temperatures were referred to in the discussion of croupous pneumonia, and appear to occur in all infectious fevers where the patient is a subject of chronic suppuration. One peculiarity of purulent otitis media during typhoid, which is mentioned by most authors, is the early involvement of the mastoid process. Inflammatory phenomena make their appearance in the mastoid process at the same time that the acute inflammation invades the middle ear, and various cases have been described in which there was marked tenderness on pressure out of all proportion to the appearance of the ear-drum. Brieger observed a case in the eighth week of typhoid in which fluctuation was made out over the mastoid process within four days after the first appearance of the earache, while the corresponding ear-drum was markedly hyperemic and quite flat, and only ruptured on the next day, the perforation being very small and followed by a slight discharge. An operation was performed a week after the onset of the pain, and showed the presence of sequestrums in the mastoid process. The case ended fatally in five weeks, death being due to thrombosis of a sinus. Brieger points out that this does not correspond to the ordinary course of bone disease following typhoid, as there is usually a tendency to spontaneous cure of the inflammation. There is no doubt that the bone is extensively involved. This is shown by Bezold's investigations; in 19 out of 41 cases he found marked tenderness on pressure, which in II cases made its appearance at the same time as the inflammation. In 5 out of these 19 cases a periosteal abscess resulted, and required incision. It being established that the bone disease either progresses pari passu with the otitis media or precedes it, the question of the etiologic relations existing between the bone disease and typhoid otitis now presents itself. According to Bezold, the inflammation in the middle ear may begin in one of the three following ways: First, by direct extension of the inflammation from the nasopharynx through the tube, simple occlusion of the tube being probably insufficient to be regarded as an etiologic factor, at least for the suppurative processes. Second, by the passage of septic material directly from the nasopharynx into the middle ear. Third, by the formation of emboli in the vessels of the mucous membrane of the middle ear, emanating either from an endocarditis and thrombosis of the left heart, or from purulent foci in the periphery. Bezold therefore considers the aural complication as secondary and excludes the effect of the general infection as an etiologic factor. If Bezold's exposition of the etiology is accepted, it is difficult to explain how the disease, which is at first localized in the middle ear, can be transplanted to the walls of the mastoid process with such rapidity as to make the secondary, appear to precede the primary disease. Even if we admit the possibility of the middle ear becoming infected through the tubes, we can not discard the theory that we have to deal with an acute osteomyelitis of the mastoid process, which is to be regarded as a true complication of the typhoid disease. The demonstration of typhoid bacilli would settle the matter beyond dispute; unfortunately, we do not possess any bacteriologic data; however, the course of the bone disease, as has been previously stated, is in itself quite different from that which is usually observed in the complications of typhoid fever, and even if we assume a mixed infection to explain the sequestration of the bone and the formation of periosteal abscesses, the question why the disease in the bone should precede or even accompany the suppuration from the ear remains unsolved. Complication of the external ear (the auricle and the external meatus) is a very rare occurrence. Haug1 quotes a case of gangrene of the auricles from Obre. Von Tröltsch and Hoffmann 2 each observed a case of suppuration of the parotid gland with rupture into the external meatus. In Hoffmann's case there was a fistula at the junction between the cartilaginous and bony portions of the meatus. On the other hand, Botkin 3 observed bilateral otitis externa 21 times among 26 typhoid patients, and erects the improbable hypothesis that suppurations from the middle ear in typhoid are due to an extension of otitis externa to the ear-drum and to the tympanic cavity. An apparent reduction in the power of hearing is frequently met with in the course of typhoid fever, although no objective changes can be found to account for it. It is quite unjustifiable to interpret such cases as nervous 1" Die Krankh. des Ohres," etc., p. 90. deafness, for clinical experience teaches that the difficult hearing is due to somnolence, and improves as soon as the mental faculties are restored. I have myself observed that the hearing varies during the febrile stage, being remarkably improved during the remissions of the temperature which follow cold baths. When Haug 1 remarks "that this typhoidal deafness sometimes reaches its highest point at the crisis of the general disease, and then gradually diminishes and allows the ear to return to its normal condition during the stage of convalescence," and insists particularly on the fact that "disturbances of the sphere of coordination have never been observed," we may be pardoned for expressing a doubt of this "nervous ear affection." This must not, however, be taken to imply that we deny the possibility of the nervous hearing apparatus being involved in typhoid fever, and there are, in fact, a few observations which prove that difficult hearing and tinnitus aurium, with the other phenomena of the nervous affection, undoubtedly occur during the stage of convalescence; in fact, the anatomic investigations of Pulitzer, Moos, Lucae, and Schwartze demonstrated an anatomic basis for this clinical picture a hyperemia of the internal ear or ecchymoses and hemorrhages in the vestibule and in the cochlea. The clinical cases of nervous deafness which have been described as progressive after typhoid fever, must, in the absence of detailed histories, be accepted with a reservation, as they may have something to do with the exhibition of quinin or salicylic acid during the course of the fever. 6. INFLUENZA. Although the port of entry for the carriers of the infection of influenza is probably to be sought in the mucous membranes of the upper air-passages, the parts themselves are directly involved in only a small percentage of the cases. Leichtenstern 2 has designated this form as catarrhal respiratory influenza, in contradistinction to the gastro-intestinal form and the purely toxic form with fever and nervous phenomena. The frequency of rhinitis is variously given at from 25% to 79%, that of laryngitis from 5% to 16 %; these figures appear remarkably low in comparison with the 1 Loc. cit., p. 95. 2 Nothnagel's spec. "Path. u. Ther.," vol. IV, I, p. 77. frequency with which these conditions are observed in practice. There can not be said to be a typical clinical picture for the complications of influenza in the upper air-passages, fcr they manifest themselves under the most various forms. Two principal groups are distinguished-one affecting principally the mucous membrane, the other the nervous system. With regard to affections of the mucous membranes, it has been pointed out by Leichtenstern that the inflammation is not uniformly distributed over all the mucous membranes, and that the deeper portions do not always become affected secondarily to the disease in the upper portions,-i. e., the nose and the nasopharynx, as is the case in most other conditions,--but every portion of the respiratory tract is capable of becoming primarily affected by the morbid process. In the nose the inflammation presents the picture of an acute rhinitis which is distinguished from an ordinary coryza only by the rapidity of its course, the inflammatory symptoms and secretion subsiding within a very few days. The rhinitis is occasionally accompanied by epistaxis, although we find very contradictory statements in regard to this symptom. Schmidt and Litten regard epistaxis as a very frequent complication, while Tissier, 1 Leichtenstern, and Fränkel,2 on the other hand, say that it is comparatively rare. We should mention the occurrence of acute or, later, chronic suppurations in the accessory cavities as one of the complications. Thus, the maxillary sinus is frequently the seat of an acute inflammation, accompanied with nasal obstruction and facial neuralgia, which immediately disappears either spontaneously or after the swelling in the mucous membrane has subsided and the orifice of the cavity has been exposed. The best descriptions of suppurations of the accessory cavities are given by Tissier, who claims to have found all the various sinuses affected. Ewald3 reports a very malignant case in which a purulent basal meningitis developed after an empyema of the antrum of Highmore had been opened; the meningeal complication at the autopsy was accounted for by the finding of a suppuration in the ethmoid cells. 1 "Ann. des mal. de l'oreille," 1892, p. 425. 2 "Semon's Centralbl.," VII, p. 38. 3"Berlin. klin. Wochen.," 1890, No. 3. Catarrh of the pharynx and larynx also presents the ordinary picture of an acute inflammation, except that hemorrhage appears to be a more frequent complication than in the nose; the term laryngitis hemorrhagica has been applied to this form of the disease. The affected mucous membranes are frequently the seat of whitish patches, not elevated above the swollen and reddened mucous membrane. They are analogous to similar patches found in acute catarrh, and are to be interpreted as a superficial necrosis. In a few instances marked edema of the laryngeal mucous membrane was observed, which even went on to abscess formation, and Rethi described a coexisting perichondritis of both plates of the thyroid cartilage.1 As regards nervous diseases, a few cases of anosmia and parosmia have been reported, and while paralysis of the palatal muscles and of the constrictors of the pharynx may occur, by far the most important complication consists in paralysis of the laryngeal nerves, which must be regarded as a typical influenza neuritis such as occurs in all parts of the body. Besides rare cases of paralysis of the sensory superior laryngeal nerve we meet with paralyses of the laryngeal muscles, both of the adductors (Onodi saw an isolated paralysis of the cricoarytenoideus lateralis, and Rosenberg frequently noticed paralyses of the vocal cords) and of the abductors; they usually make their appearance after the acute inflammation has subsided. So far as the observations have gone, the abductors appear to be more frequently involved than the adductors, and both unilateral and bilateral paralysis of the crico-arytenoideus posticus has been observed. Seifert2 reports a unique case of a right-sided total paralysis of the vagus which he regards as peripheral in origin. Besides the usual cardiac and circulatory symptoms there was paralysis of the right recurrent and of the superior laryngeal nerves. AURAL COMPLICATIONS IN INFLUENZA. Soon after the appearance of the influenza epidemic of 1889-1890 the attention of aural surgeons was directed to the frequency of purulent otitis media as a complication of influenza, and the numerous observations that have been 1 Wien. klin. Wochen," 1894, No. 48. 2" Rev. hebd. de lar., d'ot. et de rhin.," 1896, p. 1537. |