rare that they can not be included among the list of complications of the disease.

If, on the other hand, we consider that it is during the desquamation period that we find nephritis,—a disease which is unquestionably toxic in character and therefore indicates a septic condition of the organism,—the assumption that the aural complication is due to the action of the same toxins seems plausible. If a parallel could be established between nephritis and purulent otitis media, —as in a case observed by Voss, where the onset, course, and subsidence of the two diseases progressed pari passu,— it would offer another argument in support of the dependence of the aural disease on a general intoxication of the system. The bacteriology of scarlatinal otitis media and the significance of a mixed infection have not as yet been discovered.

3. VARICELLA.

In varicella, vesicles appear on the mucous membrane of the mouth and pharynx at the same time as the skin eruption; in rare cases a few isolated pustules were found in

the larynx. Cases of grave suffocative laryngitis have been described by Marfan and Hallé 1 and by Harlez, 2 which, it appears, occurred suddenly at the time of the eruption, with symptoms of asphyxia, attended with hoarseness, cough, and muffled phonation. Tracheotomy was required in every instance; no laryngoscopic examinations are reported; in one of the cases ulcers were found on the vocal cords at the autopsy.

In a unique case reported by Bürkner,3 two pustules were found in the external auditory meatus, with only a scanty eruption on the scalp.

4. VARIOLA.

In variola the mucous membranes contiguous to the external skin are regularly attacked. E. Wagner 4 found that the nasal mucous membrane was affected in every case in which it was examined. In a series of 170 cases the upper pharynx alone was affected twice; the pharynx and larynx alone, 38 times; the pharynx, larynx, and upper half of the trachea, 54 times; the pharynx, larynx, trachea, and large bronchi, 52 times. The larynx was therefore involved altogether in 144 cases out of the 170. Between the third and sixth day of the smallpox eruption (Mackenzie) pustules make their appearance in the pharynx and spread to the postnasal space and larynx. They may

be isolated in different parts of the larynx, or they may be multiple and coalesce to form large ulcers. At first the pustules resemble those on the external skin, but the covering of mucous membrane soon becomes macerated, is cast off, and leaves a red, excoriated patch, which is apt to bleed. In the hemorrhagic form ecchymoses appear in the mucous membranes. These superficial eruptions on the mucous membranes are complicated with deeper ulcerative processes, which lead to edema of the larynx and abscess formation; by extension to the cartilages this may give rise to a perichondritis of the larynx, as illustrated by

1 "Rev. d. mal. d. l' enf," XIV, Jan., 1896, rep. in "Semon's Centralb.," XII, p. 499.

214.

2 "Indép. méd.," July 14, 1897, rep. in "Semon's Centralb.," xiv, p.

3 Arch. f. Ohr.," 18, p. 300.

4"Arch. d. Heilkunde," XIII.

In addition to the pustular,

Türck 1 in a number of cases. Mackenzie mentions a papular form, and Löri reports hyperemia of the mucous membranes without pustular eruption.

Rühle, 2 among others, speaks of a diphtheric croupous inflammation of the laryngeal mucous membrane, with secondary invasion of the postnasal space. That this was the result of confluence of the pustules is denied by Löri on the ground that there never were any pustules on the mucous membrane; but E. Wagner says that in the numerous cadavers he examined the pustules were often so closely set, especially in advanced stages of the disease, that it was difficult to demonstrate their variolous character. Finally, we have the occurrence of palsies as a very rare complication. Mackenzie saw two cases which were followed by paralysis of the adductors of one cord. The nature of these palsies is not known, but they are probably due to mechanical causes, such as ankylosis of the arytenoid cartilage, observed after perichondritis or after the cicatrization of a deep ulcer.

Aural disease during smallpox was studied by Wendt3 in 168 organs taken from 84 persons of all ages who had died in various stages of the disease. As the ears were found to be intact in only 3 cases, there can be no doubt of the frequency of aural complications in variola. The nature of the lesions varies, according to Wendt's findings; in some instances the morbid process was identical with, or closely related to, variola, in others the lesions were such as occur in connection with other constitutional or local diseases, or even without them. From the external skin the eruption spreads to the concha and auditory meatus; from the mucous membrane of the pharynx to the pharyngeal orifice of the tubes. Whether the epithelial thickening and suppuration, and the hyperemias, hemorrhages, and exudations in the middle ear, are the product of the primary disease or the result of the tubal condition is an open question.

So far as has been observed, the tympanic membrane is never the seat of a pustular eruption, but it is frequently found to be red and swollen. These anatomic findings

1 "Klinik der Kehlkopf krankheiten."

2

Klinik der Kehlkopf krankheiten," 1861.

3 Arch. f. Heilkunde," XIII.

of Wendt are directly contradicted by the clinical observations of Ogston.1 The latter, after examining the ears of 229 smallpox patients, reached the conviction that "the structures and tissues of the ear itself are not affected by variola."

The prognosis, according to Wendt, is favorable; he believes that the healing of the smallpox lesions in the ear is not followed by any functional disturbance, nor have there ever been found cicatricial stenoses or synechiæ from the healing of pustules in the external auditory meatus or in the tubes.

5. TYPHOID FEVER.

The laryngeal phenomena occurring in the course of typhoid fever may be divided into three main groups— catarrhal conditions, ulcerations, and palsies; edema and perichondritis are regarded as accompaniments or complications of one of the three main divisions. There are plenty of data to determine the frequency of these complications, but a certain reserve is necessary in drawing general conclusions, for the statistics would be quite different if a systematic laryngoscopic examination were made in every case of typhoid fever, without waiting for the patient to complain of pain in the throat or for the appearance of such obvious symptoms as dyspnea and aphonia. The results obtained vary according as they are based on observations made on the living subject or on the cadaver, for complications are naturally much more frequent in cases of typhoid terminating fatally than in the milder forms. Another factor is the severity of the epidemic that happens to furnish the basis for the statistics. The most comprehensive figures are those published by Lüning, who puts the percentage, as computed from clinical statistics, at 3, and the postmortem percentage at 17.

It would be interesting to know the relative frequency of the various forms of laryngeal disease; but on this point. we can not hope for any information from the results obtained at autopsies, as they naturally include only the gravest complications, such as perichondritis or diphtheric disease.

1 "Arch f. Ohr.," vi, p. 267. 2" Langenbeck's Arch.," vol. xxx.

Clinically speaking, simple catarrh and superficial ulceration are the complications most frequently observed, while deep ulcerations which lead to edema and perichondritis, or which, when extensive, present the so-called diphtheric form ("laryngotyphus") are much rarer. If the latter are more frequently and more fully described it is only because of their alarming symptoms and the laryngeal stenosis which characterizes them and directly threatens the patient's life. Stenosis and edema of the larynx are sometimes induced by typhoid processes in neighboring organs; thus, cases have been reported in which acute inflammation or abscess formation in the thyroid gland-which condition appears to be quite frequent in the course of typhoid-led to compression of the trachea and edema of the larynx. Our knowledge of post-typhoidal palsies is of very recent date. They were formerly considered a very rare complication, for Lublinski could collect no more than 25 cases, including 6 of his own, and Landgraf met with only 2 cases of laryngeal palsies among 166 typhoid patients. A special interest, therefore, attaches to Przedborski's1 report, accompanied by very complete case histories, of 25 laryngeal palsies among 100 cases of abdominal typhoid, and of 7 among 25 cases of exanthematous typhoid.

The pharyngeal and laryngeal mucous membrane is often attacked by catarrh in the beginning of the disease, while, on the other hand, the nasal mucous membrane not only escapes but presents an unusually dry appearance. The only nasal symptom observed is epistaxis. The hemorrhage shows a predilection for the septum, but is also observed in other parts of the mucous membrane. In a few cases which came under my observation the nasal mucous membrane after the hemorrhage presented the previously mentioned desiccated appearance, the septum was marked with rhagades, while the walls and interior of the nose were covered with larger and smaller masses of black, clotted blood, which moved to and fro with the respiratory movements. The epistaxis occurs in the beginning of the disease. As the patients at this time are usually in bed and more or less prostrated by the fever, the blood usually flows backward into the throat, and the resulting bloody sputum may give rise to errors in diagnosis. Perforation of

1 Volkmann's "Sammlung klin. Vortr.," No. 182, 1897.